Clinical

With a record number of attendees, Pediatric Hospital Medicine 2013 (PHM) swept into New Orleans last month, carrying with it unbridled enthusiasm about the past, present, and future.

Virginia Moyer, MD, MPH, vice president for maintenance of certification and quality for the American Board of Pediatrics (ABP) and professor of pediatrics and chief of academic general pediatrics at Texas Children’s Hospital, delivered a keynote address to 700 attendees that focused on the challenges and opportunities of providing evidence-based, high-quality care in the hospital, as well as ABP’s role in meeting these challenges.

“If evidence-based medicine is an individual sport,” Dr. Moyer said, “then quality improvement is a team sport.”

Barriers to quality improvement (QI)— such as lack of will, lack of data, and lack of training—can be surmounted in a team environment, she said. ABP is continuing in its efforts to support QI education through its Maintenance of Certification (MOC) Part 4 modules, as well as other educational activities.

Other highlights of the 10th annual Pediatric Hospital Medicine meeting:

• The addition of a new “Community Hospitalists” track was given high marks by those in attendance. It covered such topics as perioperative management of medically complex pediatric patients, community-acquired pneumonia, and osteomyelitis.
• A 10-year retrospective of pediatric hospital medicine was given by a panel of notable pediatric hospitalists, including Erin Stucky Fisher, MD, FAAP, MHM, chief of hospital medicine at Rady Children’s Hospital in San Diego; Mary Ottolini, MD, MPH, chief of hospital medicine at Children’s National Medical Center in Washington; Jack Percelay, MD, MPH, FAAP, associate clinical professor at Pace University; and Daniel Rauch, MD, FAAP, pediatric hospitalist program director at the NYU School of Medicine in New York City. A host of new programs has been established by the PHM community, including the Quality Improvement Innovation Networks (QuIIN); the Value in Pediatrics (VIP) network; the International Network for Simulation-Based Pediatric Innovation, Research, and Education (INSPIRE); patient- and family-centered rounds; and the I-PASS Handoff Program. The panel also discussed future challenges, including reduction of unnecessary treatments, interfacing, and perhaps incorporating “hyphen hospitalists,” and learning from advances made by the adult HM community.
• The ever-popular “Top Articles in Pediatric Hospital Medicine” session was presented by H. Barrett Fromme, MD, associate professor of pediatrics at the University of Chicago, and Ben Bauer, MD, director of pediatric hospital medicine at Riley Hospital for Children at Indiana University Health in Indianapolis, which was met with raucous approval by the audience. The presentation not only educated those in attendance about the most cutting-edge pediatric literature, but it also included dance moves most likely to attract the opposite sex and clothing appropriate for the Australian pediatric hospitalist.
• The three presidents of the sponsoring societies—Thomas McInerney, MD, FAAP, of the American Academy of Pediatrics, David Keller, MD, of the Academic Pediatric Association, and Eric Howell, MD, SFHM, of SHM—presented each society’s contributions to the growth of PHM, as well as future areas for cooperative sponsorship. These include the development of the AAP Section of Hospital Medicine Library website (sohmlibrary.org), the APA Quality Scholars program, and SHM’s efforts to increase interest in hospital medicine in medical students and trainees. “Ask not what hospital medicine can do for you,” Dr. Howell implored, “ask what you can do for hospital medicine!”
• Members of the Joint Council of Pediatric Hospital Medicine (JCPHM) presented the recent recommendations of the council arising from an April 2013 meeting with the ABP in Chapel Hill, N.C. Despite acknowledgements that no decision will be met with uniform satisfaction by all the stakeholders, the JCPHM concluded that the path that would best advance the field of PHM, provide for high-quality care of hospitalized children, and ensure the public trust would be a two-year fellowship sponsored by ABP. This would ultimately lead to approved certification eligibility for fellowship graduates by the American Board of Medical Specialties (ABMS); it would also make provisions for “grandfathering” in current pediatric hospitalists. Concerns from med-peds, community hospitalists, and recent residency graduate communities were addressed by the panel.
• A recurrent theme of reducing unnecessary treatments, interventions, and, perhaps, hospitalizations was summarized eloquently by Alan Schroeder, MD, director of the pediatric ICU and chief of pediatric inpatient care at Santa Clara (Calif.) Valley Health. Barriers to reducing unnecessary care can be substantial, including pressure from families, pressure from colleagues, profit motive, and the “n’s of 1,” according to Dr. Schroeder. Ultimately, however, avoiding testing and treatments that have no benefit to children will improve care. “Ask, ‘How will this test benefit my patient?’ not ‘How will this test change management?’” Dr. Schroeder advised.

Dr. Chang is The Hospitalist’s pediatric editor and a med-peds-trained hospitalist working at the University of California San Diego and Rady Children’s Hospital.

With a record number of attendees, Pediatric Hospital Medicine 2013 (PHM) swept into New Orleans last month, carrying with it unbridled enthusiasm about the past, present, and future.

Virginia Moyer, MD, MPH, vice president for maintenance of certification and quality for the American Board of Pediatrics (ABP) and professor of pediatrics and chief of academic general pediatrics at Texas Children’s Hospital, delivered a keynote address to 700 attendees that focused on the challenges and opportunities of providing evidence-based, high-quality care in the hospital, as well as ABP’s role in meeting these challenges.

“If evidence-based medicine is an individual sport,” Dr. Moyer said, “then quality improvement is a team sport.”

Barriers to quality improvement (QI)— such as lack of will, lack of data, and lack of training—can be surmounted in a team environment, she said. ABP is continuing in its efforts to support QI education through its Maintenance of Certification (MOC) Part 4 modules, as well as other educational activities.

Other highlights of the 10th annual Pediatric Hospital Medicine meeting:

• The addition of a new “Community Hospitalists” track was given high marks by those in attendance. It covered such topics as perioperative management of medically complex pediatric patients, community-acquired pneumonia, and osteomyelitis.
• A 10-year retrospective of pediatric hospital medicine was given by a panel of notable pediatric hospitalists, including Erin Stucky Fisher, MD, FAAP, MHM, chief of hospital medicine at Rady Children’s Hospital in San Diego; Mary Ottolini, MD, MPH, chief of hospital medicine at Children’s National Medical Center in Washington; Jack Percelay, MD, MPH, FAAP, associate clinical professor at Pace University; and Daniel Rauch, MD, FAAP, pediatric hospitalist program director at the NYU School of Medicine in New York City. A host of new programs has been established by the PHM community, including the Quality Improvement Innovation Networks (QuIIN); the Value in Pediatrics (VIP) network; the International Network for Simulation-Based Pediatric Innovation, Research, and Education (INSPIRE); patient- and family-centered rounds; and the I-PASS Handoff Program. The panel also discussed future challenges, including reduction of unnecessary treatments, interfacing, and perhaps incorporating “hyphen hospitalists,” and learning from advances made by the adult HM community.
• The ever-popular “Top Articles in Pediatric Hospital Medicine” session was presented by H. Barrett Fromme, MD, associate professor of pediatrics at the University of Chicago, and Ben Bauer, MD, director of pediatric hospital medicine at Riley Hospital for Children at Indiana University Health in Indianapolis, which was met with raucous approval by the audience. The presentation not only educated those in attendance about the most cutting-edge pediatric literature, but it also included dance moves most likely to attract the opposite sex and clothing appropriate for the Australian pediatric hospitalist.
• The three presidents of the sponsoring societies—Thomas McInerney, MD, FAAP, of the American Academy of Pediatrics, David Keller, MD, of the Academic Pediatric Association, and Eric Howell, MD, SFHM, of SHM—presented each society’s contributions to the growth of PHM, as well as future areas for cooperative sponsorship. These include the development of the AAP Section of Hospital Medicine Library website (sohmlibrary.org), the APA Quality Scholars program, and SHM’s efforts to increase interest in hospital medicine in medical students and trainees. “Ask not what hospital medicine can do for you,” Dr. Howell implored, “ask what you can do for hospital medicine!”
• Members of the Joint Council of Pediatric Hospital Medicine (JCPHM) presented the recent recommendations of the council arising from an April 2013 meeting with the ABP in Chapel Hill, N.C. Despite acknowledgements that no decision will be met with uniform satisfaction by all the stakeholders, the JCPHM concluded that the path that would best advance the field of PHM, provide for high-quality care of hospitalized children, and ensure the public trust would be a two-year fellowship sponsored by ABP. This would ultimately lead to approved certification eligibility for fellowship graduates by the American Board of Medical Specialties (ABMS); it would also make provisions for “grandfathering” in current pediatric hospitalists. Concerns from med-peds, community hospitalists, and recent residency graduate communities were addressed by the panel.
• A recurrent theme of reducing unnecessary treatments, interventions, and, perhaps, hospitalizations was summarized eloquently by Alan Schroeder, MD, director of the pediatric ICU and chief of pediatric inpatient care at Santa Clara (Calif.) Valley Health. Barriers to reducing unnecessary care can be substantial, including pressure from families, pressure from colleagues, profit motive, and the “n’s of 1,” according to Dr. Schroeder. Ultimately, however, avoiding testing and treatments that have no benefit to children will improve care. “Ask, ‘How will this test benefit my patient?’ not ‘How will this test change management?’” Dr. Schroeder advised.

Dr. Chang is The Hospitalist’s pediatric editor and a med-peds-trained hospitalist working at the University of California San Diego and Rady Children’s Hospital.

With a record number of attendees, Pediatric Hospital Medicine 2013 (PHM) swept into New Orleans last month, carrying with it unbridled enthusiasm about the past, present, and future.

Virginia Moyer, MD, MPH, vice president for maintenance of certification and quality for the American Board of Pediatrics (ABP) and professor of pediatrics and chief of academic general pediatrics at Texas Children’s Hospital, delivered a keynote address to 700 attendees that focused on the challenges and opportunities of providing evidence-based, high-quality care in the hospital, as well as ABP’s role in meeting these challenges.

“If evidence-based medicine is an individual sport,” Dr. Moyer said, “then quality improvement is a team sport.”

Barriers to quality improvement (QI)— such as lack of will, lack of data, and lack of training—can be surmounted in a team environment, she said. ABP is continuing in its efforts to support QI education through its Maintenance of Certification (MOC) Part 4 modules, as well as other educational activities.

Other highlights of the 10th annual Pediatric Hospital Medicine meeting:

• The addition of a new “Community Hospitalists” track was given high marks by those in attendance. It covered such topics as perioperative management of medically complex pediatric patients, community-acquired pneumonia, and osteomyelitis.
• A 10-year retrospective of pediatric hospital medicine was given by a panel of notable pediatric hospitalists, including Erin Stucky Fisher, MD, FAAP, MHM, chief of hospital medicine at Rady Children’s Hospital in San Diego; Mary Ottolini, MD, MPH, chief of hospital medicine at Children’s National Medical Center in Washington; Jack Percelay, MD, MPH, FAAP, associate clinical professor at Pace University; and Daniel Rauch, MD, FAAP, pediatric hospitalist program director at the NYU School of Medicine in New York City. A host of new programs has been established by the PHM community, including the Quality Improvement Innovation Networks (QuIIN); the Value in Pediatrics (VIP) network; the International Network for Simulation-Based Pediatric Innovation, Research, and Education (INSPIRE); patient- and family-centered rounds; and the I-PASS Handoff Program. The panel also discussed future challenges, including reduction of unnecessary treatments, interfacing, and perhaps incorporating “hyphen hospitalists,” and learning from advances made by the adult HM community.
• The ever-popular “Top Articles in Pediatric Hospital Medicine” session was presented by H. Barrett Fromme, MD, associate professor of pediatrics at the University of Chicago, and Ben Bauer, MD, director of pediatric hospital medicine at Riley Hospital for Children at Indiana University Health in Indianapolis, which was met with raucous approval by the audience. The presentation not only educated those in attendance about the most cutting-edge pediatric literature, but it also included dance moves most likely to attract the opposite sex and clothing appropriate for the Australian pediatric hospitalist.
• The three presidents of the sponsoring societies—Thomas McInerney, MD, FAAP, of the American Academy of Pediatrics, David Keller, MD, of the Academic Pediatric Association, and Eric Howell, MD, SFHM, of SHM—presented each society’s contributions to the growth of PHM, as well as future areas for cooperative sponsorship. These include the development of the AAP Section of Hospital Medicine Library website (sohmlibrary.org), the APA Quality Scholars program, and SHM’s efforts to increase interest in hospital medicine in medical students and trainees. “Ask not what hospital medicine can do for you,” Dr. Howell implored, “ask what you can do for hospital medicine!”
• Members of the Joint Council of Pediatric Hospital Medicine (JCPHM) presented the recent recommendations of the council arising from an April 2013 meeting with the ABP in Chapel Hill, N.C. Despite acknowledgements that no decision will be met with uniform satisfaction by all the stakeholders, the JCPHM concluded that the path that would best advance the field of PHM, provide for high-quality care of hospitalized children, and ensure the public trust would be a two-year fellowship sponsored by ABP. This would ultimately lead to approved certification eligibility for fellowship graduates by the American Board of Medical Specialties (ABMS); it would also make provisions for “grandfathering” in current pediatric hospitalists. Concerns from med-peds, community hospitalists, and recent residency graduate communities were addressed by the panel.
• A recurrent theme of reducing unnecessary treatments, interventions, and, perhaps, hospitalizations was summarized eloquently by Alan Schroeder, MD, director of the pediatric ICU and chief of pediatric inpatient care at Santa Clara (Calif.) Valley Health. Barriers to reducing unnecessary care can be substantial, including pressure from families, pressure from colleagues, profit motive, and the “n’s of 1,” according to Dr. Schroeder. Ultimately, however, avoiding testing and treatments that have no benefit to children will improve care. “Ask, ‘How will this test benefit my patient?’ not ‘How will this test change management?’” Dr. Schroeder advised.

Dr. Chang is The Hospitalist’s pediatric editor and a med-peds-trained hospitalist working at the University of California San Diego and Rady Children’s Hospital.

Back to the Furture Past RIV winners talk about what the recognition meant for their careers By Larry Beresford

Twylla Tassava, MD

After winning SHM’s annual Research, Innovations, and Clinical Vignettes (RIV) scientific abstract and poster competition for an abstract illustrating a program that promoted flu vaccinations for families of neonatal patients, Shetal Shah, MD, FAAP, became a leading advocate for two laws mandating that New York hospitals offer vaccinations to families.

A poster that described a VTE prevention program led Gregory Maynard, MD, MSc, SFHM, to join SHM’s VTE Prevention Collaborative and, eventually, to become senior vice president of the society’s Center for Hospital Innovation and Improvement.

A prize-winning innovations poster for improving team communication by Vineet Chopra, MD, MS, FACP, FHM, and colleagues later took off as a new technology company.

Leonard Feldman, MD, FAAP, SFHM, won for a poster that explained online CME curriculum for hospitalists as consultants; the curriculum now resides on SHM’s website.

The evidence is clear: RIV abstracts are a vital part of hospital medicine.

Nearly 800 abstracts were submitted for HM13.

Awards are given in three categories:

• Research posters report clinical or basic science data, systematically review a clinical problem, or address efficiency, cost, or method of health-care delivery or medical decision-making;
• Innovations posters describe an existing innovative program in hospital medicine, often with preliminary data; and
• Clinical vignettes, either adult or pediatric, report on one or more cases illustrating a new disease entity, a prominent or unusual feature of an established disease, or an area of clinical controversy.

The Hospitalist asked 11 past RIV winners what the poster contest meant to their careers. Some added more data and analysis and went on to be published in such medical journals as the Journal of Hospital Medicine. Some used the recognition to launch or boost research-oriented careers; others saw their careers go in different directions.

“Winning a national poster competition gives you the confidence to continue to pursue your interest and take it to a higher level, like successfully competing for funding and publishing your line of inquiry,” says hospitalist and researcher Vineet Arora, MD, MPP, FHM, of the University of Chicago, who won the 2006 RIV research competition. “Sometimes, presenting posters can be lonely, but at SHM, you get a lot of traffic. You get a chance to practice your spiel, communicating science and research in a very concise way, which is an important skill to have.”

David Metzger, MD, PhD, also from the University of Chicago, who won the RIV research award in 2005, says recognition is a big deal, but “one of the biggest values of the RIV competition is just getting information out to colleagues, with the opportunity to talk with your peers. That’s the real prize.

“I’ve been involved in presenting posters at SHM every year that the society has been in existence,” he says. “I’ve met so many people and talked about what they’re doing. That’s what a medical society should do—bring people together like this.”

Twylla Tassava, MD

Title: Administrator, academic consult service; teaching staff physician

Institution: Saint Joseph Mercy Hospital, Ypsilanti, Mich.

Year: 2008

RIV: “A Case of Salty Voluminous Urine” (clinical vignette)

Dr. Tassava was honored two years in a row for topics drawn from her experience as a hospitalist working in the surgical ICU. Her HM08 entry won top poster, and her HM09 poster, “Permissive Hypernatremia: Co-Management of Intracranial Pressure in a Patient with Diabetes Insipidus,” was selected for an oral presentation.

The HM09 vignette described how the hypernatremia that occurs with diabetes insipidus could be used in a novel way to control intracranial pressure in a 17-year-old patient who had a traumatic brain injury from an auto accident.

“She had a beautiful outcome,” Dr. Tassava says. “She started college and she came back to our unit for a visit after her recovery.”

Dr. Tassava enjoyed the opportunity to explain to her peers how diabetes insipidus presented and how she managed the case. “I was a little surprised at how much discussion was generated by my case,” she says, “even though I knew this was an important and novel approach.”

When her hospital added intensivists, her work and research in the ICU ended and her career moved more toward hospitalist administration. She now runs the academic consult service at St. Joseph, serves as lead physician for the orthopedic surgery floor, instructs and mentors medical residents, and chairs the hospital’s Coagulation Collaborative Practice Team (Coagulation CPT). She credits the RIV honors with helping her to gain recognition as an academic hospitalist who was nominated for leadership roles. She has moved out of research for now but plans to pursue anticoagulation research in the future.

“I really appreciated the recognition for my curiosity and scientific approach, which was acknowledged by my surgical colleagues,” Dr. Tassava says. “I absolutely love the CPT. I am the hospital’s principal educator with regard to anticoagulation. Over the past year, I have given medicine and cardiology grand rounds, and have presented on the newest anticoagulants.”

Dr. Tassava still collaborates with her residents on abstracts, several of which have been submitted to SHM, the American College of Physicians, and other medical societies.

“I still love research,” she says. “I have a million ideas.”

Gregory Maynard, MD, MSc, SFHM

Title: Chief of the division of hospital medicine; senior vice president, SHM’s Center for Innovation and Improvement

Institution: University of California at San Diego (UCSD)

Year: 2008

RIV: “Prevention of Hospital-Acquired Venous Thromboembolism: Prospective Validation of a VTE Risk Assessment Model and Protocol” (research)

Citations: Maynard G, Stein J. Designing and implementing effective VTE prevention protocols: lessons from collaboratives. J Thromb Thrombolysis. 2010;29(2):159-166. Maynard G, Morris T, Jenkins I, et al. Optimizing prevention of hospital acquired venous thromboembolism: prospective validation of a VTE risk assessment model. J Hosp Med. 2010;5(1):10-18.

Dr. Maynard’s abstract described a project funded by the federal Agency for Healthcare Research and Quality to design and implement an organized, comprehensive protocol for VTE prevention within the hospital setting. The project also included a toolkit to help other hospitals do the same thing. The same group received SHM’s Award of Excellence for Teamwork.

This work, combined with similar efforts by Jason Stein, MD, and colleagues at Emory University in Atlanta and others, provided the foundation for SHM’s VTE resource room and the mentored implementation program of SHM’s VTE Prevention Collaborative, which had been launched in 2007 as one of the society’s first large-scale quality-improvement (QI) initiatives.

“SHM wanted to do something about VTE prevention, and when we got our AHRQ grant, I was interested in doing the same,” Dr. Maynard says. “We published our implementation guides on the AHRQ and SHM websites, along with a lot of valuable supporting materials.”

Dr. Maynard later took on leadership roles with SHM’s quality initiatives on glycemic control and care transitions, which made him the logical choice to become senior vice president of SHM’s Center for Hospital Innovation and Improvement.

He says the RIV honor lifted his profile not only within SHM, but also throughout the field, and it was instrumental in obtaining continued funding to advance the VTE initiative. “We did this tremendous work—with great results,” he says. “But I don’t think our local administrators appreciated it quite as much until we started to get external, national recognition.”

Dr. Maynard earned his master’s degree in biostatistics and clinical research design from the University of Michigan—skills he later brought to the academic setting at UCSD.

“It was a nice way for a hospitalist, who’s really a medical generalist, to become an expert in something,” he says. “I could never be more of an expert in cardiology than a cardiologist, or more of an expert in DVT than a hematologist or critical-care specialist. But I could help both of them do what they couldn’t do as effectively, which was to implement protocols reliably using a QI framework.”

Eduard E. Vasilevskis, MD

Title: Assistant professor of general internal medicine, hospital medicine, and public health

Institution: Vanderbilt University, Nashville, Tenn.

Year: 2009

RIV: “Predictors of Early Post-Discharge Mortality in Critically Ill Patients: Lessons for Quality Performance and Quality Assessment” (research)

Citation: Vasilevskis EE, Kuzniewicz MW, Cason BA, et al. Predictors of early post-discharge mortality in critically ill patients: a retrospective cohort study from the California Intensive Care Outcomes project. J Crit Care. 2011;26(1):65-75.

Dr. Vasilevskis has submitted abstracts to the RIV competition almost every year since 2007, when he was completing a fellowship at the University of California at San Francisco’s Institute for Health Policy Studies. He was honored in 2009 for a project based on the California Intensive Care Outcomes Project, which drew data from 35 hospitals to demonstrate that shortening ICU length of stay was predictive of early post-discharge mortality in the most severely ill patients.

He has continued to research quality and safety in the ICU, and he has published dozens of journal articles.

“My initial focus was on traditional mortality and length-of-stay outcomes,” he says. “I am now pursuing additional outcomes, most notably delirium in the ICU patient. I work with an amazing group of researchers that are trying to better measure, define, and treat delirium in the ICU—an outcome associated with a number of poor patient outcomes.”

Dr. Vasilevskis also is researching the causes of hospital readmissions and the development of novel ways to improve care transitions for elderly patients. He is pursuing a master’s of public health at Vanderbilt, and is co-principal investigator of an investigation of the Hospital Medicine Reengineering Network to improve transitions of care, supported by the Association of American Medical Colleges.

In addition to his 2009 win, he captured the HM10 and HM12 research categories. His HM12 poster, “Veterans Administration Acute Care 30-Day Mortality Model: Development, Validation and Performance Variation,” was singled out by the judging committee for its impressive sample size (1,114,327 patients in a retrospective cohort study of 131 VA hospitals), as well as for how it combined administrative and clinical risk models.

Dr. Vasilevskis says the opportunity to present his research at SHM and the recognition he received encouraged him to continue as a hospitalist engaged in medical research. He has been a member of SHM’s Research Committee since 2009, an RIV judge at HM11, and chaired the HM13 RIV competition subcommittee.

Vineet Chopra, MD, MS, FACP, FHM

Title: Assistant professor of medicine

Institution: University of Michigan Health System, Ann Arbor

Year: 2009

RIV: “MComm: Redefining Medical Communications in the 21st Century” (innovations)

Early in his career, Dr. Chopra was curious about how to improve the way patient care is delivered in the hospital setting. He was particularly interested in the inordinate amount of time hospitalists spend every day on communication.

“I saw one-way paging systems as a problem for communication between members of the medical team,” he says. “Doctors get paged and break off from what they’re doing to return the page—to someone who often isn’t there to take the call back. Sometimes the system gives us the wrong number or a cryptic message that makes no sense.”

A technological solution to this problem, which he and hospitalist Prasanth Gogineni, MD, conceived, designed, and created, then tested at the University of Michigan, is called MComm. Dr. Chopra describes it as a novel, uniform way of messaging for the entire medical team using wireless servers, PUSH technology, and iPhones. MComm was built around existing hospital workflow and patient-specific task lists, assigning priority to each message and documenting that it was delivered. The junior faculty members submitted an abstract about their innovative application, not really expecting it to get accepted. But when it won the poster competition and was selected for a plenary presentation, things got busy in a hurry. Specifically, the university hospital’s Office of Technology Transfer took a keen interest.

“We met with a number of people who had business experience in the health-care-technology space and found a CEO for the company we formed to develop MComm,” Dr. Chopra says. “I found myself getting pulled into it very quickly, with a lot of conversations about commercialization, revenue-sharing models, intellectual property, and the like.”

But running a company was not something Dr. Chopra wanted to do. Two years ago, that company, Synaptin, went one way and he went another—he stayed at Michigan as a medical researcher. He remains deeply interested in how care is delivered to hospitalized patients, but with a focus on such patient-safety questions as how to prevent negative outcomes from indwelling venous catheters.

“Winning the poster competition opened doors for me—there’s no doubt in my mind,” he says. “We demonstrated the ability to deliver a project of significance, from concept to prototype, without formal training in this area. If we didn’t have that recognition, I’m not sure I would have been ready to step into a research career as quickly. It helped me realize that medical research was what I wanted to do.”

Vineet Arora, MD, MPP, FHM

Title: Associate program director, internal-medicine residency; assistant dean of scholarship and discovery

Institution: Pritzker School of Medicine, University of Chicago

Year: 2006

RIV: “Measuring Quality of Hospital Care for Vulnerable Elders: Use of ACOVE Quality Indicators” (research)

Citation: Arora VM, Fish M, Basu A, et al. Relationship between quality of care of hospitalized vulnerable elders and postdischarge mortality. J Am Geriatrics. 2010;58:1642-1648.

David O. Meltzer, MD, PhD

Title: Associate professor, department of medicine; associate faculty member, Harris School and the Department of Economics

Institution: University of Chicago

Year: 2005

RIV: “Effects of Hospitalists on Outcomes and Costs in a Multicenter Trial of Academic Hospitalists” (research)

Dr. Meltzer was the lead author, with 11 other prominent hospitalists, of an abstract based on a multisite study of the cost and outcome implications of the hospitalist model—still a relatively new concept in 2001, when the research began. Although the study did not uncover large cost savings realized from the hospitalist model of care, as some advocates had hoped, important findings and implications for the emerging field were teased out of the data.

At the time, only a few randomly controlled, multisite studies of costs and outcomes for the hospitalist model had been performed. The study, Dr. Meltzer says, required a complicated analysis to discover that hospitalists, in fact, saved their facilities money, with their most important impact realized post-hospitalization, such as on nursing-home costs. It was important to control for spillover effect and the fact that hospitalists do a better job of teaching house staff, while a physician’s years of experience was another important variable, he says.

Dr. Meltzer was a medical researcher interested in medical specialization when the term “hospitalist” was first coined in 1996. “I thought, here was a chance to study a medical specialty in its formative stages,” he says.

He still works as a hospitalist, although with limited clinical time. In addition to his administrative work as division chief, he directs the Center for Health and the Social Sciences at the University of Chicago. His research interests include cost-effectiveness, technology assessment, and information research.

In 2010, his poster “Effects of Hospitalists on 1-Year Post-Discharge Resource Utilization by Medicare Beneficiaries” took the top prize in the HM10 research competition. In 2011, he was appointed to the methodology committee of the federal Patient-Centered Outcomes Research Institute (PCORI), which was created by the Affordable Care Act to advise the government on clinical-effectiveness research. He also sits on the Advisory Council to the National Institute of General Medical Sciences at the Institute of Medicine, and on the Congressional Budget Office’s panel of health advisors.

In a career full of recognition, Dr. Meltzer says it’s hard to pinpoint the impact of winning the poster contest. But he has continued to submit abstracts to SHM every year and appreciates the opportunities for interaction with peers at the poster exhibits.

Paul J. Grant, MD, FACP, SFHM

Title: Director of perioperative and consultative medicine

Institution: University of Michigan, Ann Arbor

Year: 2006

RIV: “Disseminated Histoplasmosis Presenting As Painful Oral Ulcers” (clinical vignettes)

Dr. Grant’s winning vignette presented a patient with a complex medical history, including heart disease and four months of painful oral ulcers, for which prior evaluations had been inconclusive, despite conducting biopsies. Following administration of high-dose corticosteroids, the patient’s condition worsened on multiple fronts. The vignette showed how the medical team was able to diagnose an unusual presentation of a fungal infection called histoplasmosis, which is prevalent in parts of the Midwest surrounding the Ohio and Mississippi river valleys.

“We see a lot of cases in the hospital where there are different angles you could take to turn it into a clinical vignette or a nice poster with good teaching points,” Dr. Grant says. “In this case, just digging deeper into the actual diagnosis was important because the empiric use of steroids can be fatal for some patients. Steroids are given for a lot of good reasons, but in this patient they caused immune suppression, allowing a smoldering infection to become very active.”

Dr. Grant did not submit the vignette for publication. “That was probably a mistake on my part,” he says, acknowledging the common complaint of too little time and too many competing priorities. But his interest in research has continued.

“I became involved at a national level with issues of perioperative medicine and last August published a textbook on the subject,” he reports.¹ “VTE is another area of interest I have developed since my hospital medicine fellowship.”

He serves as the VTE resource expert on the Michigan Hospital Medicine Safety Consortium, a quality collaborative of more than 40 hospitals with Blue Cross/Blue Shield of Michigan. “It’s exciting to be able to look at the risk factors, what kinds of patients get VTEs, and whether they were appropriately prophylaxed in the hospital,” he says.

VTE is a national quality priority, and Dr. Grant expects abstracts to emerge from the consortium’s work.

He says he appreciates the opportunities that arise from participating in poster sessions at SHM, where medical students, residents, and working hospitalists talk to the presenters of interesting cases.

“It gives you a real back-and-forth, which is good for the person asking the question and for the presenter,” he says, noting hospitalists from other parts of the country were not as familiar with histoplasmosis.

He says winning the HM06 poster contest helped him “get his feet wet” and feel more prepared for a career in academic hospital medicine. “I’m sure the award solidified my employers’ satisfaction in hiring me—and in giving me more desirable academic roles and responsibilities,” he adds.

Leonard Feldman, MD, FACP, FAAP, SFHM

Title: Assistant professor of medicine pediatrics; director of the general internal-medicine comprehensive consultation service

Institution: Johns Hopkins Hospital, Baltimore

Year: 2009

RIV: “An Internet-Based Consult Curriculum for Hospitalists” (innovations)

Dr. Feldman’s poster described an online CME curriculum for hospitalists acting as medical consultants. The concept grew out of a perceived deficiency in his own medical education when, in 2004, he was asked to lead the consultation service at Johns Hopkins—just six months after finishing his residency.

“I had no idea what I was doing as a general-internal-medicine consultant,” he says. “I maybe received two weeks of experience as a consultant during my residency. I was willing to take it on, learning on the job and asking for help. But it occurred to me that I’m probably not alone in feeling unprepared.”

In his quest for self-education, Dr. Feldman wondered whether he should write a textbook on the subject. “But the information changes so quickly, I thought I’d have a better chance to reach people online,” he notes.

After talking to publishers and CME companies, he came up with the concept of learning modules on perioperative and consultative medicine topics, which could be taken online while earning CME credits. Johns Hopkins served as the CME certifier, and medical-education company Advanced Studies in Medicine joined as a partner. Once the project got off the ground, a medical advisory committee was convened.

“Winning the SHM poster competition is a great honor to have on a CV. It really helps to legitimize your name in the world of hospital medicine,” Dr. Feldman says. “It also provided confirmation that we were on the right track with the curriculum project. People valued what we were doing.”

Dr. Feldman and SHM have since become affiliated, and the “Consultative and Perioperative Medicine Essentials for Hospitalists” modules are available on SHM’s website (www.shmconsults.com). The site has 12,000 registered members completing 500 CME modules every month.

“I do a lot of the editing still,” Dr. Feldman says. “We update the modules every two years and are still creating new ones.”

Dr. Feldman also pursues a number of clinical-research interests, including resident education and costs of care.

Kristin Wise, MD, FHM

Title: Assistant professor of medicine

Institution: Medical University of South Carolina, Charleston

Year: 2009

RIV: “Intensivists versus Hospitalists in the ICU: A Prospective Cohort Study Comparing Mortality and Length of Stay Between Two Staffing Models” (research) Citation: Wise KR, Akopov VA, Williams BR, Ido MS, Leeper KV, Dressler DD. Hospitalists and intensivists in the medical ICU: a prospective and observational study comparing mortality and length of stay between two staffing models. J Hosp Med. 2012;7(3):183-189.

Dr. Wise was recognized for research that began while she worked at Emory University in Atlanta, comparing hospitalists and intensivists in such outcomes as length of stay and mortality rates for patients in the ICU. The study was one of the first statistically rigorous examinations of this critical quality question. With an eye toward improving patient safety, national quality advocates such as the Leapfrog Group have called for hospitals to employ intensivists (critical-care specialists) to manage the care of ICU patients. In reality, Dr. Wise says, there aren’t enough intensivists to meet the need.

“Hospitalists are in the ICU anyway,” she says. “We just don’t have enough data to answer how well they do [in comparison to intensivists].”

Through a prospective cohort study of more than 1,000 patients, Dr. Wise’s group found that there was essentially no statistical difference in mortality rates between patients treated by intensivist teams or hospitalist ICU teams.

“We were also able to look at some of the intermediate-acuity patients—fairly complicated but not requiring ventilators,” she explains. “Our study wasn’t sufficiently powered for this subgroup, but it was an interesting piece of data to raise the question: Where should we deploy this scarce resource of intensivists? Which pockets of patients?”

Presenting her abstract at SHM’s annual meeting was a “good experience.”

“I’d done public speaking before, but never with an audience of about 500 people,” she says. “To go out there and field their questions was a real professional growing experience. Several people interested in the topic sought me out at the conference, introduced themselves, and we have subsequently stayed in touch.”

The manuscript published in JHM has been cited four times, including in a position paper from SHM and the Society of Critical Care Medicine.³ Another outgrowth of the research was being asked to contribute a chapter on hospitalists’ role in the ICU to a textbook on hospital medicine. Based on her still-fresh HM presentation, Dr. Wise was one of the few publicly identified experts on the subject. The chapter, co-authored by fellow Emory hospitalist Michael Heisler, MD, MPH, “The Role of the Hospitalist in Critical Care” was included in Principles and Practices of Hospital Medicine.⁴

Shetal Shah, MD, FAAP

Title: Neonatal intensivist

Institution: Stony Brook University Hospital, Great Neck, N.Y.

Year: 2006

RIV: “Administration of Inactivated Trivalent Influenza Vaccine (TIV) to Parents of Infants in the Neonatal Intensive Care Unit (NICU): A Novel Strategy to Increase Vaccination Rates” (innovations)

Citation: Shah SI, Caprio M, Hendricks-Munoz K. Administration of inactivated trivalent influenza vaccine to parents of high-risk infants in the neonatal intensive care unit. Pediatrics. 2007;120;e617-e621.

Dr. Shah was in his final year of a fellowship in neonatology at New York University when he took on the challenge of improving immunization access to protect premature, highly vulnerable patients in the NICU from influenza infections. Because these children are too young to be vaccinated directly, the concept of cocooning them from infection involves extending protection to everyone around them.

“We came up with the idea of offering flu vaccinations 24/7 in the NICU to the children’s parents,” he says. “It worked well for us as a way to define an indicated therapy for a defined population, even if it was a little outside the box. By the end of the flu season, 95% of the parents were vaccinated.”

SHM recognized the project as the top RIV innovations poster at HM06, but that was just the beginning.

“When I moved to SUNY Stony Brook, I continued to study and advocate for these vaccinations,” Dr. Shah says. “We were giving 500 to 700 vaccinations a year. Then I wrote a national resolution for the American Academy of Pediatrics, which was significant because it meant AAP was behind the project.”

Dr. Shah later became chair of AAP’s Long Island Chapter Legislative Committee and joined a statewide pediatric advocacy group. In 2009, the New York legislature enacted the Neonatal Influenza Protection Act, which required hospitals in the state to offer parents the vaccine, with Dr. Shah’s research and advocacy providing an essential basis for its passage. He’s even been recognized for his research in congressional citations.

Based on that success with influenza vaccinations, Dr. Shah and his colleagues looked at other diseases, starting with pertussis, and then tetanus, diphtheria, and whooping cough.⁵ All the while, they continued tracking immunization rates. A second state law, passed in 2011, added pertussis to the vaccinations. Next on his advocacy agenda is a project to promote smoking-cessation interventions in the NICU.⁶

“These parents come to see us every day,” he says. “What can we do, through the parents, to promote the health and well-being of their high-risk newborns?”

Jason Morrow, MD, PhD

Title: Assistant professor of medicine; medical director of inpatient palliative-care consultation

Institution: University of Texas Health Sciences Center, San Antonio

Year: 2009

RIV: “When to Depend on the Kinins of Strangers: An Unusual Case of Abdominal Pain” (clinical vignettes)

Publication: An article on the ethics of determining code status for patients with advanced cancer and a book chapter on the “last hours of life” for a forthcoming book on palliative care and hospital medicine.

As a medical resident, Dr. Morrow met a 27-year-old woman who had chronic abdominal pain and had made multiple visits to the ED for this complaint. The patient had a history of substance abuse and requested dilaudid for her pain—making it easy for staff to consign her to the stereotype of the difficult patient.

“I met her after an interesting finding,” he says. “It turns out that on the previous emergency room visit, she received a CAT scan, which showed duodenal and small-bowel thickening consistent with hereditary angioedema, although with an unusual presentation. As it happened, we had onsite a world expert in angioedema.”

The expert was able to confirm the diagnosis, Dr. Morrow says.

“By giving her this ‘legitimate,’ organic diagnosis, it just changed the whole dynamic of her relationship with her doctors,” he says. “She knew that they knew something was really wrong. The residents were empowered to have something to hang their hats on. And we were able to get better control of her pain.”

Dr. Morrow says he came on the scene late in the discovery process, but he helped to solve the puzzle, and then put together the abstract and poster that told the story of making the diagnosis.

“In my previous job, I was hired as a hospitalist but helped to build the palliative-care program within the hospital-medicine service,” he says. “In my current job, I was brought in to build the inpatient palliative-care-consultation service, although I still moonlight as a hospitalist to stay sharp.”

Dr. Morrow says he enjoys sharing stories of difficult cases and submitting case studies about them to medical conferences, often with clever titles incorporating puns (e.g. the 2009 SHM poster citing kinins, polypeptides in the blood that cause inflammation). Another example is “The Angina Monologues,” a story of an 82-year-old patient with chronic angina pectoris and complex pain syndromes that were difficult to bring under control. Palliative care also emphasizes patients’ stories, he says, in order to understand the person behind the diagnosis.

Larry Beresford is a freelance writer in San Francisco. References available at www.the-hospitalist.org.

References

Back to the Furture Past RIV winners talk about what the recognition meant for their careers By Larry Beresford

Twylla Tassava, MD

After winning SHM’s annual Research, Innovations, and Clinical Vignettes (RIV) scientific abstract and poster competition for an abstract illustrating a program that promoted flu vaccinations for families of neonatal patients, Shetal Shah, MD, FAAP, became a leading advocate for two laws mandating that New York hospitals offer vaccinations to families.

A poster that described a VTE prevention program led Gregory Maynard, MD, MSc, SFHM, to join SHM’s VTE Prevention Collaborative and, eventually, to become senior vice president of the society’s Center for Hospital Innovation and Improvement.

A prize-winning innovations poster for improving team communication by Vineet Chopra, MD, MS, FACP, FHM, and colleagues later took off as a new technology company.

Leonard Feldman, MD, FAAP, SFHM, won for a poster that explained online CME curriculum for hospitalists as consultants; the curriculum now resides on SHM’s website.

The evidence is clear: RIV abstracts are a vital part of hospital medicine.

Nearly 800 abstracts were submitted for HM13.

Awards are given in three categories:

• Research posters report clinical or basic science data, systematically review a clinical problem, or address efficiency, cost, or method of health-care delivery or medical decision-making;
• Innovations posters describe an existing innovative program in hospital medicine, often with preliminary data; and
• Clinical vignettes, either adult or pediatric, report on one or more cases illustrating a new disease entity, a prominent or unusual feature of an established disease, or an area of clinical controversy.

The Hospitalist asked 11 past RIV winners what the poster contest meant to their careers. Some added more data and analysis and went on to be published in such medical journals as the Journal of Hospital Medicine. Some used the recognition to launch or boost research-oriented careers; others saw their careers go in different directions.

“Winning a national poster competition gives you the confidence to continue to pursue your interest and take it to a higher level, like successfully competing for funding and publishing your line of inquiry,” says hospitalist and researcher Vineet Arora, MD, MPP, FHM, of the University of Chicago, who won the 2006 RIV research competition. “Sometimes, presenting posters can be lonely, but at SHM, you get a lot of traffic. You get a chance to practice your spiel, communicating science and research in a very concise way, which is an important skill to have.”

David Metzger, MD, PhD, also from the University of Chicago, who won the RIV research award in 2005, says recognition is a big deal, but “one of the biggest values of the RIV competition is just getting information out to colleagues, with the opportunity to talk with your peers. That’s the real prize.

“I’ve been involved in presenting posters at SHM every year that the society has been in existence,” he says. “I’ve met so many people and talked about what they’re doing. That’s what a medical society should do—bring people together like this.”

Twylla Tassava, MD

Title: Administrator, academic consult service; teaching staff physician

Institution: Saint Joseph Mercy Hospital, Ypsilanti, Mich.

Year: 2008

RIV: “A Case of Salty Voluminous Urine” (clinical vignette)

Dr. Tassava was honored two years in a row for topics drawn from her experience as a hospitalist working in the surgical ICU. Her HM08 entry won top poster, and her HM09 poster, “Permissive Hypernatremia: Co-Management of Intracranial Pressure in a Patient with Diabetes Insipidus,” was selected for an oral presentation.

The HM09 vignette described how the hypernatremia that occurs with diabetes insipidus could be used in a novel way to control intracranial pressure in a 17-year-old patient who had a traumatic brain injury from an auto accident.

“She had a beautiful outcome,” Dr. Tassava says. “She started college and she came back to our unit for a visit after her recovery.”

Dr. Tassava enjoyed the opportunity to explain to her peers how diabetes insipidus presented and how she managed the case. “I was a little surprised at how much discussion was generated by my case,” she says, “even though I knew this was an important and novel approach.”

When her hospital added intensivists, her work and research in the ICU ended and her career moved more toward hospitalist administration. She now runs the academic consult service at St. Joseph, serves as lead physician for the orthopedic surgery floor, instructs and mentors medical residents, and chairs the hospital’s Coagulation Collaborative Practice Team (Coagulation CPT). She credits the RIV honors with helping her to gain recognition as an academic hospitalist who was nominated for leadership roles. She has moved out of research for now but plans to pursue anticoagulation research in the future.

“I really appreciated the recognition for my curiosity and scientific approach, which was acknowledged by my surgical colleagues,” Dr. Tassava says. “I absolutely love the CPT. I am the hospital’s principal educator with regard to anticoagulation. Over the past year, I have given medicine and cardiology grand rounds, and have presented on the newest anticoagulants.”

Dr. Tassava still collaborates with her residents on abstracts, several of which have been submitted to SHM, the American College of Physicians, and other medical societies.

“I still love research,” she says. “I have a million ideas.”

Gregory Maynard, MD, MSc, SFHM

Title: Chief of the division of hospital medicine; senior vice president, SHM’s Center for Innovation and Improvement

Institution: University of California at San Diego (UCSD)

Year: 2008

RIV: “Prevention of Hospital-Acquired Venous Thromboembolism: Prospective Validation of a VTE Risk Assessment Model and Protocol” (research)

Citations: Maynard G, Stein J. Designing and implementing effective VTE prevention protocols: lessons from collaboratives. J Thromb Thrombolysis. 2010;29(2):159-166. Maynard G, Morris T, Jenkins I, et al. Optimizing prevention of hospital acquired venous thromboembolism: prospective validation of a VTE risk assessment model. J Hosp Med. 2010;5(1):10-18.

Dr. Maynard’s abstract described a project funded by the federal Agency for Healthcare Research and Quality to design and implement an organized, comprehensive protocol for VTE prevention within the hospital setting. The project also included a toolkit to help other hospitals do the same thing. The same group received SHM’s Award of Excellence for Teamwork.

This work, combined with similar efforts by Jason Stein, MD, and colleagues at Emory University in Atlanta and others, provided the foundation for SHM’s VTE resource room and the mentored implementation program of SHM’s VTE Prevention Collaborative, which had been launched in 2007 as one of the society’s first large-scale quality-improvement (QI) initiatives.

“SHM wanted to do something about VTE prevention, and when we got our AHRQ grant, I was interested in doing the same,” Dr. Maynard says. “We published our implementation guides on the AHRQ and SHM websites, along with a lot of valuable supporting materials.”

Dr. Maynard later took on leadership roles with SHM’s quality initiatives on glycemic control and care transitions, which made him the logical choice to become senior vice president of SHM’s Center for Hospital Innovation and Improvement.

He says the RIV honor lifted his profile not only within SHM, but also throughout the field, and it was instrumental in obtaining continued funding to advance the VTE initiative. “We did this tremendous work—with great results,” he says. “But I don’t think our local administrators appreciated it quite as much until we started to get external, national recognition.”

Dr. Maynard earned his master’s degree in biostatistics and clinical research design from the University of Michigan—skills he later brought to the academic setting at UCSD.

“It was a nice way for a hospitalist, who’s really a medical generalist, to become an expert in something,” he says. “I could never be more of an expert in cardiology than a cardiologist, or more of an expert in DVT than a hematologist or critical-care specialist. But I could help both of them do what they couldn’t do as effectively, which was to implement protocols reliably using a QI framework.”

Eduard E. Vasilevskis, MD

Title: Assistant professor of general internal medicine, hospital medicine, and public health

Institution: Vanderbilt University, Nashville, Tenn.

Year: 2009

RIV: “Predictors of Early Post-Discharge Mortality in Critically Ill Patients: Lessons for Quality Performance and Quality Assessment” (research)

Citation: Vasilevskis EE, Kuzniewicz MW, Cason BA, et al. Predictors of early post-discharge mortality in critically ill patients: a retrospective cohort study from the California Intensive Care Outcomes project. J Crit Care. 2011;26(1):65-75.

Dr. Vasilevskis has submitted abstracts to the RIV competition almost every year since 2007, when he was completing a fellowship at the University of California at San Francisco’s Institute for Health Policy Studies. He was honored in 2009 for a project based on the California Intensive Care Outcomes Project, which drew data from 35 hospitals to demonstrate that shortening ICU length of stay was predictive of early post-discharge mortality in the most severely ill patients.

He has continued to research quality and safety in the ICU, and he has published dozens of journal articles.

“My initial focus was on traditional mortality and length-of-stay outcomes,” he says. “I am now pursuing additional outcomes, most notably delirium in the ICU patient. I work with an amazing group of researchers that are trying to better measure, define, and treat delirium in the ICU—an outcome associated with a number of poor patient outcomes.”

Dr. Vasilevskis also is researching the causes of hospital readmissions and the development of novel ways to improve care transitions for elderly patients. He is pursuing a master’s of public health at Vanderbilt, and is co-principal investigator of an investigation of the Hospital Medicine Reengineering Network to improve transitions of care, supported by the Association of American Medical Colleges.

In addition to his 2009 win, he captured the HM10 and HM12 research categories. His HM12 poster, “Veterans Administration Acute Care 30-Day Mortality Model: Development, Validation and Performance Variation,” was singled out by the judging committee for its impressive sample size (1,114,327 patients in a retrospective cohort study of 131 VA hospitals), as well as for how it combined administrative and clinical risk models.

Dr. Vasilevskis says the opportunity to present his research at SHM and the recognition he received encouraged him to continue as a hospitalist engaged in medical research. He has been a member of SHM’s Research Committee since 2009, an RIV judge at HM11, and chaired the HM13 RIV competition subcommittee.

Vineet Chopra, MD, MS, FACP, FHM

Title: Assistant professor of medicine

Institution: University of Michigan Health System, Ann Arbor

Year: 2009

RIV: “MComm: Redefining Medical Communications in the 21st Century” (innovations)

Early in his career, Dr. Chopra was curious about how to improve the way patient care is delivered in the hospital setting. He was particularly interested in the inordinate amount of time hospitalists spend every day on communication.

“I saw one-way paging systems as a problem for communication between members of the medical team,” he says. “Doctors get paged and break off from what they’re doing to return the page—to someone who often isn’t there to take the call back. Sometimes the system gives us the wrong number or a cryptic message that makes no sense.”

A technological solution to this problem, which he and hospitalist Prasanth Gogineni, MD, conceived, designed, and created, then tested at the University of Michigan, is called MComm. Dr. Chopra describes it as a novel, uniform way of messaging for the entire medical team using wireless servers, PUSH technology, and iPhones. MComm was built around existing hospital workflow and patient-specific task lists, assigning priority to each message and documenting that it was delivered. The junior faculty members submitted an abstract about their innovative application, not really expecting it to get accepted. But when it won the poster competition and was selected for a plenary presentation, things got busy in a hurry. Specifically, the university hospital’s Office of Technology Transfer took a keen interest.

“We met with a number of people who had business experience in the health-care-technology space and found a CEO for the company we formed to develop MComm,” Dr. Chopra says. “I found myself getting pulled into it very quickly, with a lot of conversations about commercialization, revenue-sharing models, intellectual property, and the like.”

But running a company was not something Dr. Chopra wanted to do. Two years ago, that company, Synaptin, went one way and he went another—he stayed at Michigan as a medical researcher. He remains deeply interested in how care is delivered to hospitalized patients, but with a focus on such patient-safety questions as how to prevent negative outcomes from indwelling venous catheters.

“Winning the poster competition opened doors for me—there’s no doubt in my mind,” he says. “We demonstrated the ability to deliver a project of significance, from concept to prototype, without formal training in this area. If we didn’t have that recognition, I’m not sure I would have been ready to step into a research career as quickly. It helped me realize that medical research was what I wanted to do.”

Vineet Arora, MD, MPP, FHM

Title: Associate program director, internal-medicine residency; assistant dean of scholarship and discovery

Institution: Pritzker School of Medicine, University of Chicago

Year: 2006

RIV: “Measuring Quality of Hospital Care for Vulnerable Elders: Use of ACOVE Quality Indicators” (research)

Citation: Arora VM, Fish M, Basu A, et al. Relationship between quality of care of hospitalized vulnerable elders and postdischarge mortality. J Am Geriatrics. 2010;58:1642-1648.

David O. Meltzer, MD, PhD

Title: Associate professor, department of medicine; associate faculty member, Harris School and the Department of Economics

Institution: University of Chicago

Year: 2005

RIV: “Effects of Hospitalists on Outcomes and Costs in a Multicenter Trial of Academic Hospitalists” (research)

Dr. Meltzer was the lead author, with 11 other prominent hospitalists, of an abstract based on a multisite study of the cost and outcome implications of the hospitalist model—still a relatively new concept in 2001, when the research began. Although the study did not uncover large cost savings realized from the hospitalist model of care, as some advocates had hoped, important findings and implications for the emerging field were teased out of the data.

At the time, only a few randomly controlled, multisite studies of costs and outcomes for the hospitalist model had been performed. The study, Dr. Meltzer says, required a complicated analysis to discover that hospitalists, in fact, saved their facilities money, with their most important impact realized post-hospitalization, such as on nursing-home costs. It was important to control for spillover effect and the fact that hospitalists do a better job of teaching house staff, while a physician’s years of experience was another important variable, he says.

Dr. Meltzer was a medical researcher interested in medical specialization when the term “hospitalist” was first coined in 1996. “I thought, here was a chance to study a medical specialty in its formative stages,” he says.

He still works as a hospitalist, although with limited clinical time. In addition to his administrative work as division chief, he directs the Center for Health and the Social Sciences at the University of Chicago. His research interests include cost-effectiveness, technology assessment, and information research.

In 2010, his poster “Effects of Hospitalists on 1-Year Post-Discharge Resource Utilization by Medicare Beneficiaries” took the top prize in the HM10 research competition. In 2011, he was appointed to the methodology committee of the federal Patient-Centered Outcomes Research Institute (PCORI), which was created by the Affordable Care Act to advise the government on clinical-effectiveness research. He also sits on the Advisory Council to the National Institute of General Medical Sciences at the Institute of Medicine, and on the Congressional Budget Office’s panel of health advisors.

In a career full of recognition, Dr. Meltzer says it’s hard to pinpoint the impact of winning the poster contest. But he has continued to submit abstracts to SHM every year and appreciates the opportunities for interaction with peers at the poster exhibits.

Paul J. Grant, MD, FACP, SFHM

Title: Director of perioperative and consultative medicine

Institution: University of Michigan, Ann Arbor

Year: 2006

RIV: “Disseminated Histoplasmosis Presenting As Painful Oral Ulcers” (clinical vignettes)

Dr. Grant’s winning vignette presented a patient with a complex medical history, including heart disease and four months of painful oral ulcers, for which prior evaluations had been inconclusive, despite conducting biopsies. Following administration of high-dose corticosteroids, the patient’s condition worsened on multiple fronts. The vignette showed how the medical team was able to diagnose an unusual presentation of a fungal infection called histoplasmosis, which is prevalent in parts of the Midwest surrounding the Ohio and Mississippi river valleys.

“We see a lot of cases in the hospital where there are different angles you could take to turn it into a clinical vignette or a nice poster with good teaching points,” Dr. Grant says. “In this case, just digging deeper into the actual diagnosis was important because the empiric use of steroids can be fatal for some patients. Steroids are given for a lot of good reasons, but in this patient they caused immune suppression, allowing a smoldering infection to become very active.”

Dr. Grant did not submit the vignette for publication. “That was probably a mistake on my part,” he says, acknowledging the common complaint of too little time and too many competing priorities. But his interest in research has continued.

“I became involved at a national level with issues of perioperative medicine and last August published a textbook on the subject,” he reports.¹ “VTE is another area of interest I have developed since my hospital medicine fellowship.”

He serves as the VTE resource expert on the Michigan Hospital Medicine Safety Consortium, a quality collaborative of more than 40 hospitals with Blue Cross/Blue Shield of Michigan. “It’s exciting to be able to look at the risk factors, what kinds of patients get VTEs, and whether they were appropriately prophylaxed in the hospital,” he says.

VTE is a national quality priority, and Dr. Grant expects abstracts to emerge from the consortium’s work.

He says he appreciates the opportunities that arise from participating in poster sessions at SHM, where medical students, residents, and working hospitalists talk to the presenters of interesting cases.

“It gives you a real back-and-forth, which is good for the person asking the question and for the presenter,” he says, noting hospitalists from other parts of the country were not as familiar with histoplasmosis.

He says winning the HM06 poster contest helped him “get his feet wet” and feel more prepared for a career in academic hospital medicine. “I’m sure the award solidified my employers’ satisfaction in hiring me—and in giving me more desirable academic roles and responsibilities,” he adds.

Leonard Feldman, MD, FACP, FAAP, SFHM

Title: Assistant professor of medicine pediatrics; director of the general internal-medicine comprehensive consultation service

Institution: Johns Hopkins Hospital, Baltimore

Year: 2009

RIV: “An Internet-Based Consult Curriculum for Hospitalists” (innovations)

Dr. Feldman’s poster described an online CME curriculum for hospitalists acting as medical consultants. The concept grew out of a perceived deficiency in his own medical education when, in 2004, he was asked to lead the consultation service at Johns Hopkins—just six months after finishing his residency.

“I had no idea what I was doing as a general-internal-medicine consultant,” he says. “I maybe received two weeks of experience as a consultant during my residency. I was willing to take it on, learning on the job and asking for help. But it occurred to me that I’m probably not alone in feeling unprepared.”

In his quest for self-education, Dr. Feldman wondered whether he should write a textbook on the subject. “But the information changes so quickly, I thought I’d have a better chance to reach people online,” he notes.

After talking to publishers and CME companies, he came up with the concept of learning modules on perioperative and consultative medicine topics, which could be taken online while earning CME credits. Johns Hopkins served as the CME certifier, and medical-education company Advanced Studies in Medicine joined as a partner. Once the project got off the ground, a medical advisory committee was convened.

“Winning the SHM poster competition is a great honor to have on a CV. It really helps to legitimize your name in the world of hospital medicine,” Dr. Feldman says. “It also provided confirmation that we were on the right track with the curriculum project. People valued what we were doing.”

Dr. Feldman and SHM have since become affiliated, and the “Consultative and Perioperative Medicine Essentials for Hospitalists” modules are available on SHM’s website (www.shmconsults.com). The site has 12,000 registered members completing 500 CME modules every month.

“I do a lot of the editing still,” Dr. Feldman says. “We update the modules every two years and are still creating new ones.”

Dr. Feldman also pursues a number of clinical-research interests, including resident education and costs of care.

Kristin Wise, MD, FHM

Title: Assistant professor of medicine

Institution: Medical University of South Carolina, Charleston

Year: 2009

RIV: “Intensivists versus Hospitalists in the ICU: A Prospective Cohort Study Comparing Mortality and Length of Stay Between Two Staffing Models” (research) Citation: Wise KR, Akopov VA, Williams BR, Ido MS, Leeper KV, Dressler DD. Hospitalists and intensivists in the medical ICU: a prospective and observational study comparing mortality and length of stay between two staffing models. J Hosp Med. 2012;7(3):183-189.

Dr. Wise was recognized for research that began while she worked at Emory University in Atlanta, comparing hospitalists and intensivists in such outcomes as length of stay and mortality rates for patients in the ICU. The study was one of the first statistically rigorous examinations of this critical quality question. With an eye toward improving patient safety, national quality advocates such as the Leapfrog Group have called for hospitals to employ intensivists (critical-care specialists) to manage the care of ICU patients. In reality, Dr. Wise says, there aren’t enough intensivists to meet the need.

“Hospitalists are in the ICU anyway,” she says. “We just don’t have enough data to answer how well they do [in comparison to intensivists].”

Through a prospective cohort study of more than 1,000 patients, Dr. Wise’s group found that there was essentially no statistical difference in mortality rates between patients treated by intensivist teams or hospitalist ICU teams.

“We were also able to look at some of the intermediate-acuity patients—fairly complicated but not requiring ventilators,” she explains. “Our study wasn’t sufficiently powered for this subgroup, but it was an interesting piece of data to raise the question: Where should we deploy this scarce resource of intensivists? Which pockets of patients?”

Presenting her abstract at SHM’s annual meeting was a “good experience.”

“I’d done public speaking before, but never with an audience of about 500 people,” she says. “To go out there and field their questions was a real professional growing experience. Several people interested in the topic sought me out at the conference, introduced themselves, and we have subsequently stayed in touch.”

The manuscript published in JHM has been cited four times, including in a position paper from SHM and the Society of Critical Care Medicine.³ Another outgrowth of the research was being asked to contribute a chapter on hospitalists’ role in the ICU to a textbook on hospital medicine. Based on her still-fresh HM presentation, Dr. Wise was one of the few publicly identified experts on the subject. The chapter, co-authored by fellow Emory hospitalist Michael Heisler, MD, MPH, “The Role of the Hospitalist in Critical Care” was included in Principles and Practices of Hospital Medicine.⁴

Shetal Shah, MD, FAAP

Title: Neonatal intensivist

Institution: Stony Brook University Hospital, Great Neck, N.Y.

Year: 2006

RIV: “Administration of Inactivated Trivalent Influenza Vaccine (TIV) to Parents of Infants in the Neonatal Intensive Care Unit (NICU): A Novel Strategy to Increase Vaccination Rates” (innovations)

Citation: Shah SI, Caprio M, Hendricks-Munoz K. Administration of inactivated trivalent influenza vaccine to parents of high-risk infants in the neonatal intensive care unit. Pediatrics. 2007;120;e617-e621.

Dr. Shah was in his final year of a fellowship in neonatology at New York University when he took on the challenge of improving immunization access to protect premature, highly vulnerable patients in the NICU from influenza infections. Because these children are too young to be vaccinated directly, the concept of cocooning them from infection involves extending protection to everyone around them.

“We came up with the idea of offering flu vaccinations 24/7 in the NICU to the children’s parents,” he says. “It worked well for us as a way to define an indicated therapy for a defined population, even if it was a little outside the box. By the end of the flu season, 95% of the parents were vaccinated.”

SHM recognized the project as the top RIV innovations poster at HM06, but that was just the beginning.

“When I moved to SUNY Stony Brook, I continued to study and advocate for these vaccinations,” Dr. Shah says. “We were giving 500 to 700 vaccinations a year. Then I wrote a national resolution for the American Academy of Pediatrics, which was significant because it meant AAP was behind the project.”

Dr. Shah later became chair of AAP’s Long Island Chapter Legislative Committee and joined a statewide pediatric advocacy group. In 2009, the New York legislature enacted the Neonatal Influenza Protection Act, which required hospitals in the state to offer parents the vaccine, with Dr. Shah’s research and advocacy providing an essential basis for its passage. He’s even been recognized for his research in congressional citations.

Based on that success with influenza vaccinations, Dr. Shah and his colleagues looked at other diseases, starting with pertussis, and then tetanus, diphtheria, and whooping cough.⁵ All the while, they continued tracking immunization rates. A second state law, passed in 2011, added pertussis to the vaccinations. Next on his advocacy agenda is a project to promote smoking-cessation interventions in the NICU.⁶

“These parents come to see us every day,” he says. “What can we do, through the parents, to promote the health and well-being of their high-risk newborns?”

Jason Morrow, MD, PhD

Title: Assistant professor of medicine; medical director of inpatient palliative-care consultation

Institution: University of Texas Health Sciences Center, San Antonio

Year: 2009

RIV: “When to Depend on the Kinins of Strangers: An Unusual Case of Abdominal Pain” (clinical vignettes)

Publication: An article on the ethics of determining code status for patients with advanced cancer and a book chapter on the “last hours of life” for a forthcoming book on palliative care and hospital medicine.

As a medical resident, Dr. Morrow met a 27-year-old woman who had chronic abdominal pain and had made multiple visits to the ED for this complaint. The patient had a history of substance abuse and requested dilaudid for her pain—making it easy for staff to consign her to the stereotype of the difficult patient.

“I met her after an interesting finding,” he says. “It turns out that on the previous emergency room visit, she received a CAT scan, which showed duodenal and small-bowel thickening consistent with hereditary angioedema, although with an unusual presentation. As it happened, we had onsite a world expert in angioedema.”

The expert was able to confirm the diagnosis, Dr. Morrow says.

“By giving her this ‘legitimate,’ organic diagnosis, it just changed the whole dynamic of her relationship with her doctors,” he says. “She knew that they knew something was really wrong. The residents were empowered to have something to hang their hats on. And we were able to get better control of her pain.”

Dr. Morrow says he came on the scene late in the discovery process, but he helped to solve the puzzle, and then put together the abstract and poster that told the story of making the diagnosis.

“In my previous job, I was hired as a hospitalist but helped to build the palliative-care program within the hospital-medicine service,” he says. “In my current job, I was brought in to build the inpatient palliative-care-consultation service, although I still moonlight as a hospitalist to stay sharp.”

Dr. Morrow says he enjoys sharing stories of difficult cases and submitting case studies about them to medical conferences, often with clever titles incorporating puns (e.g. the 2009 SHM poster citing kinins, polypeptides in the blood that cause inflammation). Another example is “The Angina Monologues,” a story of an 82-year-old patient with chronic angina pectoris and complex pain syndromes that were difficult to bring under control. Palliative care also emphasizes patients’ stories, he says, in order to understand the person behind the diagnosis.

Larry Beresford is a freelance writer in San Francisco. References available at www.the-hospitalist.org.

References

Back to the Furture Past RIV winners talk about what the recognition meant for their careers By Larry Beresford

Twylla Tassava, MD

After winning SHM’s annual Research, Innovations, and Clinical Vignettes (RIV) scientific abstract and poster competition for an abstract illustrating a program that promoted flu vaccinations for families of neonatal patients, Shetal Shah, MD, FAAP, became a leading advocate for two laws mandating that New York hospitals offer vaccinations to families.

A poster that described a VTE prevention program led Gregory Maynard, MD, MSc, SFHM, to join SHM’s VTE Prevention Collaborative and, eventually, to become senior vice president of the society’s Center for Hospital Innovation and Improvement.

A prize-winning innovations poster for improving team communication by Vineet Chopra, MD, MS, FACP, FHM, and colleagues later took off as a new technology company.

Leonard Feldman, MD, FAAP, SFHM, won for a poster that explained online CME curriculum for hospitalists as consultants; the curriculum now resides on SHM’s website.

The evidence is clear: RIV abstracts are a vital part of hospital medicine.

Nearly 800 abstracts were submitted for HM13.

Awards are given in three categories:

• Research posters report clinical or basic science data, systematically review a clinical problem, or address efficiency, cost, or method of health-care delivery or medical decision-making;
• Innovations posters describe an existing innovative program in hospital medicine, often with preliminary data; and
• Clinical vignettes, either adult or pediatric, report on one or more cases illustrating a new disease entity, a prominent or unusual feature of an established disease, or an area of clinical controversy.

The Hospitalist asked 11 past RIV winners what the poster contest meant to their careers. Some added more data and analysis and went on to be published in such medical journals as the Journal of Hospital Medicine. Some used the recognition to launch or boost research-oriented careers; others saw their careers go in different directions.

“Winning a national poster competition gives you the confidence to continue to pursue your interest and take it to a higher level, like successfully competing for funding and publishing your line of inquiry,” says hospitalist and researcher Vineet Arora, MD, MPP, FHM, of the University of Chicago, who won the 2006 RIV research competition. “Sometimes, presenting posters can be lonely, but at SHM, you get a lot of traffic. You get a chance to practice your spiel, communicating science and research in a very concise way, which is an important skill to have.”

David Metzger, MD, PhD, also from the University of Chicago, who won the RIV research award in 2005, says recognition is a big deal, but “one of the biggest values of the RIV competition is just getting information out to colleagues, with the opportunity to talk with your peers. That’s the real prize.

“I’ve been involved in presenting posters at SHM every year that the society has been in existence,” he says. “I’ve met so many people and talked about what they’re doing. That’s what a medical society should do—bring people together like this.”

Twylla Tassava, MD

Title: Administrator, academic consult service; teaching staff physician

Institution: Saint Joseph Mercy Hospital, Ypsilanti, Mich.

Year: 2008

RIV: “A Case of Salty Voluminous Urine” (clinical vignette)

Dr. Tassava was honored two years in a row for topics drawn from her experience as a hospitalist working in the surgical ICU. Her HM08 entry won top poster, and her HM09 poster, “Permissive Hypernatremia: Co-Management of Intracranial Pressure in a Patient with Diabetes Insipidus,” was selected for an oral presentation.

The HM09 vignette described how the hypernatremia that occurs with diabetes insipidus could be used in a novel way to control intracranial pressure in a 17-year-old patient who had a traumatic brain injury from an auto accident.

“She had a beautiful outcome,” Dr. Tassava says. “She started college and she came back to our unit for a visit after her recovery.”

Dr. Tassava enjoyed the opportunity to explain to her peers how diabetes insipidus presented and how she managed the case. “I was a little surprised at how much discussion was generated by my case,” she says, “even though I knew this was an important and novel approach.”

When her hospital added intensivists, her work and research in the ICU ended and her career moved more toward hospitalist administration. She now runs the academic consult service at St. Joseph, serves as lead physician for the orthopedic surgery floor, instructs and mentors medical residents, and chairs the hospital’s Coagulation Collaborative Practice Team (Coagulation CPT). She credits the RIV honors with helping her to gain recognition as an academic hospitalist who was nominated for leadership roles. She has moved out of research for now but plans to pursue anticoagulation research in the future.

“I really appreciated the recognition for my curiosity and scientific approach, which was acknowledged by my surgical colleagues,” Dr. Tassava says. “I absolutely love the CPT. I am the hospital’s principal educator with regard to anticoagulation. Over the past year, I have given medicine and cardiology grand rounds, and have presented on the newest anticoagulants.”

Dr. Tassava still collaborates with her residents on abstracts, several of which have been submitted to SHM, the American College of Physicians, and other medical societies.

“I still love research,” she says. “I have a million ideas.”

Gregory Maynard, MD, MSc, SFHM

Title: Chief of the division of hospital medicine; senior vice president, SHM’s Center for Innovation and Improvement

Institution: University of California at San Diego (UCSD)

Year: 2008

RIV: “Prevention of Hospital-Acquired Venous Thromboembolism: Prospective Validation of a VTE Risk Assessment Model and Protocol” (research)

Citations: Maynard G, Stein J. Designing and implementing effective VTE prevention protocols: lessons from collaboratives. J Thromb Thrombolysis. 2010;29(2):159-166. Maynard G, Morris T, Jenkins I, et al. Optimizing prevention of hospital acquired venous thromboembolism: prospective validation of a VTE risk assessment model. J Hosp Med. 2010;5(1):10-18.

Dr. Maynard’s abstract described a project funded by the federal Agency for Healthcare Research and Quality to design and implement an organized, comprehensive protocol for VTE prevention within the hospital setting. The project also included a toolkit to help other hospitals do the same thing. The same group received SHM’s Award of Excellence for Teamwork.

This work, combined with similar efforts by Jason Stein, MD, and colleagues at Emory University in Atlanta and others, provided the foundation for SHM’s VTE resource room and the mentored implementation program of SHM’s VTE Prevention Collaborative, which had been launched in 2007 as one of the society’s first large-scale quality-improvement (QI) initiatives.

“SHM wanted to do something about VTE prevention, and when we got our AHRQ grant, I was interested in doing the same,” Dr. Maynard says. “We published our implementation guides on the AHRQ and SHM websites, along with a lot of valuable supporting materials.”

Dr. Maynard later took on leadership roles with SHM’s quality initiatives on glycemic control and care transitions, which made him the logical choice to become senior vice president of SHM’s Center for Hospital Innovation and Improvement.

He says the RIV honor lifted his profile not only within SHM, but also throughout the field, and it was instrumental in obtaining continued funding to advance the VTE initiative. “We did this tremendous work—with great results,” he says. “But I don’t think our local administrators appreciated it quite as much until we started to get external, national recognition.”

Dr. Maynard earned his master’s degree in biostatistics and clinical research design from the University of Michigan—skills he later brought to the academic setting at UCSD.

“It was a nice way for a hospitalist, who’s really a medical generalist, to become an expert in something,” he says. “I could never be more of an expert in cardiology than a cardiologist, or more of an expert in DVT than a hematologist or critical-care specialist. But I could help both of them do what they couldn’t do as effectively, which was to implement protocols reliably using a QI framework.”

Eduard E. Vasilevskis, MD

Title: Assistant professor of general internal medicine, hospital medicine, and public health

Institution: Vanderbilt University, Nashville, Tenn.

Year: 2009

RIV: “Predictors of Early Post-Discharge Mortality in Critically Ill Patients: Lessons for Quality Performance and Quality Assessment” (research)

Citation: Vasilevskis EE, Kuzniewicz MW, Cason BA, et al. Predictors of early post-discharge mortality in critically ill patients: a retrospective cohort study from the California Intensive Care Outcomes project. J Crit Care. 2011;26(1):65-75.

Dr. Vasilevskis has submitted abstracts to the RIV competition almost every year since 2007, when he was completing a fellowship at the University of California at San Francisco’s Institute for Health Policy Studies. He was honored in 2009 for a project based on the California Intensive Care Outcomes Project, which drew data from 35 hospitals to demonstrate that shortening ICU length of stay was predictive of early post-discharge mortality in the most severely ill patients.

He has continued to research quality and safety in the ICU, and he has published dozens of journal articles.

“My initial focus was on traditional mortality and length-of-stay outcomes,” he says. “I am now pursuing additional outcomes, most notably delirium in the ICU patient. I work with an amazing group of researchers that are trying to better measure, define, and treat delirium in the ICU—an outcome associated with a number of poor patient outcomes.”

Dr. Vasilevskis also is researching the causes of hospital readmissions and the development of novel ways to improve care transitions for elderly patients. He is pursuing a master’s of public health at Vanderbilt, and is co-principal investigator of an investigation of the Hospital Medicine Reengineering Network to improve transitions of care, supported by the Association of American Medical Colleges.

In addition to his 2009 win, he captured the HM10 and HM12 research categories. His HM12 poster, “Veterans Administration Acute Care 30-Day Mortality Model: Development, Validation and Performance Variation,” was singled out by the judging committee for its impressive sample size (1,114,327 patients in a retrospective cohort study of 131 VA hospitals), as well as for how it combined administrative and clinical risk models.

Dr. Vasilevskis says the opportunity to present his research at SHM and the recognition he received encouraged him to continue as a hospitalist engaged in medical research. He has been a member of SHM’s Research Committee since 2009, an RIV judge at HM11, and chaired the HM13 RIV competition subcommittee.

Vineet Chopra, MD, MS, FACP, FHM

Title: Assistant professor of medicine

Institution: University of Michigan Health System, Ann Arbor

Year: 2009

RIV: “MComm: Redefining Medical Communications in the 21st Century” (innovations)

Early in his career, Dr. Chopra was curious about how to improve the way patient care is delivered in the hospital setting. He was particularly interested in the inordinate amount of time hospitalists spend every day on communication.

“I saw one-way paging systems as a problem for communication between members of the medical team,” he says. “Doctors get paged and break off from what they’re doing to return the page—to someone who often isn’t there to take the call back. Sometimes the system gives us the wrong number or a cryptic message that makes no sense.”

A technological solution to this problem, which he and hospitalist Prasanth Gogineni, MD, conceived, designed, and created, then tested at the University of Michigan, is called MComm. Dr. Chopra describes it as a novel, uniform way of messaging for the entire medical team using wireless servers, PUSH technology, and iPhones. MComm was built around existing hospital workflow and patient-specific task lists, assigning priority to each message and documenting that it was delivered. The junior faculty members submitted an abstract about their innovative application, not really expecting it to get accepted. But when it won the poster competition and was selected for a plenary presentation, things got busy in a hurry. Specifically, the university hospital’s Office of Technology Transfer took a keen interest.

“We met with a number of people who had business experience in the health-care-technology space and found a CEO for the company we formed to develop MComm,” Dr. Chopra says. “I found myself getting pulled into it very quickly, with a lot of conversations about commercialization, revenue-sharing models, intellectual property, and the like.”

But running a company was not something Dr. Chopra wanted to do. Two years ago, that company, Synaptin, went one way and he went another—he stayed at Michigan as a medical researcher. He remains deeply interested in how care is delivered to hospitalized patients, but with a focus on such patient-safety questions as how to prevent negative outcomes from indwelling venous catheters.

“Winning the poster competition opened doors for me—there’s no doubt in my mind,” he says. “We demonstrated the ability to deliver a project of significance, from concept to prototype, without formal training in this area. If we didn’t have that recognition, I’m not sure I would have been ready to step into a research career as quickly. It helped me realize that medical research was what I wanted to do.”

Vineet Arora, MD, MPP, FHM

Title: Associate program director, internal-medicine residency; assistant dean of scholarship and discovery

Institution: Pritzker School of Medicine, University of Chicago

Year: 2006

RIV: “Measuring Quality of Hospital Care for Vulnerable Elders: Use of ACOVE Quality Indicators” (research)

Citation: Arora VM, Fish M, Basu A, et al. Relationship between quality of care of hospitalized vulnerable elders and postdischarge mortality. J Am Geriatrics. 2010;58:1642-1648.

David O. Meltzer, MD, PhD

Title: Associate professor, department of medicine; associate faculty member, Harris School and the Department of Economics

Institution: University of Chicago

Year: 2005

RIV: “Effects of Hospitalists on Outcomes and Costs in a Multicenter Trial of Academic Hospitalists” (research)

Dr. Meltzer was the lead author, with 11 other prominent hospitalists, of an abstract based on a multisite study of the cost and outcome implications of the hospitalist model—still a relatively new concept in 2001, when the research began. Although the study did not uncover large cost savings realized from the hospitalist model of care, as some advocates had hoped, important findings and implications for the emerging field were teased out of the data.

At the time, only a few randomly controlled, multisite studies of costs and outcomes for the hospitalist model had been performed. The study, Dr. Meltzer says, required a complicated analysis to discover that hospitalists, in fact, saved their facilities money, with their most important impact realized post-hospitalization, such as on nursing-home costs. It was important to control for spillover effect and the fact that hospitalists do a better job of teaching house staff, while a physician’s years of experience was another important variable, he says.

Dr. Meltzer was a medical researcher interested in medical specialization when the term “hospitalist” was first coined in 1996. “I thought, here was a chance to study a medical specialty in its formative stages,” he says.

He still works as a hospitalist, although with limited clinical time. In addition to his administrative work as division chief, he directs the Center for Health and the Social Sciences at the University of Chicago. His research interests include cost-effectiveness, technology assessment, and information research.

In 2010, his poster “Effects of Hospitalists on 1-Year Post-Discharge Resource Utilization by Medicare Beneficiaries” took the top prize in the HM10 research competition. In 2011, he was appointed to the methodology committee of the federal Patient-Centered Outcomes Research Institute (PCORI), which was created by the Affordable Care Act to advise the government on clinical-effectiveness research. He also sits on the Advisory Council to the National Institute of General Medical Sciences at the Institute of Medicine, and on the Congressional Budget Office’s panel of health advisors.

In a career full of recognition, Dr. Meltzer says it’s hard to pinpoint the impact of winning the poster contest. But he has continued to submit abstracts to SHM every year and appreciates the opportunities for interaction with peers at the poster exhibits.

Paul J. Grant, MD, FACP, SFHM

Title: Director of perioperative and consultative medicine

Institution: University of Michigan, Ann Arbor

Year: 2006

RIV: “Disseminated Histoplasmosis Presenting As Painful Oral Ulcers” (clinical vignettes)

Dr. Grant’s winning vignette presented a patient with a complex medical history, including heart disease and four months of painful oral ulcers, for which prior evaluations had been inconclusive, despite conducting biopsies. Following administration of high-dose corticosteroids, the patient’s condition worsened on multiple fronts. The vignette showed how the medical team was able to diagnose an unusual presentation of a fungal infection called histoplasmosis, which is prevalent in parts of the Midwest surrounding the Ohio and Mississippi river valleys.

“We see a lot of cases in the hospital where there are different angles you could take to turn it into a clinical vignette or a nice poster with good teaching points,” Dr. Grant says. “In this case, just digging deeper into the actual diagnosis was important because the empiric use of steroids can be fatal for some patients. Steroids are given for a lot of good reasons, but in this patient they caused immune suppression, allowing a smoldering infection to become very active.”

Dr. Grant did not submit the vignette for publication. “That was probably a mistake on my part,” he says, acknowledging the common complaint of too little time and too many competing priorities. But his interest in research has continued.

“I became involved at a national level with issues of perioperative medicine and last August published a textbook on the subject,” he reports.¹ “VTE is another area of interest I have developed since my hospital medicine fellowship.”

He serves as the VTE resource expert on the Michigan Hospital Medicine Safety Consortium, a quality collaborative of more than 40 hospitals with Blue Cross/Blue Shield of Michigan. “It’s exciting to be able to look at the risk factors, what kinds of patients get VTEs, and whether they were appropriately prophylaxed in the hospital,” he says.

VTE is a national quality priority, and Dr. Grant expects abstracts to emerge from the consortium’s work.

He says he appreciates the opportunities that arise from participating in poster sessions at SHM, where medical students, residents, and working hospitalists talk to the presenters of interesting cases.

“It gives you a real back-and-forth, which is good for the person asking the question and for the presenter,” he says, noting hospitalists from other parts of the country were not as familiar with histoplasmosis.

He says winning the HM06 poster contest helped him “get his feet wet” and feel more prepared for a career in academic hospital medicine. “I’m sure the award solidified my employers’ satisfaction in hiring me—and in giving me more desirable academic roles and responsibilities,” he adds.

Leonard Feldman, MD, FACP, FAAP, SFHM

Title: Assistant professor of medicine pediatrics; director of the general internal-medicine comprehensive consultation service

Institution: Johns Hopkins Hospital, Baltimore

Year: 2009

RIV: “An Internet-Based Consult Curriculum for Hospitalists” (innovations)

Dr. Feldman’s poster described an online CME curriculum for hospitalists acting as medical consultants. The concept grew out of a perceived deficiency in his own medical education when, in 2004, he was asked to lead the consultation service at Johns Hopkins—just six months after finishing his residency.

“I had no idea what I was doing as a general-internal-medicine consultant,” he says. “I maybe received two weeks of experience as a consultant during my residency. I was willing to take it on, learning on the job and asking for help. But it occurred to me that I’m probably not alone in feeling unprepared.”

In his quest for self-education, Dr. Feldman wondered whether he should write a textbook on the subject. “But the information changes so quickly, I thought I’d have a better chance to reach people online,” he notes.

After talking to publishers and CME companies, he came up with the concept of learning modules on perioperative and consultative medicine topics, which could be taken online while earning CME credits. Johns Hopkins served as the CME certifier, and medical-education company Advanced Studies in Medicine joined as a partner. Once the project got off the ground, a medical advisory committee was convened.

“Winning the SHM poster competition is a great honor to have on a CV. It really helps to legitimize your name in the world of hospital medicine,” Dr. Feldman says. “It also provided confirmation that we were on the right track with the curriculum project. People valued what we were doing.”

Dr. Feldman and SHM have since become affiliated, and the “Consultative and Perioperative Medicine Essentials for Hospitalists” modules are available on SHM’s website (www.shmconsults.com). The site has 12,000 registered members completing 500 CME modules every month.

“I do a lot of the editing still,” Dr. Feldman says. “We update the modules every two years and are still creating new ones.”

Dr. Feldman also pursues a number of clinical-research interests, including resident education and costs of care.

Kristin Wise, MD, FHM

Title: Assistant professor of medicine

Institution: Medical University of South Carolina, Charleston

Year: 2009

RIV: “Intensivists versus Hospitalists in the ICU: A Prospective Cohort Study Comparing Mortality and Length of Stay Between Two Staffing Models” (research) Citation: Wise KR, Akopov VA, Williams BR, Ido MS, Leeper KV, Dressler DD. Hospitalists and intensivists in the medical ICU: a prospective and observational study comparing mortality and length of stay between two staffing models. J Hosp Med. 2012;7(3):183-189.

Dr. Wise was recognized for research that began while she worked at Emory University in Atlanta, comparing hospitalists and intensivists in such outcomes as length of stay and mortality rates for patients in the ICU. The study was one of the first statistically rigorous examinations of this critical quality question. With an eye toward improving patient safety, national quality advocates such as the Leapfrog Group have called for hospitals to employ intensivists (critical-care specialists) to manage the care of ICU patients. In reality, Dr. Wise says, there aren’t enough intensivists to meet the need.

“Hospitalists are in the ICU anyway,” she says. “We just don’t have enough data to answer how well they do [in comparison to intensivists].”

Through a prospective cohort study of more than 1,000 patients, Dr. Wise’s group found that there was essentially no statistical difference in mortality rates between patients treated by intensivist teams or hospitalist ICU teams.

“We were also able to look at some of the intermediate-acuity patients—fairly complicated but not requiring ventilators,” she explains. “Our study wasn’t sufficiently powered for this subgroup, but it was an interesting piece of data to raise the question: Where should we deploy this scarce resource of intensivists? Which pockets of patients?”

Presenting her abstract at SHM’s annual meeting was a “good experience.”

“I’d done public speaking before, but never with an audience of about 500 people,” she says. “To go out there and field their questions was a real professional growing experience. Several people interested in the topic sought me out at the conference, introduced themselves, and we have subsequently stayed in touch.”

The manuscript published in JHM has been cited four times, including in a position paper from SHM and the Society of Critical Care Medicine.³ Another outgrowth of the research was being asked to contribute a chapter on hospitalists’ role in the ICU to a textbook on hospital medicine. Based on her still-fresh HM presentation, Dr. Wise was one of the few publicly identified experts on the subject. The chapter, co-authored by fellow Emory hospitalist Michael Heisler, MD, MPH, “The Role of the Hospitalist in Critical Care” was included in Principles and Practices of Hospital Medicine.⁴

Shetal Shah, MD, FAAP

Title: Neonatal intensivist

Institution: Stony Brook University Hospital, Great Neck, N.Y.

Year: 2006

RIV: “Administration of Inactivated Trivalent Influenza Vaccine (TIV) to Parents of Infants in the Neonatal Intensive Care Unit (NICU): A Novel Strategy to Increase Vaccination Rates” (innovations)

Citation: Shah SI, Caprio M, Hendricks-Munoz K. Administration of inactivated trivalent influenza vaccine to parents of high-risk infants in the neonatal intensive care unit. Pediatrics. 2007;120;e617-e621.

Dr. Shah was in his final year of a fellowship in neonatology at New York University when he took on the challenge of improving immunization access to protect premature, highly vulnerable patients in the NICU from influenza infections. Because these children are too young to be vaccinated directly, the concept of cocooning them from infection involves extending protection to everyone around them.

“We came up with the idea of offering flu vaccinations 24/7 in the NICU to the children’s parents,” he says. “It worked well for us as a way to define an indicated therapy for a defined population, even if it was a little outside the box. By the end of the flu season, 95% of the parents were vaccinated.”

SHM recognized the project as the top RIV innovations poster at HM06, but that was just the beginning.

“When I moved to SUNY Stony Brook, I continued to study and advocate for these vaccinations,” Dr. Shah says. “We were giving 500 to 700 vaccinations a year. Then I wrote a national resolution for the American Academy of Pediatrics, which was significant because it meant AAP was behind the project.”

Dr. Shah later became chair of AAP’s Long Island Chapter Legislative Committee and joined a statewide pediatric advocacy group. In 2009, the New York legislature enacted the Neonatal Influenza Protection Act, which required hospitals in the state to offer parents the vaccine, with Dr. Shah’s research and advocacy providing an essential basis for its passage. He’s even been recognized for his research in congressional citations.

Based on that success with influenza vaccinations, Dr. Shah and his colleagues looked at other diseases, starting with pertussis, and then tetanus, diphtheria, and whooping cough.⁵ All the while, they continued tracking immunization rates. A second state law, passed in 2011, added pertussis to the vaccinations. Next on his advocacy agenda is a project to promote smoking-cessation interventions in the NICU.⁶

“These parents come to see us every day,” he says. “What can we do, through the parents, to promote the health and well-being of their high-risk newborns?”

Jason Morrow, MD, PhD

Title: Assistant professor of medicine; medical director of inpatient palliative-care consultation

Institution: University of Texas Health Sciences Center, San Antonio

Year: 2009

RIV: “When to Depend on the Kinins of Strangers: An Unusual Case of Abdominal Pain” (clinical vignettes)

Publication: An article on the ethics of determining code status for patients with advanced cancer and a book chapter on the “last hours of life” for a forthcoming book on palliative care and hospital medicine.

As a medical resident, Dr. Morrow met a 27-year-old woman who had chronic abdominal pain and had made multiple visits to the ED for this complaint. The patient had a history of substance abuse and requested dilaudid for her pain—making it easy for staff to consign her to the stereotype of the difficult patient.

“I met her after an interesting finding,” he says. “It turns out that on the previous emergency room visit, she received a CAT scan, which showed duodenal and small-bowel thickening consistent with hereditary angioedema, although with an unusual presentation. As it happened, we had onsite a world expert in angioedema.”

The expert was able to confirm the diagnosis, Dr. Morrow says.

“By giving her this ‘legitimate,’ organic diagnosis, it just changed the whole dynamic of her relationship with her doctors,” he says. “She knew that they knew something was really wrong. The residents were empowered to have something to hang their hats on. And we were able to get better control of her pain.”

Dr. Morrow says he came on the scene late in the discovery process, but he helped to solve the puzzle, and then put together the abstract and poster that told the story of making the diagnosis.

“In my previous job, I was hired as a hospitalist but helped to build the palliative-care program within the hospital-medicine service,” he says. “In my current job, I was brought in to build the inpatient palliative-care-consultation service, although I still moonlight as a hospitalist to stay sharp.”

Dr. Morrow says he enjoys sharing stories of difficult cases and submitting case studies about them to medical conferences, often with clever titles incorporating puns (e.g. the 2009 SHM poster citing kinins, polypeptides in the blood that cause inflammation). Another example is “The Angina Monologues,” a story of an 82-year-old patient with chronic angina pectoris and complex pain syndromes that were difficult to bring under control. Palliative care also emphasizes patients’ stories, he says, in order to understand the person behind the diagnosis.

Larry Beresford is a freelance writer in San Francisco. References available at www.the-hospitalist.org.

References

Dr. Georgiou

It would be premature for a hospital to install copper based on this study if future studies confirm earlier results, then hospitals should seriously consider copper installations.

—James Pile, MD, FACP, SFHM, vice chair, department of hospital medicine, Cleveland Clinic

Hospital-acquired infections (HAIs) are on the rise despite efforts to decrease them. HAIs cause an estimated 100,000 deaths annually and account for up to $45 billion in health-care costs. Adding fuel to the fire, bacteria increasingly are becoming resistant to last-resort drugs. Despite this gloomy outlook, a recent study in Infection Control and Hospital Epidemiology shows that a material known for its antimicrobial properties for more than 4,000 years—copper—might be a light at the end of this darkening tunnel.¹

Ancient Indians stored water in copper pots to prevent illness, says lead study author Cassandra D. Salgado, MD, associate professor of medicine, hospital epidemiologist, and medical director for infection prevention at the Medical University of South Carolina (MUSC) in Charleston. But copper rarely is used in that manner today because molded plastics and stainless steel are less expensive and easier to mass-produce.

Dr. Salgado explains that the antimicrobial effect of copper-alloy surfaces is a result of the metal stealing electrons from the bacteria when they come into contact with each other. “Once the bacteria donate the electrons to the copper metal, this places the organism into a state of electrical-charge deficit,” she says. “As a consequence, free radicals are generated inside the cell, which ultimately leads to the cell’s death.”

Copper-alloy surfaces kill 99.9% of bacteria in less than two hours, says Harold T. Michels, PhD, PE, senior vice president of technology and technical services for Copper Development Association Inc. in New York, who was a study author. On other surfaces, bacteria may live for multiple days or even months.

Unlike current methods used to decrease HAIs (i.e. hand-washing and sanitizing surfaces), copper components don’t require human intervention or compliance to be effective.

“It supplements what these other things can do; it’s in the background and it’s always working,” Michels says.

A study needs to be done on the cost-effectiveness of copper surfaces. Health economists estimate that if copper surfaces were incorporated into ICUs, after three to six months, those surfaces would pay for themselves. That is not a long time period. Hospitals need to understand that there will be upfront costs but that they will realize benefits downstream.

—Cassandra D. Salgado, MD, associate professor of medicine, hospital epidemiologist, medical director for infection prevention, Medical University of South Carolina, Charleston

Study Specifics

To conduct the study, copper prototypes of items touched most frequently by patients, health-care providers, and visitors were made and placed in patient rooms located within ICUs. “We placed the copper around the patient [much like a defensive perimeter] to reduce the likelihood that the health-care worker or visitor would introduce the infectious agent to the patient,” says the study’s lead investigator, Michael Schmidt, PhD, a professor and vice chair of MUSC’s department of microbiology and immunology.

Then, bacterial loads were measured on each object. For every study room, there was a control room without copper objects. Researchers were most interested in methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). For a period of time, bacterial burdens were measured in both copper rooms and control rooms.

Results exceeded the researchers’ expectations. Although only 7% of the touch surfaces in each ICU were replaced with copper components, there were 58% fewer HAI cases. The rate of HAI and/or MRSA or VRE colonization in ICU rooms with copper-alloy surfaces was significantly lower than that in standard ICU rooms (0.071 versus 0.123). For HAIs only, the rate was reduced to 0.034 from 0.081.³

“We were pleasantly surprised with the reductions,” Dr. Salgado says. “We consistently saw a more than 50% reduction in HAIs in all study sites.”

Archelle Georgiou, MD, president of Georgiou Consulting LLC in Minneapolis and an advisor to the Copper Development Association, is an advocate for making the health-care system simpler and safer for consumers. She says copper is a “game-changer.”

“It’s a brand-new way of thinking about decreasing the number of HAIs,” she says.

Green Light?

In light of the study’s encouraging findings, hospitalist and infectious-disease specialist James Pile, MD, FACP, SFHM, vice chair of the Department of Hospital Medicine at Cleveland Clinic, says that although study results appear valid, “it didn’t provide any final answers.”

Dr. Georgiou

“It would be premature for a hospital to install copper based on this study,” he says, adding he didn’t find the study results surprising, because copper is known to have antimicrobial properties.

But, Dr. Pile says, the study did provide proof of concept and opens the door for larger, more definitive studies that will show if installing copper in hospital rooms is worthwhile.

“If future studies confirm earlier results, then hospitals should seriously consider copper installations,” he says.

Dr. Georgiou

Barriers to Implementation

Despite the promising outlook for copper in dramatically reducing HAIs, implantation of copper components is off to a slow start.

Negotiations with the Environmental Protection Agency, the federal agency with jurisdiction over public-health claims for antimicrobial surfaces, started in 2004. Testing started in 2005. Although federal registration was completed in February 2008, it wasn’t until late 2011 that all regulatory issues were resolved for manufacturers.

“The regulatory process created delays in educating hospitals and the public about copper’s effectiveness in killing certain bacteria,” Dr. Georgiou explains. “As a result, American manufacturers with the ability to make copper components weren’t developing products because they couldn’t sell them.”

Now that the regulatory issues have been resolved, U.S. manufacturers are beginning to make copper components. The first wave of commercial products came on the market in late 2011. Meanwhile, European countries have not been delayed and are well ahead of U.S. hospitals in implementing copper components.

Presently, nine U.S. hospitals have installed some form of copper components, including door hardware, cabinet pulls, sinks, stretchers, and IV poles, Michels reports.

Despite these advances, hospitals may be slow to incorporate copper components due to a variety of reasons:

Cost. Dr. Pile believes that cost will be the major barrier. “Installing copper surfaces won’t be cheap,” he says. “But, then again, HAIs are very costly. I think it will be more difficult to justify their existence if they can be prevented. If copper is effective in preventing HAIs, it would prove to be cost-effective over time.”

Dr. Salgado concurs. “A study needs to be done on the cost-effectiveness of copper surfaces,” she says. “Health economists estimate that if copper surfaces were incorporated into ICUs, after three to six months, those surfaces would pay for themselves. That is not a long time period. Hospitals need to understand that there will be upfront costs but that they will realize benefits downstream.”

The Center for Medicare & Medicaid Services (CMS) has reported that one infection adds $43,000 in patient costs.⁴ A typical U.S. hospital room contains $100,000 worth of goods and equipment.

“When you do the math using the amount of copper in our study, the cost would be between $1 and $10 per patient,” Dr. Schmidt says. “It’s also important to note that an infection adds 19 days to a patient’s hospital stay.”

Aesthetics. For some, appearance may be a concern. “Copper is actually an appealing material that is offered in an array of colors and surface finishes,” Dr. Michels says. Because a copper-and-brass combination is more prone to tarnishing, a copper-nickel alloy may be more desirable.

Availability. Copper components are not produced and marketed to U.S. hospitals; however, they are available. “We are hoping with our study and future studies that some medical-device companies, as well as hospital-furniture manufacturers, will jump on board to look at ways to mass-produce items,” Dr. Salgado says.

Acceptance. The study published in Infection Control and Hospital Epidemiology validated the effectiveness of copper in decreasing HAIs. This pilot study, however, was not blinded.³

“It was pretty apparent to providers where copper surfaces were located, which tends to result in some bias. Future studies will, hopefully, try to answer questions regarding healthcare providers’ behaviors with different surfaces,” says Dr. Salgado, noting researchers in California and Chile also are studying the effects of copper surfaces in hospitals.

Possible loss of efficacy. Even if a surface is effective initially, Dr. Pile points out that it’s possible for that to change. “I have a theoretical concern that, over time, bacterial pathogens may develop a tolerance to copper,” he says. “Bacterial adversaries have been able to overcome any type of treatment that we have devised for them thus far. But this remains to be seen.”

This has been an issue with other surfaces; once microbes establish a foothold, it is hard to eliminate them. But Dr. Schmidt says because bacteria are killed so quickly on copper surfaces and cleaning is only required once daily, the ability to establish a foothold is greatly reduced, if not completely eliminated.

Copper supplements what these other things can do; it’s in the background and it’s always working..

—Harold T. Michels, PhD, PE, senior vice president of technology and technical services, Copper Development Association Inc.

Champion Proven Strategies

Dr. Pile sees antimicrobial stewardship as a great opportunity for hospitalists as a specialty. In fact, the Centers for Disease Control and Prevention is partnering with HM groups on piloting multiple antimicrobial stewardship initiatives at several sites.

Dr. Pile suggests that leaders spearhead formal quality-improvement efforts, be involved with patient-safety efforts, and serve as physician champions.

“No one is better positioned to do this than hospitalists, because we own the hospital environment,” he says. “We have an incredible stake in making sure that our inpatient environment provides safe and high-value care.”

As a result of the published study, Dr. Salgado says discussions are underway with hospital leaders at MUSC to determine if copper surfaces will be used in its ICUs and, if so, how changes will be implemented.

Karen Appold is a freelance writer in Pennsylvania.

References

1. Klevens RM, Edwards JR, Richards CL, et al. Estimating healthcare-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122:160-166.
2. Scott RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Atlanta: Centers for Disease Control and Prevention, 2009.
3. Salgado CD, Sepkowitz KA, John JF, et al. Copper Surfaces Reduce the Rate of Healthcare-Acquired Infections in the Intensive Care Unit. Infect Control Hosp Epidemiol. 2013;34(5):479-486.
4. Healthcare Cost and Utilization Project. Statistical Brief No. 94. Agency for Healthcare Research and Quality. Aug. 2010. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb94.pdf. Accessed Aug. 6, 2013.

Dr. Georgiou

It would be premature for a hospital to install copper based on this study if future studies confirm earlier results, then hospitals should seriously consider copper installations.

—James Pile, MD, FACP, SFHM, vice chair, department of hospital medicine, Cleveland Clinic

Hospital-acquired infections (HAIs) are on the rise despite efforts to decrease them. HAIs cause an estimated 100,000 deaths annually and account for up to $45 billion in health-care costs. Adding fuel to the fire, bacteria increasingly are becoming resistant to last-resort drugs. Despite this gloomy outlook, a recent study in Infection Control and Hospital Epidemiology shows that a material known for its antimicrobial properties for more than 4,000 years—copper—might be a light at the end of this darkening tunnel.¹

Ancient Indians stored water in copper pots to prevent illness, says lead study author Cassandra D. Salgado, MD, associate professor of medicine, hospital epidemiologist, and medical director for infection prevention at the Medical University of South Carolina (MUSC) in Charleston. But copper rarely is used in that manner today because molded plastics and stainless steel are less expensive and easier to mass-produce.

Dr. Salgado explains that the antimicrobial effect of copper-alloy surfaces is a result of the metal stealing electrons from the bacteria when they come into contact with each other. “Once the bacteria donate the electrons to the copper metal, this places the organism into a state of electrical-charge deficit,” she says. “As a consequence, free radicals are generated inside the cell, which ultimately leads to the cell’s death.”

Copper-alloy surfaces kill 99.9% of bacteria in less than two hours, says Harold T. Michels, PhD, PE, senior vice president of technology and technical services for Copper Development Association Inc. in New York, who was a study author. On other surfaces, bacteria may live for multiple days or even months.

Unlike current methods used to decrease HAIs (i.e. hand-washing and sanitizing surfaces), copper components don’t require human intervention or compliance to be effective.

“It supplements what these other things can do; it’s in the background and it’s always working,” Michels says.

A study needs to be done on the cost-effectiveness of copper surfaces. Health economists estimate that if copper surfaces were incorporated into ICUs, after three to six months, those surfaces would pay for themselves. That is not a long time period. Hospitals need to understand that there will be upfront costs but that they will realize benefits downstream.

—Cassandra D. Salgado, MD, associate professor of medicine, hospital epidemiologist, medical director for infection prevention, Medical University of South Carolina, Charleston

Study Specifics

To conduct the study, copper prototypes of items touched most frequently by patients, health-care providers, and visitors were made and placed in patient rooms located within ICUs. “We placed the copper around the patient [much like a defensive perimeter] to reduce the likelihood that the health-care worker or visitor would introduce the infectious agent to the patient,” says the study’s lead investigator, Michael Schmidt, PhD, a professor and vice chair of MUSC’s department of microbiology and immunology.

Then, bacterial loads were measured on each object. For every study room, there was a control room without copper objects. Researchers were most interested in methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). For a period of time, bacterial burdens were measured in both copper rooms and control rooms.

Results exceeded the researchers’ expectations. Although only 7% of the touch surfaces in each ICU were replaced with copper components, there were 58% fewer HAI cases. The rate of HAI and/or MRSA or VRE colonization in ICU rooms with copper-alloy surfaces was significantly lower than that in standard ICU rooms (0.071 versus 0.123). For HAIs only, the rate was reduced to 0.034 from 0.081.³

“We were pleasantly surprised with the reductions,” Dr. Salgado says. “We consistently saw a more than 50% reduction in HAIs in all study sites.”

Archelle Georgiou, MD, president of Georgiou Consulting LLC in Minneapolis and an advisor to the Copper Development Association, is an advocate for making the health-care system simpler and safer for consumers. She says copper is a “game-changer.”

“It’s a brand-new way of thinking about decreasing the number of HAIs,” she says.

Green Light?

In light of the study’s encouraging findings, hospitalist and infectious-disease specialist James Pile, MD, FACP, SFHM, vice chair of the Department of Hospital Medicine at Cleveland Clinic, says that although study results appear valid, “it didn’t provide any final answers.”

Dr. Georgiou

“It would be premature for a hospital to install copper based on this study,” he says, adding he didn’t find the study results surprising, because copper is known to have antimicrobial properties.

But, Dr. Pile says, the study did provide proof of concept and opens the door for larger, more definitive studies that will show if installing copper in hospital rooms is worthwhile.

“If future studies confirm earlier results, then hospitals should seriously consider copper installations,” he says.

Dr. Georgiou

Barriers to Implementation

Despite the promising outlook for copper in dramatically reducing HAIs, implantation of copper components is off to a slow start.

Negotiations with the Environmental Protection Agency, the federal agency with jurisdiction over public-health claims for antimicrobial surfaces, started in 2004. Testing started in 2005. Although federal registration was completed in February 2008, it wasn’t until late 2011 that all regulatory issues were resolved for manufacturers.

“The regulatory process created delays in educating hospitals and the public about copper’s effectiveness in killing certain bacteria,” Dr. Georgiou explains. “As a result, American manufacturers with the ability to make copper components weren’t developing products because they couldn’t sell them.”

Now that the regulatory issues have been resolved, U.S. manufacturers are beginning to make copper components. The first wave of commercial products came on the market in late 2011. Meanwhile, European countries have not been delayed and are well ahead of U.S. hospitals in implementing copper components.

Presently, nine U.S. hospitals have installed some form of copper components, including door hardware, cabinet pulls, sinks, stretchers, and IV poles, Michels reports.

Despite these advances, hospitals may be slow to incorporate copper components due to a variety of reasons:

Cost. Dr. Pile believes that cost will be the major barrier. “Installing copper surfaces won’t be cheap,” he says. “But, then again, HAIs are very costly. I think it will be more difficult to justify their existence if they can be prevented. If copper is effective in preventing HAIs, it would prove to be cost-effective over time.”

Dr. Salgado concurs. “A study needs to be done on the cost-effectiveness of copper surfaces,” she says. “Health economists estimate that if copper surfaces were incorporated into ICUs, after three to six months, those surfaces would pay for themselves. That is not a long time period. Hospitals need to understand that there will be upfront costs but that they will realize benefits downstream.”

The Center for Medicare & Medicaid Services (CMS) has reported that one infection adds $43,000 in patient costs.⁴ A typical U.S. hospital room contains $100,000 worth of goods and equipment.

“When you do the math using the amount of copper in our study, the cost would be between $1 and $10 per patient,” Dr. Schmidt says. “It’s also important to note that an infection adds 19 days to a patient’s hospital stay.”

Aesthetics. For some, appearance may be a concern. “Copper is actually an appealing material that is offered in an array of colors and surface finishes,” Dr. Michels says. Because a copper-and-brass combination is more prone to tarnishing, a copper-nickel alloy may be more desirable.

Availability. Copper components are not produced and marketed to U.S. hospitals; however, they are available. “We are hoping with our study and future studies that some medical-device companies, as well as hospital-furniture manufacturers, will jump on board to look at ways to mass-produce items,” Dr. Salgado says.

Acceptance. The study published in Infection Control and Hospital Epidemiology validated the effectiveness of copper in decreasing HAIs. This pilot study, however, was not blinded.³

“It was pretty apparent to providers where copper surfaces were located, which tends to result in some bias. Future studies will, hopefully, try to answer questions regarding healthcare providers’ behaviors with different surfaces,” says Dr. Salgado, noting researchers in California and Chile also are studying the effects of copper surfaces in hospitals.

Possible loss of efficacy. Even if a surface is effective initially, Dr. Pile points out that it’s possible for that to change. “I have a theoretical concern that, over time, bacterial pathogens may develop a tolerance to copper,” he says. “Bacterial adversaries have been able to overcome any type of treatment that we have devised for them thus far. But this remains to be seen.”

This has been an issue with other surfaces; once microbes establish a foothold, it is hard to eliminate them. But Dr. Schmidt says because bacteria are killed so quickly on copper surfaces and cleaning is only required once daily, the ability to establish a foothold is greatly reduced, if not completely eliminated.

Copper supplements what these other things can do; it’s in the background and it’s always working..

—Harold T. Michels, PhD, PE, senior vice president of technology and technical services, Copper Development Association Inc.

Champion Proven Strategies

Dr. Pile sees antimicrobial stewardship as a great opportunity for hospitalists as a specialty. In fact, the Centers for Disease Control and Prevention is partnering with HM groups on piloting multiple antimicrobial stewardship initiatives at several sites.

Dr. Pile suggests that leaders spearhead formal quality-improvement efforts, be involved with patient-safety efforts, and serve as physician champions.

“No one is better positioned to do this than hospitalists, because we own the hospital environment,” he says. “We have an incredible stake in making sure that our inpatient environment provides safe and high-value care.”

As a result of the published study, Dr. Salgado says discussions are underway with hospital leaders at MUSC to determine if copper surfaces will be used in its ICUs and, if so, how changes will be implemented.

Karen Appold is a freelance writer in Pennsylvania.

References

1. Klevens RM, Edwards JR, Richards CL, et al. Estimating healthcare-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122:160-166.
2. Scott RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Atlanta: Centers for Disease Control and Prevention, 2009.
3. Salgado CD, Sepkowitz KA, John JF, et al. Copper Surfaces Reduce the Rate of Healthcare-Acquired Infections in the Intensive Care Unit. Infect Control Hosp Epidemiol. 2013;34(5):479-486.
4. Healthcare Cost and Utilization Project. Statistical Brief No. 94. Agency for Healthcare Research and Quality. Aug. 2010. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb94.pdf. Accessed Aug. 6, 2013.

Dr. Georgiou

It would be premature for a hospital to install copper based on this study if future studies confirm earlier results, then hospitals should seriously consider copper installations.

—James Pile, MD, FACP, SFHM, vice chair, department of hospital medicine, Cleveland Clinic

Hospital-acquired infections (HAIs) are on the rise despite efforts to decrease them. HAIs cause an estimated 100,000 deaths annually and account for up to $45 billion in health-care costs. Adding fuel to the fire, bacteria increasingly are becoming resistant to last-resort drugs. Despite this gloomy outlook, a recent study in Infection Control and Hospital Epidemiology shows that a material known for its antimicrobial properties for more than 4,000 years—copper—might be a light at the end of this darkening tunnel.¹

Ancient Indians stored water in copper pots to prevent illness, says lead study author Cassandra D. Salgado, MD, associate professor of medicine, hospital epidemiologist, and medical director for infection prevention at the Medical University of South Carolina (MUSC) in Charleston. But copper rarely is used in that manner today because molded plastics and stainless steel are less expensive and easier to mass-produce.

Dr. Salgado explains that the antimicrobial effect of copper-alloy surfaces is a result of the metal stealing electrons from the bacteria when they come into contact with each other. “Once the bacteria donate the electrons to the copper metal, this places the organism into a state of electrical-charge deficit,” she says. “As a consequence, free radicals are generated inside the cell, which ultimately leads to the cell’s death.”

Copper-alloy surfaces kill 99.9% of bacteria in less than two hours, says Harold T. Michels, PhD, PE, senior vice president of technology and technical services for Copper Development Association Inc. in New York, who was a study author. On other surfaces, bacteria may live for multiple days or even months.

Unlike current methods used to decrease HAIs (i.e. hand-washing and sanitizing surfaces), copper components don’t require human intervention or compliance to be effective.

“It supplements what these other things can do; it’s in the background and it’s always working,” Michels says.

A study needs to be done on the cost-effectiveness of copper surfaces. Health economists estimate that if copper surfaces were incorporated into ICUs, after three to six months, those surfaces would pay for themselves. That is not a long time period. Hospitals need to understand that there will be upfront costs but that they will realize benefits downstream.

—Cassandra D. Salgado, MD, associate professor of medicine, hospital epidemiologist, medical director for infection prevention, Medical University of South Carolina, Charleston

Study Specifics

To conduct the study, copper prototypes of items touched most frequently by patients, health-care providers, and visitors were made and placed in patient rooms located within ICUs. “We placed the copper around the patient [much like a defensive perimeter] to reduce the likelihood that the health-care worker or visitor would introduce the infectious agent to the patient,” says the study’s lead investigator, Michael Schmidt, PhD, a professor and vice chair of MUSC’s department of microbiology and immunology.

Then, bacterial loads were measured on each object. For every study room, there was a control room without copper objects. Researchers were most interested in methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). For a period of time, bacterial burdens were measured in both copper rooms and control rooms.

Results exceeded the researchers’ expectations. Although only 7% of the touch surfaces in each ICU were replaced with copper components, there were 58% fewer HAI cases. The rate of HAI and/or MRSA or VRE colonization in ICU rooms with copper-alloy surfaces was significantly lower than that in standard ICU rooms (0.071 versus 0.123). For HAIs only, the rate was reduced to 0.034 from 0.081.³

“We were pleasantly surprised with the reductions,” Dr. Salgado says. “We consistently saw a more than 50% reduction in HAIs in all study sites.”

Archelle Georgiou, MD, president of Georgiou Consulting LLC in Minneapolis and an advisor to the Copper Development Association, is an advocate for making the health-care system simpler and safer for consumers. She says copper is a “game-changer.”

“It’s a brand-new way of thinking about decreasing the number of HAIs,” she says.

Green Light?

In light of the study’s encouraging findings, hospitalist and infectious-disease specialist James Pile, MD, FACP, SFHM, vice chair of the Department of Hospital Medicine at Cleveland Clinic, says that although study results appear valid, “it didn’t provide any final answers.”

Dr. Georgiou

“It would be premature for a hospital to install copper based on this study,” he says, adding he didn’t find the study results surprising, because copper is known to have antimicrobial properties.

But, Dr. Pile says, the study did provide proof of concept and opens the door for larger, more definitive studies that will show if installing copper in hospital rooms is worthwhile.

“If future studies confirm earlier results, then hospitals should seriously consider copper installations,” he says.

Dr. Georgiou

Barriers to Implementation

Despite the promising outlook for copper in dramatically reducing HAIs, implantation of copper components is off to a slow start.

Negotiations with the Environmental Protection Agency, the federal agency with jurisdiction over public-health claims for antimicrobial surfaces, started in 2004. Testing started in 2005. Although federal registration was completed in February 2008, it wasn’t until late 2011 that all regulatory issues were resolved for manufacturers.

“The regulatory process created delays in educating hospitals and the public about copper’s effectiveness in killing certain bacteria,” Dr. Georgiou explains. “As a result, American manufacturers with the ability to make copper components weren’t developing products because they couldn’t sell them.”

Now that the regulatory issues have been resolved, U.S. manufacturers are beginning to make copper components. The first wave of commercial products came on the market in late 2011. Meanwhile, European countries have not been delayed and are well ahead of U.S. hospitals in implementing copper components.

Presently, nine U.S. hospitals have installed some form of copper components, including door hardware, cabinet pulls, sinks, stretchers, and IV poles, Michels reports.

Despite these advances, hospitals may be slow to incorporate copper components due to a variety of reasons:

Cost. Dr. Pile believes that cost will be the major barrier. “Installing copper surfaces won’t be cheap,” he says. “But, then again, HAIs are very costly. I think it will be more difficult to justify their existence if they can be prevented. If copper is effective in preventing HAIs, it would prove to be cost-effective over time.”

Dr. Salgado concurs. “A study needs to be done on the cost-effectiveness of copper surfaces,” she says. “Health economists estimate that if copper surfaces were incorporated into ICUs, after three to six months, those surfaces would pay for themselves. That is not a long time period. Hospitals need to understand that there will be upfront costs but that they will realize benefits downstream.”

The Center for Medicare & Medicaid Services (CMS) has reported that one infection adds $43,000 in patient costs.⁴ A typical U.S. hospital room contains $100,000 worth of goods and equipment.

“When you do the math using the amount of copper in our study, the cost would be between $1 and $10 per patient,” Dr. Schmidt says. “It’s also important to note that an infection adds 19 days to a patient’s hospital stay.”

Aesthetics. For some, appearance may be a concern. “Copper is actually an appealing material that is offered in an array of colors and surface finishes,” Dr. Michels says. Because a copper-and-brass combination is more prone to tarnishing, a copper-nickel alloy may be more desirable.

Availability. Copper components are not produced and marketed to U.S. hospitals; however, they are available. “We are hoping with our study and future studies that some medical-device companies, as well as hospital-furniture manufacturers, will jump on board to look at ways to mass-produce items,” Dr. Salgado says.

Acceptance. The study published in Infection Control and Hospital Epidemiology validated the effectiveness of copper in decreasing HAIs. This pilot study, however, was not blinded.³

“It was pretty apparent to providers where copper surfaces were located, which tends to result in some bias. Future studies will, hopefully, try to answer questions regarding healthcare providers’ behaviors with different surfaces,” says Dr. Salgado, noting researchers in California and Chile also are studying the effects of copper surfaces in hospitals.

Possible loss of efficacy. Even if a surface is effective initially, Dr. Pile points out that it’s possible for that to change. “I have a theoretical concern that, over time, bacterial pathogens may develop a tolerance to copper,” he says. “Bacterial adversaries have been able to overcome any type of treatment that we have devised for them thus far. But this remains to be seen.”

This has been an issue with other surfaces; once microbes establish a foothold, it is hard to eliminate them. But Dr. Schmidt says because bacteria are killed so quickly on copper surfaces and cleaning is only required once daily, the ability to establish a foothold is greatly reduced, if not completely eliminated.

Copper supplements what these other things can do; it’s in the background and it’s always working..

—Harold T. Michels, PhD, PE, senior vice president of technology and technical services, Copper Development Association Inc.

Champion Proven Strategies

Dr. Pile sees antimicrobial stewardship as a great opportunity for hospitalists as a specialty. In fact, the Centers for Disease Control and Prevention is partnering with HM groups on piloting multiple antimicrobial stewardship initiatives at several sites.

Dr. Pile suggests that leaders spearhead formal quality-improvement efforts, be involved with patient-safety efforts, and serve as physician champions.

“No one is better positioned to do this than hospitalists, because we own the hospital environment,” he says. “We have an incredible stake in making sure that our inpatient environment provides safe and high-value care.”

As a result of the published study, Dr. Salgado says discussions are underway with hospital leaders at MUSC to determine if copper surfaces will be used in its ICUs and, if so, how changes will be implemented.

Karen Appold is a freelance writer in Pennsylvania.

References

1. Klevens RM, Edwards JR, Richards CL, et al. Estimating healthcare-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122:160-166.
2. Scott RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Atlanta: Centers for Disease Control and Prevention, 2009.
3. Salgado CD, Sepkowitz KA, John JF, et al. Copper Surfaces Reduce the Rate of Healthcare-Acquired Infections in the Intensive Care Unit. Infect Control Hosp Epidemiol. 2013;34(5):479-486.
4. Healthcare Cost and Utilization Project. Statistical Brief No. 94. Agency for Healthcare Research and Quality. Aug. 2010. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb94.pdf. Accessed Aug. 6, 2013.

Click here to listen to more of our interview with Dr. Vazquez

Click here to listen to more of our interview with Dr. Vazquez

Click here to listen to more of our interview with Dr. Vazquez

“It’s really hard to put it into words. It’s the only hospital in that city, and it’s just me and my partner to take care of virtually everyone that comes in with any kind of medical problem. … It’s devastating. What is the rest of the city going to do for their hospital care? They essentially will not have a hospital in their city. They’ll have to drive toanother city for care.”

–Joe R. Womble, MD

The first bit of feedback was fantastic: Everyone who had been inside the hospital—roughly 200 to 300 people, including 30 patients—had survived.

“Everyone was fine,” he said. “All the patients and staff, no one got injured. I was thinking that either the hospital was missed by the storm or that it must not have really damaged it very significantly.”

Unfortunately, the hospital was not OK. He watched as local TV painted a very different picture.

“They started showing aerial shots and I was just shocked. My jaw was just dropped,” Dr. Womble said. “The main entrance that I go in every day was literally stacked with three or four cars deep. A huge stack of about 30 cars was piled up on the main entrance, essentially.”

It was as though they were “toy cars.”

The May 20 tornado, a two-mile-wide superstorm boasting 200-mph winds that struck just south of Oklahoma City, claimed 24 lives and left the regional health system with a void in its network. It also left hospitalists mourning the loss of the place they called a second home several times a week. About a week after the storm, officials announced that Moore Medical Center would have to be demolished.

Miraculous Moments

Despite the terrible events, hospitalists and hospital officials were astounded by the good fortune of the hospital’s inhabitants. Dr. Womble said about 100 people from nearby neighborhoods and businesses used the hospital as shelter.

Senthil Raju, MD, a hospitalist who had done rounds at Moore Medical earlier that day, said the protocol was to take shelter in the hallways. But at some point, probably only minutes before the storm hit, the chief nurse and the house supervisor made the decision to move all the patients to the ground floor because they were in “reasonably stable condition,” according to Dr. Womble, who relayed accounts by staffers who were there. Most of the people in the hospital rode out the storm in the first-floor cafeteria.

After the storm, patient rooms on the second floor were either no longer there or had been reduced to their steel innards.

The decision to move everyone undoubtedly saved lives. “If any of our patients stayed there, they’re probably all dead,” Dr. Raju said.

David Whitaker, CEO of Norman Regional Health System, which includes Moore Medical, marveled at the outcome.

“We had some bumps and bruises, some scratches, but no major lacerations, no broken bones, no injuries that people couldn’t ambulate. It’s totally amazing,” he said. “The leadership that was in place, the employees that were working at that time, they sprang into action, they took command and control of the situation. They got people into the proper areas.”

Dr. Womble said hospital staff at Moore Medical had still more amazing stories of death-defiance. They told him 30 people refused to leave the chapel. Somehow, the chapel remained intact, even though the hospital all around it was destroyed. Whitaker confirmed this.

One woman in active labor was kept in a second-floor operating room—which the medical staff thought was the best place for her, all things considered. Nurses covered the woman with pillows, blankets, and their own bodies as the tornado barreled through the town. She survived and gave birth to a boy several hours later. The parents gave him the middle name Emmanuel, which means “God is with us.”

As the tornado approached, an elderly volunteer had gone outside to get something from a van he used to transport elderly patients to and from a physical therapy program. “Nobody inside knew he had gone outside,” Dr. Womble said. By the time he tried to get back in, the power had gone out, and the doors wouldn’t open. He huddled behind a concrete pillar and ended up with just one minor laceration.

Patients eventually were taken to another hospital, Norman’s HealthPlex, about five miles south. Both Dr. Womble and Dr. Raju have begun working full time at the HealthPlex.

Dr. Raju said that he avoided being at Moore Medical during the tornado only by a turn of luck. He normally rounds at Moore in the afternoon and at the HealthPlex in the morning. But on that day, there were three new admissions at Moore, and only one at HealthPlex. So he went to Moore first, and was gone by the time the tornado hit.

“So lucky,” he said.

“We had some bumps and bruises, some scratches, but no major lacerations, no broken bones, no injuries that people couldn’t ambulate. It’s totally amazing. The leadership that was in place, the employees that were working at that time, they sprang into action, they took command and control of the situation. They got people into the proper areas.”

–David Whitaker, CEO of Norman Regional Health System

The Aftermath

It remains to be seen what kind of medical facility will be built to replace Moore Medical Center.

“Nobody knows what will happen next, but a lot of us speculate that they will not rebuild an inpatient facility,” said Dr. Womble, who had worked at Moore Medical Center for four years.

Whitaker said the first priority was to re-establish the clinics located at Moore Medical, and that has been done. The next step is, possibly, a temporary building in Moore for urgent care. The long-term plan remains in the discussion phase.

“We’ve already started having some meetings,” Whitaker said. “We’re going to determine what type of facility, what service levels it will be offering as we go back.”

It’s hard knowing that his hospital is no longer there, Dr. Raju said.

“We are going to miss it,” he said. “It’s unimaginable.”

Dr. Womble said those first few hours, when he wasn’t sure of where he’d be working, were difficult. He struggles to describe the feeling of not being able to provide care at his hospital at the time it’s most needed.

“It’s really hard to put it into words,” he said. “It’s the only hospital in that city, and it’s just me and my partner to take care of virtually everyone that comes in with any kind of medical problem. I definitely feel a tie to the community.

“It’s devastating. What is the rest of the city going to do for their hospital care? They essentially will not have a hospital in their city. They’ll have to drive to another city for care.”

Tom Collins is a freelance writer in South Florida.

“It’s really hard to put it into words. It’s the only hospital in that city, and it’s just me and my partner to take care of virtually everyone that comes in with any kind of medical problem. … It’s devastating. What is the rest of the city going to do for their hospital care? They essentially will not have a hospital in their city. They’ll have to drive toanother city for care.”

–Joe R. Womble, MD

The first bit of feedback was fantastic: Everyone who had been inside the hospital—roughly 200 to 300 people, including 30 patients—had survived.

“Everyone was fine,” he said. “All the patients and staff, no one got injured. I was thinking that either the hospital was missed by the storm or that it must not have really damaged it very significantly.”

Unfortunately, the hospital was not OK. He watched as local TV painted a very different picture.

“They started showing aerial shots and I was just shocked. My jaw was just dropped,” Dr. Womble said. “The main entrance that I go in every day was literally stacked with three or four cars deep. A huge stack of about 30 cars was piled up on the main entrance, essentially.”

It was as though they were “toy cars.”

The May 20 tornado, a two-mile-wide superstorm boasting 200-mph winds that struck just south of Oklahoma City, claimed 24 lives and left the regional health system with a void in its network. It also left hospitalists mourning the loss of the place they called a second home several times a week. About a week after the storm, officials announced that Moore Medical Center would have to be demolished.

Miraculous Moments

Despite the terrible events, hospitalists and hospital officials were astounded by the good fortune of the hospital’s inhabitants. Dr. Womble said about 100 people from nearby neighborhoods and businesses used the hospital as shelter.

Senthil Raju, MD, a hospitalist who had done rounds at Moore Medical earlier that day, said the protocol was to take shelter in the hallways. But at some point, probably only minutes before the storm hit, the chief nurse and the house supervisor made the decision to move all the patients to the ground floor because they were in “reasonably stable condition,” according to Dr. Womble, who relayed accounts by staffers who were there. Most of the people in the hospital rode out the storm in the first-floor cafeteria.

After the storm, patient rooms on the second floor were either no longer there or had been reduced to their steel innards.

The decision to move everyone undoubtedly saved lives. “If any of our patients stayed there, they’re probably all dead,” Dr. Raju said.

David Whitaker, CEO of Norman Regional Health System, which includes Moore Medical, marveled at the outcome.

“We had some bumps and bruises, some scratches, but no major lacerations, no broken bones, no injuries that people couldn’t ambulate. It’s totally amazing,” he said. “The leadership that was in place, the employees that were working at that time, they sprang into action, they took command and control of the situation. They got people into the proper areas.”

Dr. Womble said hospital staff at Moore Medical had still more amazing stories of death-defiance. They told him 30 people refused to leave the chapel. Somehow, the chapel remained intact, even though the hospital all around it was destroyed. Whitaker confirmed this.

One woman in active labor was kept in a second-floor operating room—which the medical staff thought was the best place for her, all things considered. Nurses covered the woman with pillows, blankets, and their own bodies as the tornado barreled through the town. She survived and gave birth to a boy several hours later. The parents gave him the middle name Emmanuel, which means “God is with us.”

As the tornado approached, an elderly volunteer had gone outside to get something from a van he used to transport elderly patients to and from a physical therapy program. “Nobody inside knew he had gone outside,” Dr. Womble said. By the time he tried to get back in, the power had gone out, and the doors wouldn’t open. He huddled behind a concrete pillar and ended up with just one minor laceration.

Patients eventually were taken to another hospital, Norman’s HealthPlex, about five miles south. Both Dr. Womble and Dr. Raju have begun working full time at the HealthPlex.

Dr. Raju said that he avoided being at Moore Medical during the tornado only by a turn of luck. He normally rounds at Moore in the afternoon and at the HealthPlex in the morning. But on that day, there were three new admissions at Moore, and only one at HealthPlex. So he went to Moore first, and was gone by the time the tornado hit.

“So lucky,” he said.

“We had some bumps and bruises, some scratches, but no major lacerations, no broken bones, no injuries that people couldn’t ambulate. It’s totally amazing. The leadership that was in place, the employees that were working at that time, they sprang into action, they took command and control of the situation. They got people into the proper areas.”

–David Whitaker, CEO of Norman Regional Health System

The Aftermath

It remains to be seen what kind of medical facility will be built to replace Moore Medical Center.

“Nobody knows what will happen next, but a lot of us speculate that they will not rebuild an inpatient facility,” said Dr. Womble, who had worked at Moore Medical Center for four years.

Whitaker said the first priority was to re-establish the clinics located at Moore Medical, and that has been done. The next step is, possibly, a temporary building in Moore for urgent care. The long-term plan remains in the discussion phase.

“We’ve already started having some meetings,” Whitaker said. “We’re going to determine what type of facility, what service levels it will be offering as we go back.”

It’s hard knowing that his hospital is no longer there, Dr. Raju said.

“We are going to miss it,” he said. “It’s unimaginable.”

Dr. Womble said those first few hours, when he wasn’t sure of where he’d be working, were difficult. He struggles to describe the feeling of not being able to provide care at his hospital at the time it’s most needed.

“It’s really hard to put it into words,” he said. “It’s the only hospital in that city, and it’s just me and my partner to take care of virtually everyone that comes in with any kind of medical problem. I definitely feel a tie to the community.

“It’s devastating. What is the rest of the city going to do for their hospital care? They essentially will not have a hospital in their city. They’ll have to drive to another city for care.”

Tom Collins is a freelance writer in South Florida.

“It’s really hard to put it into words. It’s the only hospital in that city, and it’s just me and my partner to take care of virtually everyone that comes in with any kind of medical problem. … It’s devastating. What is the rest of the city going to do for their hospital care? They essentially will not have a hospital in their city. They’ll have to drive toanother city for care.”

–Joe R. Womble, MD

The first bit of feedback was fantastic: Everyone who had been inside the hospital—roughly 200 to 300 people, including 30 patients—had survived.

“Everyone was fine,” he said. “All the patients and staff, no one got injured. I was thinking that either the hospital was missed by the storm or that it must not have really damaged it very significantly.”

Unfortunately, the hospital was not OK. He watched as local TV painted a very different picture.

“They started showing aerial shots and I was just shocked. My jaw was just dropped,” Dr. Womble said. “The main entrance that I go in every day was literally stacked with three or four cars deep. A huge stack of about 30 cars was piled up on the main entrance, essentially.”

It was as though they were “toy cars.”

The May 20 tornado, a two-mile-wide superstorm boasting 200-mph winds that struck just south of Oklahoma City, claimed 24 lives and left the regional health system with a void in its network. It also left hospitalists mourning the loss of the place they called a second home several times a week. About a week after the storm, officials announced that Moore Medical Center would have to be demolished.

Miraculous Moments

Despite the terrible events, hospitalists and hospital officials were astounded by the good fortune of the hospital’s inhabitants. Dr. Womble said about 100 people from nearby neighborhoods and businesses used the hospital as shelter.

Senthil Raju, MD, a hospitalist who had done rounds at Moore Medical earlier that day, said the protocol was to take shelter in the hallways. But at some point, probably only minutes before the storm hit, the chief nurse and the house supervisor made the decision to move all the patients to the ground floor because they were in “reasonably stable condition,” according to Dr. Womble, who relayed accounts by staffers who were there. Most of the people in the hospital rode out the storm in the first-floor cafeteria.

After the storm, patient rooms on the second floor were either no longer there or had been reduced to their steel innards.

The decision to move everyone undoubtedly saved lives. “If any of our patients stayed there, they’re probably all dead,” Dr. Raju said.

David Whitaker, CEO of Norman Regional Health System, which includes Moore Medical, marveled at the outcome.

“We had some bumps and bruises, some scratches, but no major lacerations, no broken bones, no injuries that people couldn’t ambulate. It’s totally amazing,” he said. “The leadership that was in place, the employees that were working at that time, they sprang into action, they took command and control of the situation. They got people into the proper areas.”

Dr. Womble said hospital staff at Moore Medical had still more amazing stories of death-defiance. They told him 30 people refused to leave the chapel. Somehow, the chapel remained intact, even though the hospital all around it was destroyed. Whitaker confirmed this.

One woman in active labor was kept in a second-floor operating room—which the medical staff thought was the best place for her, all things considered. Nurses covered the woman with pillows, blankets, and their own bodies as the tornado barreled through the town. She survived and gave birth to a boy several hours later. The parents gave him the middle name Emmanuel, which means “God is with us.”

As the tornado approached, an elderly volunteer had gone outside to get something from a van he used to transport elderly patients to and from a physical therapy program. “Nobody inside knew he had gone outside,” Dr. Womble said. By the time he tried to get back in, the power had gone out, and the doors wouldn’t open. He huddled behind a concrete pillar and ended up with just one minor laceration.

Patients eventually were taken to another hospital, Norman’s HealthPlex, about five miles south. Both Dr. Womble and Dr. Raju have begun working full time at the HealthPlex.

Dr. Raju said that he avoided being at Moore Medical during the tornado only by a turn of luck. He normally rounds at Moore in the afternoon and at the HealthPlex in the morning. But on that day, there were three new admissions at Moore, and only one at HealthPlex. So he went to Moore first, and was gone by the time the tornado hit.

“So lucky,” he said.

“We had some bumps and bruises, some scratches, but no major lacerations, no broken bones, no injuries that people couldn’t ambulate. It’s totally amazing. The leadership that was in place, the employees that were working at that time, they sprang into action, they took command and control of the situation. They got people into the proper areas.”

–David Whitaker, CEO of Norman Regional Health System

The Aftermath

It remains to be seen what kind of medical facility will be built to replace Moore Medical Center.

“Nobody knows what will happen next, but a lot of us speculate that they will not rebuild an inpatient facility,” said Dr. Womble, who had worked at Moore Medical Center for four years.

Whitaker said the first priority was to re-establish the clinics located at Moore Medical, and that has been done. The next step is, possibly, a temporary building in Moore for urgent care. The long-term plan remains in the discussion phase.

“We’ve already started having some meetings,” Whitaker said. “We’re going to determine what type of facility, what service levels it will be offering as we go back.”

It’s hard knowing that his hospital is no longer there, Dr. Raju said.

“We are going to miss it,” he said. “It’s unimaginable.”

Dr. Womble said those first few hours, when he wasn’t sure of where he’d be working, were difficult. He struggles to describe the feeling of not being able to provide care at his hospital at the time it’s most needed.

“It’s really hard to put it into words,” he said. “It’s the only hospital in that city, and it’s just me and my partner to take care of virtually everyone that comes in with any kind of medical problem. I definitely feel a tie to the community.

“It’s devastating. What is the rest of the city going to do for their hospital care? They essentially will not have a hospital in their city. They’ll have to drive to another city for care.”

Tom Collins is a freelance writer in South Florida.

Dr. Barrett

11 Things: At a Glance

1. You might be overdiagnosing transient ischemic attacks (TIA).
2. Early mobilization after a stroke might be better for some patients.
3. MRI is the best tool to evaluate TIA patients.
4. Consider focal seizure or complex partial seizure as one of the possible causes of confusion or speech disturbance, or both.
5. Tracking the time a hospitalized patient was last seen to be normal is crucial.
6. Consider neuromuscular disorders when a patient presents with weakness.
7. Urinary tract infections (UTIs) are not the only cause of altered mental status.
8. Take care in distinguishing aphasia from general confusion.
9. A simple checklist might eliminate the need to consult the neurologist.
10. Calling a neurologist earlier is way better than calling later.
11. Hire a neurohospitalist if your institution doesn’t have one already.

When a patient is admitted to the hospital with neurological symptoms, such as altered mental status, he or she might not be the only one who is confused. Hospitalists might be a little confused, too.

Of all the subspecialties to which hospitalists are exposed, none might make them more uncomfortable than neurology. Because of what often is a dearth of training in this area, and because of the vexing and sometimes fleeting nature of symptoms, hospitalists might be inclined to lean on neurologists more than other specialists.

The Hospitalist spoke with a half-dozen experts, gathering their words of guidance and clinical tips. Here’s hoping they give you a little extra confidence the next time you see a patient with altered mental status.

You might be overdiagnosing transient ischemic attacks (TIA).

Ira Chang, MD, a neurohospitalist with Blue Sky Neurology in Englewood, Colo., and assistant clinical professor at the University of Colorado Health Sciences Center in Denver, says TIA is all too commonly a go-to diagnosis, frequently when there’s another cause.

“I think that hospitalists, and maybe medical internists in general, are very quick to diagnose anything that has a neurologic symptom that comes and goes as a TIA,” she says. “Patients have to have specific neurologic symptoms that we think are due to arterial blood flow or ischemia problems.”

Near-fainting spells and dizzy spells involving confusion commonly are diagnosed as TIA when these symptoms could be due to “a number of other causes,” Dr. Chang adds.

Dr. Barrett

Kevin Barrett, MD, assistant professor of neurology and a neurohospitalist at Mayo Clinic in Jacksonville, Fla., says the suspicion of a TIA should be greater if the patient is older or has traditional cardiovascular risk factors, such as hyptertension, diabetes, hyperlipidemia, or tobacco use.

A TIA typically causes symptoms referable to common arterial distributions. Carotid-distribution TIA often causes ipsilateral loss of vision and contralateral weakness or numbness. Posterior-circulation TIAs bring on symptoms such as ataxia, unilateral or bilateral limb weakness, diplopia, and slurred or slow speech.

TIA diagnoses can be tricky even for those trained in neurology, Dr. Barrett says.

“Even among fellowship-trained vascular neurologists, TIA can be a challenging diagnosis, often with poor inter-observer agreement,” he notes.

Early mobilization after a stroke might be better for some patients.

After receiving tissue plasminogen activator (tPA) therapy for stroke, patients historically were kept on bed rest for 24 hours to reduce the risk of hemorrhage. Evidence now is coming to light that some patients might benefit from getting out of bed sooner, Dr. Barrett says.¹

“We’re learning that in selected patients, they can actually be mobilized at 12 hours,” he says. “In some cases, that would not only reduce the risk of complications related to immobilization like DVT but shorten length of stay. These are all important metrics for anybody who practices primarily within an inpatient setting.”

Early mobilization generally is more suitable for patients with less severe deficits and who are hemodynamically stable.

MRI is the best tool to evaluate TIA patients.

TIA patients who have transient symptoms and normal diffusion-weighted imaging (DWI) abnormalities on an MRI are at a very low risk. “Less than 1% of those patients have a stroke within the subsequent seven days,” Dr. Barrett says.² “But those patients who do have a DWI abnormality, they’re at very high risk: 7.1% at seven days.

“The utility of MRI following TIA is becoming very much apparent. It is something that hospitalists should be aware of.”

Consider focal seizure or complex partial seizure as one of the possible causes of confusion or speech disturbance, or both.

Patients experiencing confusion or speech disturbance or altered mentation—particularly if they’re elderly or have dementia—could be having a partial seizure, Dr. Chang says. Dementia patients have a 10% to 15% incidence of complex partial seizures, she says.

“I see that underdiagnosed a lot,” she says. “They keep coming back, and everybody diagnoses them with TIAs. So they keep getting put on aspirin, and they get switched to Aggrenox [to prevent clotting]. They keep coming back with the same symptoms.”

Tracking the time a hospitalized patient was last seen to be normal is crucial.

About 10% to 15% of strokes occur in patients who are in the hospital.

“While a lot of those strokes are perioperative, there also are patients who are going to be on hospitalist services,” says Eric Adelman, MD, assistant professor of neurology at the University of Michigan in Ann Arbor.

Dr. Adelman

Hospitalists should note that patients suffering strokes are found not just in the ED but also on the floor, where all the tools for treatment might not be as readily available. That makes those cases a challenge and makes forethought that much more important, Dr. Adelman says.

“It’s a matter of trying to track down last normal times,” he says. “If they’re eligible for tPA and they’re within the therapeutic window, we should be able to do that within a hospital.”

Establishing a neurological baseline is particularly important for patients who are at higher stroke risk, like those with atrial fibrillation and other cardiovascular risk factors.

“In case something does happen,” Dr. Adelman says, “at least you have a baseline so you can [know that] at time X, we knew they had full strength in their right arm, and now they don’t.”

Consider neuromuscular disorders when a patient presents with weakness.

It’s safe to say some hospitalists might miss a neuromuscular disorder, Dr. Chang says.

“A lot of disorders that are harder for hospitalists to diagnose and that tend to take longer to call a neurologist [on] are things that are due to myasthenia gravis [a breakdown between nerves and muscles leading to muscle fatigue], myopathy, or ALS,” she says. “Many patients present with weakness. I think a lot of times there will be a lot of tests on and a lot of treatment for general medical conditions that can cause weakness.”

And that might be a case of misdirected attention. Patients with weakness accompanied by persistent swallowing problems, slurred speech with no other obvious cause, or the inability to lift their head off the bed without an obvious cause may end up with a neuromuscular diagnosis, she says.

It would be helpful to have a neurologist’s input in these cases, she says, where “nothing’s getting better, and three, four, five days later, the patient’s still weak.

“I think a neurologist would be more in tune with something like that,” she adds.

Urinary tract infections (UTIs) are not the only cause of altered mental status.

That might seem obvious, but too often, a UTI can be pegged as the source of altered mental status when it should not be, Dr. Chang says.

“We get a lot of people who come in with confusion and they have a slightly abnormal urinalysis and they diagnose them with UTI,” Dr. Chang says. “And it turns out that they actually had a stroke or they had a seizure.”

Significantly altered mentation should show a significantly abnormal urine with a positive culture, she says. “They ought to have significant laboratory support for a urinary tract infection.”

Dr. Barrett says a neurologic review of systems, or at least a neurologic exam, should be the physician’s guide.

“Those are key parts of a hospitalist’s practice,” he says, “because that’s what’s truly going to guide them to consider primary neurological causes of altered mental status.”

Take care in distinguishing aphasia from general confusion.

If a patient is still talking and is fairly fluent, that doesn’t mean they aren’t suffering from certain types of aphasia, a disorder caused by damage to parts of the brain that control language, Dr. Adelman says.

“Oftentimes, when you’re dealing with a patient with confusion, you want to make sure that it’s confusion, or encephalopathy, rather than a focal neurologic problem like aphasia,” he says. “Frequently patients with aphasia will have other symptoms such as a facial drop or weakness in the arm, but stroke can present as isolated aphasia.”

A good habit to get into is to determine whether the patient can repeat a phrase, follow a command, or name objects, he says. If they can, they probably do not have aphasia.

“The thing that you worry about with aphasia, particularly acute onset aphasia, is an ischemic stroke,” Dr. Adelman says.

A simple checklist might eliminate the need to consult the neurologist.

When Edgar Kenton, MD, now director of the stroke program at Geisinger Health System in Danville, Pa., was at Emory University Hospital in Atlanta, he found he was getting snowed under with consults from hospitalists. There were about 15 hospitalists for just one or two neurologists.

“There was no way I was able to see these patients, particularly in follow-up, because you might get five consults every day,” he says. “By the middle of the week, that’s 15 consults. You don’t get a chance to go back and see the patients because you’re just going from one consult to the other.”

The situation improved with a checklist of things to consider when a patient presents with altered mental status. Before seeking a consult, neurologists suggested the hospitalists check the electrolytes, blood pressure, and urine, and use CT scans as a screening test. That might uncover the root of the patient’s problems. If those are clear, by all means get the neurologist involved, he says.

“We were able to educate the hospitalists so they knew when to call; they knew when it was beyond their expertise to take care of the patient, so we weren’t getting called for every patient with altered mental status when all they needed to do was to check the electrolytes,” Dr. Kenton says.

Calling a neurologist earlier is way better than calling later.

Once the decision is made to consult with a neurologist, the consult should be done right away, Dr. Kenton says, not after a few days when symptoms don’t appear to be improving.

“We’ll get the call on a Friday afternoon because they thought, finally, ‘Well, you know, we need to get neurology involved because we a) haven’t solved the problem and b) there may be some other tests we should be getting,’” he says of common situations. “That has been a problem. If you don’t have a neurohospitalist involved day by day, working with the patient and the general hospitalist, neurology becomes an afterthought.”

He says accurate and early diagnosis is paramount to the patient.

“If the diagnosis is delayed, obviously there’s more insult to the patients, more persistent insult,” he says, noting the timing is particularly important in neurological conditions “because things can get bad in a hurry.”

He strongly urges hospitalists to consult with a neurologist before ordering an entire battery of tests.

At Geisinger, neurologists are encouraging hospitalists to chat informally with neurosurgeons about cases for guidance at the outset rather than after several days.

Hire a neurohospitalist if your institution doesn’t have one already.

At the top of the list of Dr. Kenton’s suggestions on caring for hospitalized neurology patients is this declaration: “Get a neurohospitalist.”

“It’s important to have the neurologist involved from the time the patient’s admitted,” he says. “That’s the value of connecting the general hospitalist with neurologists.”

S. Andrew Josephson, MD, director of the neurohospitalist program at the University of California at San Francisco, says his colleagues are team players and improve patient care.

“Neurology consultations can be called very quickly, and a nice partnership can develop between internal medicine hospitalists and neurohospitalists to care for those patients who have those medical and neurologic problems,” he says.

He also says having a neurohospitalist on board can ease some of the tension.

“No longer if there’s a neurologic condition does a hospitalist have to think about, ‘Well, does this rise to the level of something that I need to get the neurologist to drive across the city to come see?’” he explains. “‘Or is this something we should try to manage ourselves?’”

Tom Collins is a freelance writer in South Florida.

“Neurophobia” a Challenge for Hospitalists, Other Physicians

The unease that many hospitalists, internal-medicine doctors, and other providers feel about treating neurologic conditions is so readily recognized that a term has been coined to describe it: “neurophobia.”

The term has been used in published literature for at least two decades. A 2010 survey found that medical students and residents felt that neurology was the specialty they had the least knowledge about and was the one that was the most difficult.³ And trainees had the least confidence in treating patients with neurological complaints.

S. Andrew Josephson, MD, director of the neurohospitalist program at the University of California at San Francisco, says internal-medicine hospitalists are “increasingly feeling uncomfortable with requests that they have to care for patients with a wide range of primary neurologic conditions in some instances.”

That has helped lead to the emergence of neurohospitalists, he says.

John Vazquez, MD, medical director of the division hospital medicine of Emory University Hospital in Atlanta, says neurophobia is real.

“Every hospitalist has different subspecialty areas that they’re less comfortable with, and I think neurology specifically is one that does scare a lot of hospitalists,” he says. “I think on one side there are hospitalists that might ignore a neurologic problem because they don’t really know what they don’t know. On the other side are the hospitalists who I think are just concerned that they don’t know the field very well and may not feel comfortable.”

Dr. Vazquez did rotations in nephrology, pulmonology, cardiology, and rheumatology but, like many hospitalists, not neurology.

“Neurology is not one that you have to go through,” he says.

He made these suggestions:

• Know what you don’t know and get guidance when necessary.
• Do your own neurologic assessment. Even if a neurologist decides confusion is due to a patient being elderly and having a urinary tract infection, that doesn’t mean that they didn’t actually have a stroke. So if something seems not quite right, be willing to challenge the neurologist.
• Use the resources available to widen your knowledge base.

“You can utilize the consultants for your own education if you have neurologists in your hospital, and many at least have some that rotate in,” Dr. Vazquez says. “You can pick their brain on what they would do with different strokes and what’s the newest thing and ongoing treatment and whatever it is you’re concerned about.”

—Thomas R. Collins

---

John Vazquez, MD, of Emory University Hospital talks about neurophobia and provides tips for adjusting to the discomfort of working with neurology patients.

References

1. Bernhardt J, Dewey H, Thrift A, Collier J, Donnan G. A very early rehabilitation trial for stroke (AVERT): phase II safety and feasibility. Stroke. 2008;39;390-396.
2. Giles MF, Albers GW, Amarenco P, et al. Early stroke risk and ABCD2 score performance in tissue- vs. time-defined TIA: a multicenter study. Neurology. 2011;77(13):1222-1228.
3. Zinchuk AV, Flanagan EP, Tubridy NJ, Miller WA, McCullough LD. Attitudes of US medical trainees towards neurology education: “Neurophobia”—a global issue. BMC Med Educ. 2010;10:49.

Dr. Barrett

11 Things: At a Glance

1. You might be overdiagnosing transient ischemic attacks (TIA).
2. Early mobilization after a stroke might be better for some patients.
3. MRI is the best tool to evaluate TIA patients.
4. Consider focal seizure or complex partial seizure as one of the possible causes of confusion or speech disturbance, or both.
5. Tracking the time a hospitalized patient was last seen to be normal is crucial.
6. Consider neuromuscular disorders when a patient presents with weakness.
7. Urinary tract infections (UTIs) are not the only cause of altered mental status.
8. Take care in distinguishing aphasia from general confusion.
9. A simple checklist might eliminate the need to consult the neurologist.
10. Calling a neurologist earlier is way better than calling later.
11. Hire a neurohospitalist if your institution doesn’t have one already.

When a patient is admitted to the hospital with neurological symptoms, such as altered mental status, he or she might not be the only one who is confused. Hospitalists might be a little confused, too.

Of all the subspecialties to which hospitalists are exposed, none might make them more uncomfortable than neurology. Because of what often is a dearth of training in this area, and because of the vexing and sometimes fleeting nature of symptoms, hospitalists might be inclined to lean on neurologists more than other specialists.

The Hospitalist spoke with a half-dozen experts, gathering their words of guidance and clinical tips. Here’s hoping they give you a little extra confidence the next time you see a patient with altered mental status.

You might be overdiagnosing transient ischemic attacks (TIA).

Ira Chang, MD, a neurohospitalist with Blue Sky Neurology in Englewood, Colo., and assistant clinical professor at the University of Colorado Health Sciences Center in Denver, says TIA is all too commonly a go-to diagnosis, frequently when there’s another cause.

“I think that hospitalists, and maybe medical internists in general, are very quick to diagnose anything that has a neurologic symptom that comes and goes as a TIA,” she says. “Patients have to have specific neurologic symptoms that we think are due to arterial blood flow or ischemia problems.”

Near-fainting spells and dizzy spells involving confusion commonly are diagnosed as TIA when these symptoms could be due to “a number of other causes,” Dr. Chang adds.

Dr. Barrett

Kevin Barrett, MD, assistant professor of neurology and a neurohospitalist at Mayo Clinic in Jacksonville, Fla., says the suspicion of a TIA should be greater if the patient is older or has traditional cardiovascular risk factors, such as hyptertension, diabetes, hyperlipidemia, or tobacco use.

A TIA typically causes symptoms referable to common arterial distributions. Carotid-distribution TIA often causes ipsilateral loss of vision and contralateral weakness or numbness. Posterior-circulation TIAs bring on symptoms such as ataxia, unilateral or bilateral limb weakness, diplopia, and slurred or slow speech.

TIA diagnoses can be tricky even for those trained in neurology, Dr. Barrett says.

“Even among fellowship-trained vascular neurologists, TIA can be a challenging diagnosis, often with poor inter-observer agreement,” he notes.

Early mobilization after a stroke might be better for some patients.

After receiving tissue plasminogen activator (tPA) therapy for stroke, patients historically were kept on bed rest for 24 hours to reduce the risk of hemorrhage. Evidence now is coming to light that some patients might benefit from getting out of bed sooner, Dr. Barrett says.¹

“We’re learning that in selected patients, they can actually be mobilized at 12 hours,” he says. “In some cases, that would not only reduce the risk of complications related to immobilization like DVT but shorten length of stay. These are all important metrics for anybody who practices primarily within an inpatient setting.”

Early mobilization generally is more suitable for patients with less severe deficits and who are hemodynamically stable.

MRI is the best tool to evaluate TIA patients.

TIA patients who have transient symptoms and normal diffusion-weighted imaging (DWI) abnormalities on an MRI are at a very low risk. “Less than 1% of those patients have a stroke within the subsequent seven days,” Dr. Barrett says.² “But those patients who do have a DWI abnormality, they’re at very high risk: 7.1% at seven days.

“The utility of MRI following TIA is becoming very much apparent. It is something that hospitalists should be aware of.”

Consider focal seizure or complex partial seizure as one of the possible causes of confusion or speech disturbance, or both.

Patients experiencing confusion or speech disturbance or altered mentation—particularly if they’re elderly or have dementia—could be having a partial seizure, Dr. Chang says. Dementia patients have a 10% to 15% incidence of complex partial seizures, she says.

“I see that underdiagnosed a lot,” she says. “They keep coming back, and everybody diagnoses them with TIAs. So they keep getting put on aspirin, and they get switched to Aggrenox [to prevent clotting]. They keep coming back with the same symptoms.”

Tracking the time a hospitalized patient was last seen to be normal is crucial.

About 10% to 15% of strokes occur in patients who are in the hospital.

“While a lot of those strokes are perioperative, there also are patients who are going to be on hospitalist services,” says Eric Adelman, MD, assistant professor of neurology at the University of Michigan in Ann Arbor.

Dr. Adelman

Hospitalists should note that patients suffering strokes are found not just in the ED but also on the floor, where all the tools for treatment might not be as readily available. That makes those cases a challenge and makes forethought that much more important, Dr. Adelman says.

“It’s a matter of trying to track down last normal times,” he says. “If they’re eligible for tPA and they’re within the therapeutic window, we should be able to do that within a hospital.”

Establishing a neurological baseline is particularly important for patients who are at higher stroke risk, like those with atrial fibrillation and other cardiovascular risk factors.

“In case something does happen,” Dr. Adelman says, “at least you have a baseline so you can [know that] at time X, we knew they had full strength in their right arm, and now they don’t.”

Consider neuromuscular disorders when a patient presents with weakness.

It’s safe to say some hospitalists might miss a neuromuscular disorder, Dr. Chang says.

“A lot of disorders that are harder for hospitalists to diagnose and that tend to take longer to call a neurologist [on] are things that are due to myasthenia gravis [a breakdown between nerves and muscles leading to muscle fatigue], myopathy, or ALS,” she says. “Many patients present with weakness. I think a lot of times there will be a lot of tests on and a lot of treatment for general medical conditions that can cause weakness.”

And that might be a case of misdirected attention. Patients with weakness accompanied by persistent swallowing problems, slurred speech with no other obvious cause, or the inability to lift their head off the bed without an obvious cause may end up with a neuromuscular diagnosis, she says.

It would be helpful to have a neurologist’s input in these cases, she says, where “nothing’s getting better, and three, four, five days later, the patient’s still weak.

“I think a neurologist would be more in tune with something like that,” she adds.

Urinary tract infections (UTIs) are not the only cause of altered mental status.

That might seem obvious, but too often, a UTI can be pegged as the source of altered mental status when it should not be, Dr. Chang says.

“We get a lot of people who come in with confusion and they have a slightly abnormal urinalysis and they diagnose them with UTI,” Dr. Chang says. “And it turns out that they actually had a stroke or they had a seizure.”

Significantly altered mentation should show a significantly abnormal urine with a positive culture, she says. “They ought to have significant laboratory support for a urinary tract infection.”

Dr. Barrett says a neurologic review of systems, or at least a neurologic exam, should be the physician’s guide.

“Those are key parts of a hospitalist’s practice,” he says, “because that’s what’s truly going to guide them to consider primary neurological causes of altered mental status.”

Take care in distinguishing aphasia from general confusion.

If a patient is still talking and is fairly fluent, that doesn’t mean they aren’t suffering from certain types of aphasia, a disorder caused by damage to parts of the brain that control language, Dr. Adelman says.

“Oftentimes, when you’re dealing with a patient with confusion, you want to make sure that it’s confusion, or encephalopathy, rather than a focal neurologic problem like aphasia,” he says. “Frequently patients with aphasia will have other symptoms such as a facial drop or weakness in the arm, but stroke can present as isolated aphasia.”

A good habit to get into is to determine whether the patient can repeat a phrase, follow a command, or name objects, he says. If they can, they probably do not have aphasia.

“The thing that you worry about with aphasia, particularly acute onset aphasia, is an ischemic stroke,” Dr. Adelman says.

A simple checklist might eliminate the need to consult the neurologist.

When Edgar Kenton, MD, now director of the stroke program at Geisinger Health System in Danville, Pa., was at Emory University Hospital in Atlanta, he found he was getting snowed under with consults from hospitalists. There were about 15 hospitalists for just one or two neurologists.

“There was no way I was able to see these patients, particularly in follow-up, because you might get five consults every day,” he says. “By the middle of the week, that’s 15 consults. You don’t get a chance to go back and see the patients because you’re just going from one consult to the other.”

The situation improved with a checklist of things to consider when a patient presents with altered mental status. Before seeking a consult, neurologists suggested the hospitalists check the electrolytes, blood pressure, and urine, and use CT scans as a screening test. That might uncover the root of the patient’s problems. If those are clear, by all means get the neurologist involved, he says.

“We were able to educate the hospitalists so they knew when to call; they knew when it was beyond their expertise to take care of the patient, so we weren’t getting called for every patient with altered mental status when all they needed to do was to check the electrolytes,” Dr. Kenton says.

Calling a neurologist earlier is way better than calling later.

Once the decision is made to consult with a neurologist, the consult should be done right away, Dr. Kenton says, not after a few days when symptoms don’t appear to be improving.

“We’ll get the call on a Friday afternoon because they thought, finally, ‘Well, you know, we need to get neurology involved because we a) haven’t solved the problem and b) there may be some other tests we should be getting,’” he says of common situations. “That has been a problem. If you don’t have a neurohospitalist involved day by day, working with the patient and the general hospitalist, neurology becomes an afterthought.”

He says accurate and early diagnosis is paramount to the patient.

“If the diagnosis is delayed, obviously there’s more insult to the patients, more persistent insult,” he says, noting the timing is particularly important in neurological conditions “because things can get bad in a hurry.”

He strongly urges hospitalists to consult with a neurologist before ordering an entire battery of tests.

At Geisinger, neurologists are encouraging hospitalists to chat informally with neurosurgeons about cases for guidance at the outset rather than after several days.

Hire a neurohospitalist if your institution doesn’t have one already.

At the top of the list of Dr. Kenton’s suggestions on caring for hospitalized neurology patients is this declaration: “Get a neurohospitalist.”

“It’s important to have the neurologist involved from the time the patient’s admitted,” he says. “That’s the value of connecting the general hospitalist with neurologists.”

S. Andrew Josephson, MD, director of the neurohospitalist program at the University of California at San Francisco, says his colleagues are team players and improve patient care.

“Neurology consultations can be called very quickly, and a nice partnership can develop between internal medicine hospitalists and neurohospitalists to care for those patients who have those medical and neurologic problems,” he says.

He also says having a neurohospitalist on board can ease some of the tension.

“No longer if there’s a neurologic condition does a hospitalist have to think about, ‘Well, does this rise to the level of something that I need to get the neurologist to drive across the city to come see?’” he explains. “‘Or is this something we should try to manage ourselves?’”

Tom Collins is a freelance writer in South Florida.

“Neurophobia” a Challenge for Hospitalists, Other Physicians

The unease that many hospitalists, internal-medicine doctors, and other providers feel about treating neurologic conditions is so readily recognized that a term has been coined to describe it: “neurophobia.”

The term has been used in published literature for at least two decades. A 2010 survey found that medical students and residents felt that neurology was the specialty they had the least knowledge about and was the one that was the most difficult.³ And trainees had the least confidence in treating patients with neurological complaints.

S. Andrew Josephson, MD, director of the neurohospitalist program at the University of California at San Francisco, says internal-medicine hospitalists are “increasingly feeling uncomfortable with requests that they have to care for patients with a wide range of primary neurologic conditions in some instances.”

That has helped lead to the emergence of neurohospitalists, he says.

John Vazquez, MD, medical director of the division hospital medicine of Emory University Hospital in Atlanta, says neurophobia is real.

“Every hospitalist has different subspecialty areas that they’re less comfortable with, and I think neurology specifically is one that does scare a lot of hospitalists,” he says. “I think on one side there are hospitalists that might ignore a neurologic problem because they don’t really know what they don’t know. On the other side are the hospitalists who I think are just concerned that they don’t know the field very well and may not feel comfortable.”

Dr. Vazquez did rotations in nephrology, pulmonology, cardiology, and rheumatology but, like many hospitalists, not neurology.

“Neurology is not one that you have to go through,” he says.

He made these suggestions:

• Know what you don’t know and get guidance when necessary.
• Do your own neurologic assessment. Even if a neurologist decides confusion is due to a patient being elderly and having a urinary tract infection, that doesn’t mean that they didn’t actually have a stroke. So if something seems not quite right, be willing to challenge the neurologist.
• Use the resources available to widen your knowledge base.

“You can utilize the consultants for your own education if you have neurologists in your hospital, and many at least have some that rotate in,” Dr. Vazquez says. “You can pick their brain on what they would do with different strokes and what’s the newest thing and ongoing treatment and whatever it is you’re concerned about.”

—Thomas R. Collins

---

John Vazquez, MD, of Emory University Hospital talks about neurophobia and provides tips for adjusting to the discomfort of working with neurology patients.

References

1. Bernhardt J, Dewey H, Thrift A, Collier J, Donnan G. A very early rehabilitation trial for stroke (AVERT): phase II safety and feasibility. Stroke. 2008;39;390-396.
2. Giles MF, Albers GW, Amarenco P, et al. Early stroke risk and ABCD2 score performance in tissue- vs. time-defined TIA: a multicenter study. Neurology. 2011;77(13):1222-1228.
3. Zinchuk AV, Flanagan EP, Tubridy NJ, Miller WA, McCullough LD. Attitudes of US medical trainees towards neurology education: “Neurophobia”—a global issue. BMC Med Educ. 2010;10:49.

Dr. Barrett

11 Things: At a Glance

1. You might be overdiagnosing transient ischemic attacks (TIA).
2. Early mobilization after a stroke might be better for some patients.
3. MRI is the best tool to evaluate TIA patients.
4. Consider focal seizure or complex partial seizure as one of the possible causes of confusion or speech disturbance, or both.
5. Tracking the time a hospitalized patient was last seen to be normal is crucial.
6. Consider neuromuscular disorders when a patient presents with weakness.
7. Urinary tract infections (UTIs) are not the only cause of altered mental status.
8. Take care in distinguishing aphasia from general confusion.
9. A simple checklist might eliminate the need to consult the neurologist.
10. Calling a neurologist earlier is way better than calling later.
11. Hire a neurohospitalist if your institution doesn’t have one already.

When a patient is admitted to the hospital with neurological symptoms, such as altered mental status, he or she might not be the only one who is confused. Hospitalists might be a little confused, too.

Of all the subspecialties to which hospitalists are exposed, none might make them more uncomfortable than neurology. Because of what often is a dearth of training in this area, and because of the vexing and sometimes fleeting nature of symptoms, hospitalists might be inclined to lean on neurologists more than other specialists.

The Hospitalist spoke with a half-dozen experts, gathering their words of guidance and clinical tips. Here’s hoping they give you a little extra confidence the next time you see a patient with altered mental status.

You might be overdiagnosing transient ischemic attacks (TIA).

Ira Chang, MD, a neurohospitalist with Blue Sky Neurology in Englewood, Colo., and assistant clinical professor at the University of Colorado Health Sciences Center in Denver, says TIA is all too commonly a go-to diagnosis, frequently when there’s another cause.

“I think that hospitalists, and maybe medical internists in general, are very quick to diagnose anything that has a neurologic symptom that comes and goes as a TIA,” she says. “Patients have to have specific neurologic symptoms that we think are due to arterial blood flow or ischemia problems.”

Near-fainting spells and dizzy spells involving confusion commonly are diagnosed as TIA when these symptoms could be due to “a number of other causes,” Dr. Chang adds.

Dr. Barrett

Kevin Barrett, MD, assistant professor of neurology and a neurohospitalist at Mayo Clinic in Jacksonville, Fla., says the suspicion of a TIA should be greater if the patient is older or has traditional cardiovascular risk factors, such as hyptertension, diabetes, hyperlipidemia, or tobacco use.

A TIA typically causes symptoms referable to common arterial distributions. Carotid-distribution TIA often causes ipsilateral loss of vision and contralateral weakness or numbness. Posterior-circulation TIAs bring on symptoms such as ataxia, unilateral or bilateral limb weakness, diplopia, and slurred or slow speech.

TIA diagnoses can be tricky even for those trained in neurology, Dr. Barrett says.

“Even among fellowship-trained vascular neurologists, TIA can be a challenging diagnosis, often with poor inter-observer agreement,” he notes.

Early mobilization after a stroke might be better for some patients.

After receiving tissue plasminogen activator (tPA) therapy for stroke, patients historically were kept on bed rest for 24 hours to reduce the risk of hemorrhage. Evidence now is coming to light that some patients might benefit from getting out of bed sooner, Dr. Barrett says.¹

“We’re learning that in selected patients, they can actually be mobilized at 12 hours,” he says. “In some cases, that would not only reduce the risk of complications related to immobilization like DVT but shorten length of stay. These are all important metrics for anybody who practices primarily within an inpatient setting.”

Early mobilization generally is more suitable for patients with less severe deficits and who are hemodynamically stable.

MRI is the best tool to evaluate TIA patients.

TIA patients who have transient symptoms and normal diffusion-weighted imaging (DWI) abnormalities on an MRI are at a very low risk. “Less than 1% of those patients have a stroke within the subsequent seven days,” Dr. Barrett says.² “But those patients who do have a DWI abnormality, they’re at very high risk: 7.1% at seven days.

“The utility of MRI following TIA is becoming very much apparent. It is something that hospitalists should be aware of.”

Consider focal seizure or complex partial seizure as one of the possible causes of confusion or speech disturbance, or both.

Patients experiencing confusion or speech disturbance or altered mentation—particularly if they’re elderly or have dementia—could be having a partial seizure, Dr. Chang says. Dementia patients have a 10% to 15% incidence of complex partial seizures, she says.

“I see that underdiagnosed a lot,” she says. “They keep coming back, and everybody diagnoses them with TIAs. So they keep getting put on aspirin, and they get switched to Aggrenox [to prevent clotting]. They keep coming back with the same symptoms.”

Tracking the time a hospitalized patient was last seen to be normal is crucial.

About 10% to 15% of strokes occur in patients who are in the hospital.

“While a lot of those strokes are perioperative, there also are patients who are going to be on hospitalist services,” says Eric Adelman, MD, assistant professor of neurology at the University of Michigan in Ann Arbor.

Dr. Adelman

Hospitalists should note that patients suffering strokes are found not just in the ED but also on the floor, where all the tools for treatment might not be as readily available. That makes those cases a challenge and makes forethought that much more important, Dr. Adelman says.

“It’s a matter of trying to track down last normal times,” he says. “If they’re eligible for tPA and they’re within the therapeutic window, we should be able to do that within a hospital.”

Establishing a neurological baseline is particularly important for patients who are at higher stroke risk, like those with atrial fibrillation and other cardiovascular risk factors.

“In case something does happen,” Dr. Adelman says, “at least you have a baseline so you can [know that] at time X, we knew they had full strength in their right arm, and now they don’t.”

Consider neuromuscular disorders when a patient presents with weakness.

It’s safe to say some hospitalists might miss a neuromuscular disorder, Dr. Chang says.

“A lot of disorders that are harder for hospitalists to diagnose and that tend to take longer to call a neurologist [on] are things that are due to myasthenia gravis [a breakdown between nerves and muscles leading to muscle fatigue], myopathy, or ALS,” she says. “Many patients present with weakness. I think a lot of times there will be a lot of tests on and a lot of treatment for general medical conditions that can cause weakness.”

And that might be a case of misdirected attention. Patients with weakness accompanied by persistent swallowing problems, slurred speech with no other obvious cause, or the inability to lift their head off the bed without an obvious cause may end up with a neuromuscular diagnosis, she says.

It would be helpful to have a neurologist’s input in these cases, she says, where “nothing’s getting better, and three, four, five days later, the patient’s still weak.

“I think a neurologist would be more in tune with something like that,” she adds.

Urinary tract infections (UTIs) are not the only cause of altered mental status.

That might seem obvious, but too often, a UTI can be pegged as the source of altered mental status when it should not be, Dr. Chang says.

“We get a lot of people who come in with confusion and they have a slightly abnormal urinalysis and they diagnose them with UTI,” Dr. Chang says. “And it turns out that they actually had a stroke or they had a seizure.”

Significantly altered mentation should show a significantly abnormal urine with a positive culture, she says. “They ought to have significant laboratory support for a urinary tract infection.”

Dr. Barrett says a neurologic review of systems, or at least a neurologic exam, should be the physician’s guide.

“Those are key parts of a hospitalist’s practice,” he says, “because that’s what’s truly going to guide them to consider primary neurological causes of altered mental status.”

Take care in distinguishing aphasia from general confusion.

If a patient is still talking and is fairly fluent, that doesn’t mean they aren’t suffering from certain types of aphasia, a disorder caused by damage to parts of the brain that control language, Dr. Adelman says.

“Oftentimes, when you’re dealing with a patient with confusion, you want to make sure that it’s confusion, or encephalopathy, rather than a focal neurologic problem like aphasia,” he says. “Frequently patients with aphasia will have other symptoms such as a facial drop or weakness in the arm, but stroke can present as isolated aphasia.”

A good habit to get into is to determine whether the patient can repeat a phrase, follow a command, or name objects, he says. If they can, they probably do not have aphasia.

“The thing that you worry about with aphasia, particularly acute onset aphasia, is an ischemic stroke,” Dr. Adelman says.

A simple checklist might eliminate the need to consult the neurologist.

When Edgar Kenton, MD, now director of the stroke program at Geisinger Health System in Danville, Pa., was at Emory University Hospital in Atlanta, he found he was getting snowed under with consults from hospitalists. There were about 15 hospitalists for just one or two neurologists.

“There was no way I was able to see these patients, particularly in follow-up, because you might get five consults every day,” he says. “By the middle of the week, that’s 15 consults. You don’t get a chance to go back and see the patients because you’re just going from one consult to the other.”

The situation improved with a checklist of things to consider when a patient presents with altered mental status. Before seeking a consult, neurologists suggested the hospitalists check the electrolytes, blood pressure, and urine, and use CT scans as a screening test. That might uncover the root of the patient’s problems. If those are clear, by all means get the neurologist involved, he says.

“We were able to educate the hospitalists so they knew when to call; they knew when it was beyond their expertise to take care of the patient, so we weren’t getting called for every patient with altered mental status when all they needed to do was to check the electrolytes,” Dr. Kenton says.

Calling a neurologist earlier is way better than calling later.

Once the decision is made to consult with a neurologist, the consult should be done right away, Dr. Kenton says, not after a few days when symptoms don’t appear to be improving.

“We’ll get the call on a Friday afternoon because they thought, finally, ‘Well, you know, we need to get neurology involved because we a) haven’t solved the problem and b) there may be some other tests we should be getting,’” he says of common situations. “That has been a problem. If you don’t have a neurohospitalist involved day by day, working with the patient and the general hospitalist, neurology becomes an afterthought.”

He says accurate and early diagnosis is paramount to the patient.

“If the diagnosis is delayed, obviously there’s more insult to the patients, more persistent insult,” he says, noting the timing is particularly important in neurological conditions “because things can get bad in a hurry.”

He strongly urges hospitalists to consult with a neurologist before ordering an entire battery of tests.

At Geisinger, neurologists are encouraging hospitalists to chat informally with neurosurgeons about cases for guidance at the outset rather than after several days.

Hire a neurohospitalist if your institution doesn’t have one already.

At the top of the list of Dr. Kenton’s suggestions on caring for hospitalized neurology patients is this declaration: “Get a neurohospitalist.”

“It’s important to have the neurologist involved from the time the patient’s admitted,” he says. “That’s the value of connecting the general hospitalist with neurologists.”

S. Andrew Josephson, MD, director of the neurohospitalist program at the University of California at San Francisco, says his colleagues are team players and improve patient care.

“Neurology consultations can be called very quickly, and a nice partnership can develop between internal medicine hospitalists and neurohospitalists to care for those patients who have those medical and neurologic problems,” he says.

He also says having a neurohospitalist on board can ease some of the tension.

“No longer if there’s a neurologic condition does a hospitalist have to think about, ‘Well, does this rise to the level of something that I need to get the neurologist to drive across the city to come see?’” he explains. “‘Or is this something we should try to manage ourselves?’”

Tom Collins is a freelance writer in South Florida.

“Neurophobia” a Challenge for Hospitalists, Other Physicians

The unease that many hospitalists, internal-medicine doctors, and other providers feel about treating neurologic conditions is so readily recognized that a term has been coined to describe it: “neurophobia.”

The term has been used in published literature for at least two decades. A 2010 survey found that medical students and residents felt that neurology was the specialty they had the least knowledge about and was the one that was the most difficult.³ And trainees had the least confidence in treating patients with neurological complaints.

S. Andrew Josephson, MD, director of the neurohospitalist program at the University of California at San Francisco, says internal-medicine hospitalists are “increasingly feeling uncomfortable with requests that they have to care for patients with a wide range of primary neurologic conditions in some instances.”

That has helped lead to the emergence of neurohospitalists, he says.

John Vazquez, MD, medical director of the division hospital medicine of Emory University Hospital in Atlanta, says neurophobia is real.

“Every hospitalist has different subspecialty areas that they’re less comfortable with, and I think neurology specifically is one that does scare a lot of hospitalists,” he says. “I think on one side there are hospitalists that might ignore a neurologic problem because they don’t really know what they don’t know. On the other side are the hospitalists who I think are just concerned that they don’t know the field very well and may not feel comfortable.”

Dr. Vazquez did rotations in nephrology, pulmonology, cardiology, and rheumatology but, like many hospitalists, not neurology.

“Neurology is not one that you have to go through,” he says.

He made these suggestions:

• Know what you don’t know and get guidance when necessary.
• Do your own neurologic assessment. Even if a neurologist decides confusion is due to a patient being elderly and having a urinary tract infection, that doesn’t mean that they didn’t actually have a stroke. So if something seems not quite right, be willing to challenge the neurologist.
• Use the resources available to widen your knowledge base.

“You can utilize the consultants for your own education if you have neurologists in your hospital, and many at least have some that rotate in,” Dr. Vazquez says. “You can pick their brain on what they would do with different strokes and what’s the newest thing and ongoing treatment and whatever it is you’re concerned about.”

—Thomas R. Collins

---

John Vazquez, MD, of Emory University Hospital talks about neurophobia and provides tips for adjusting to the discomfort of working with neurology patients.

References

1. Bernhardt J, Dewey H, Thrift A, Collier J, Donnan G. A very early rehabilitation trial for stroke (AVERT): phase II safety and feasibility. Stroke. 2008;39;390-396.
2. Giles MF, Albers GW, Amarenco P, et al. Early stroke risk and ABCD2 score performance in tissue- vs. time-defined TIA: a multicenter study. Neurology. 2011;77(13):1222-1228.
3. Zinchuk AV, Flanagan EP, Tubridy NJ, Miller WA, McCullough LD. Attitudes of US medical trainees towards neurology education: “Neurophobia”—a global issue. BMC Med Educ. 2010;10:49.

Laura Mirkinson, MD, MSc, FAAP, pediatric hospitalist and a founder of the American Academy of Pediatrics’ (AAP) Section on Hospital Medicine Executive Committee, died April 29 of ovarian cancer. She was 60.

Dr. Mirkinson received her medical degree from Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Md., before serving her pediatrics residency at Bethesda Naval Hospital and Walter Reed Army Medical Center. She served as an active-duty medical officer in the U.S. Naval Medical Corps Reserves before retiring as a captain in 2000. She then worked at Children’s Hospital of Washington and the pediatric hospitalist group at Holy Cross Hospital in Silver Spring, Md.

Dr. Mirkinson played a role in the development of pediatric hospital medicine during and after her military service. In 2007, she was elected chief of pediatrics at Blythedale Children’s Hospital in Valhalla, N.Y. She also served as director of education for the AAP’s Section on Hospital Medicine and was its second chairperson, following the section’s co-founder Jack Percelay, MD, FAAP. Through this work, she helped promote the AAP Section on Hospital Medicine newsletter, as well as the Hospital Pediatrics journal.

Dr. Mirkinson’s colleagues and students remember her as a caring, insightful teacher and mentor who offered wise advice on all matters professional and personal. Her devotion to patient care was evident throughout her career. Even in her administrative roles, she would often practice clinical medicine to help fill scheduling gaps or cover other physicians’ vacations.

Laura Mirkinson, MD, MSc, FAAP, pediatric hospitalist and a founder of the American Academy of Pediatrics’ (AAP) Section on Hospital Medicine Executive Committee, died April 29 of ovarian cancer. She was 60.

Dr. Mirkinson received her medical degree from Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Md., before serving her pediatrics residency at Bethesda Naval Hospital and Walter Reed Army Medical Center. She served as an active-duty medical officer in the U.S. Naval Medical Corps Reserves before retiring as a captain in 2000. She then worked at Children’s Hospital of Washington and the pediatric hospitalist group at Holy Cross Hospital in Silver Spring, Md.

Dr. Mirkinson played a role in the development of pediatric hospital medicine during and after her military service. In 2007, she was elected chief of pediatrics at Blythedale Children’s Hospital in Valhalla, N.Y. She also served as director of education for the AAP’s Section on Hospital Medicine and was its second chairperson, following the section’s co-founder Jack Percelay, MD, FAAP. Through this work, she helped promote the AAP Section on Hospital Medicine newsletter, as well as the Hospital Pediatrics journal.

Dr. Mirkinson’s colleagues and students remember her as a caring, insightful teacher and mentor who offered wise advice on all matters professional and personal. Her devotion to patient care was evident throughout her career. Even in her administrative roles, she would often practice clinical medicine to help fill scheduling gaps or cover other physicians’ vacations.

Laura Mirkinson, MD, MSc, FAAP, pediatric hospitalist and a founder of the American Academy of Pediatrics’ (AAP) Section on Hospital Medicine Executive Committee, died April 29 of ovarian cancer. She was 60.

Dr. Mirkinson received her medical degree from Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Md., before serving her pediatrics residency at Bethesda Naval Hospital and Walter Reed Army Medical Center. She served as an active-duty medical officer in the U.S. Naval Medical Corps Reserves before retiring as a captain in 2000. She then worked at Children’s Hospital of Washington and the pediatric hospitalist group at Holy Cross Hospital in Silver Spring, Md.

Dr. Mirkinson played a role in the development of pediatric hospital medicine during and after her military service. In 2007, she was elected chief of pediatrics at Blythedale Children’s Hospital in Valhalla, N.Y. She also served as director of education for the AAP’s Section on Hospital Medicine and was its second chairperson, following the section’s co-founder Jack Percelay, MD, FAAP. Through this work, she helped promote the AAP Section on Hospital Medicine newsletter, as well as the Hospital Pediatrics journal.

Dr. Mirkinson’s colleagues and students remember her as a caring, insightful teacher and mentor who offered wise advice on all matters professional and personal. Her devotion to patient care was evident throughout her career. Even in her administrative roles, she would often practice clinical medicine to help fill scheduling gaps or cover other physicians’ vacations.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Steroids may increase VTE risk
2. Mortality rates rise at critical-care hospitals
3. Physicians don’t discuss advance-care planning with elderly, families
4. Ultrasound imaging for lumbar puncture, epidural catheterization
5. Financial impact of surgical complications on hospitals
6. Lab test fees and frequency of test ordering
7. Inpatient elderly multidisciplinary teams reduce readmissions
8. Use of beta-blockers in high-risk patients during noncardiac surgery
9. Patient-centered decision-making and health-care outcomes
10. Adverse surgical outcomes in patients with schizophrenia

Steroids May Increase VTE Risk

Clinical question: Is exogenous glucocorticoid administration associated with an increased risk of VTE?

Background: Endogenous hypercortisolism is linked to increased VTE rates, and pathophysiologic data exist to suggest glucocorticoids increase clotting, but few studies have measured the clinical link between glucocorticoid administration and VTE events.

Study design: Case-control study.

Setting: Denmark.

Synopsis: The authors analyzed Danish national registries, which include information on diagnoses and prescriptions. The study selection period was Jan. 1, 2005, to Dec. 31, 2011. During this period, 38,675 cases of VTE (both DVT and pulmonary embolism) were identified in the population of Denmark. These cases were matched with 387,650 controls. Three routes of glucocorticoid use were studied: systemic (oral and intravenous), inhaled, and intestinal-acting. Cases were classified as present (within 90 days of VTE event), recent (91 to 365 days), or former (over 365 days) users of glucocorticoids. Categories were also created for new versus continuous users.

Glucocorticoid use was associated with a significant increase in VTE occurrence. The strongest link was in new and recent users, and the effect diminished over time. Key limitations of the study included its reliance on registry data, as well as the fact that cases had more comorbid conditions than controls (e.g. recent infection, chronic illnesses).

Bottom line: Recipients of glucocorticoids had an increased risk of VTE; the effect was strongest in new and recent users.

Citation: Johannesdottir SA, Horvath-Puho E, Dekkers OM, et al. Use of glucocorticoids and risk of venous thromboembolism. JAMA Intern Med. 2013;173(9):743-752.

Mortality Rates Rise at Critical-Access Hospitals

Clinical question: How have trends in mortality changed in the past decade at critical-access hospitals when compared to other hospitals?

Background: Hospitals are designated as critical-access hospitals (CAH) by meeting certain requirements—namely, rural setting, small number of beds, and minimum distance from the nearest hospital. Because of the intrinsic challenges they face, CAHs are exempt from certain quality measures. Little data exist on patient outcomes at CAHs.

Study design: Retrospective observational study.

Setting: All nonfederal hospitals in the U.S. that provide acute care to Medicare beneficiaries.

Synopsis: Using Medicare data, risk-adjusted 30-day mortality rates were calculated at critical-access hospitals and non-critical-access hospitals from 2002 to 2010 for three conditions: acute myocardial infarction, congestive heart failure, and pneumonia. Mortality trends across these conditions were compared at baseline and over time. In 2002, CAHs had mortality rates comparable with non-CAHs. From 2002 to 2010, mortality rates increased by 0.1% per year at CAHs and decreased by 0.2% per year at non-CAHs, resulting in a mortality difference between these two hospital groups at the end of the study period. The authors postulate that differences in policy initiatives, enforcement of quality measures, and access to technology may play a role.

This study is limited in its ability to explain the findings. Notably, within the CAHs, the authors found that 48% did improve from 2002 to 2010; there were no significant differences in hospital characteristics between the CAHs that did and did not improve. The reasons for the overall widening gap between CAHs and non-CAHs, therefore, merit further investigation.

Bottom line: From 2002 to 2010, mortality rates at U.S. critical-access hospitals rose while rates fell at non-critical access hospitals.

Citation: Joynt KE, Orav EJ, Jha AK. Mortality rates for Medicare beneficiaries admitted to critical access and non-critical access hospitals, 2002-2010. JAMA. 2013;309(13):1379-1387.

Physicians Fail to Discuss Advance-Care Planning with Hospitalized Elderly, Relatives

Clinical question: Do elderly patients who are at high risk for death have documented advance-care plans, and do their physicians discuss goals of care with them?

Background: While studies indicate that most sick, elderly patients prefer a better quality of life to life-sustaining treatment, many patients still die in the hospital, often in the ICU. It is unclear whether this is due to the absence of advance-care planning or the lack of communicating goals of care.

Study design: Multicenter prospective cohort study.

Setting: Canada.

Synopsis: A validated questionnaire was used to evaluate advance-care planning both before hospitalization and on admission. Patients and their families were enrolled if they were considered at high risk for dying, including patients with advanced disease, or aged >80 years. Of the 278 patients enrolled, 76.3% had thought about advance-care planning. Approximately 47.9% of patients had written an advance-care plan, and 73.3% had formally documented a surrogate health-care decision-maker. Only a quarter of patients reported that they had been asked about advance-care planning on admission to the hospital. Patients’ stated preferences for end-of-life care were notably incongruent with goals-of-care orders documented in the hospital records. While 28% of patients preferred comfort-only care, this was documented in the hospital records for only 4.5% of patients.

In this study of mostly white, English-speaking hospitalized patients, many had considered and made advance-care plans but few had discussed this with their health-care providers. Not surprisingly, the goals-of-care orders that were documented did not match patients’ previously stated end-of-life preferences.

Bottom line: Physicians routinely fail to discuss patients’ advance-care planning, which may have profound effects on their inpatient care.

Citation: Heyland DK, Barwich D, Pichora D, et al. Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Intern Med. 2013;173(9):778-787.

Ultrasound Use Reduces Lumbar Puncture and Epidural Catheterization Failure

Clinical question: Does ultrasound imaging for lumbar puncture and epidural catheterization reduce risk of procedure failures?

Background: Numerous studies have compared ultrasound-guided lumbar puncture and epidural catheterization with standard techniques, but they have been underpowered to evaluate whether ultrasound use reduces lumbar puncture and epidural catheterization failure.

Study design: Systematic review and meta-analysis of randomized controlled trials.

Setting: Hospitals in North America, Europe, and Asia.

Synopsis: Among 14 trials, a total of 1,334 patients (including one pediatric study group) were randomly assigned either to receive ultrasound imaging or to a control group (using manual palpation or loss of resistance). Ultrasound imaging comprised a preprocedure marking approach, real-time visual guidance, or both. In the 12 trials in which the primary outcome was available, ultrasound imaging significantly reduced the risk of failed procedures with a risk ratio of 0.21 (95% confidence interval 0.10 to 0.43). A total of 16 ultrasound-guided procedures were needed to avoid one procedure failure. Ultrasound guidance also reduced the number of traumatic procedures, needle reinsertions, and needle redirections. These results were consistent across multiple subgroup analyses.

Only one of the studies included in the meta-analysis was double-blind, and in all of the studies, ultrasound imaging was performed by a clinician with high-level ultrasound experience. While this study suggests that ultrasound does reduce the frequency of procedure failure, the investigators did not include cost-effectiveness analyses.

Bottom line: Ultrasound imaging likely reduces the failure of lumbar puncture and epidural catheterization, but future research will be necessary to evaluate the cost-effectiveness of ultrasound use for these procedures.

Citation: Shaikh F, Brzezinski J, Alexander S, et al. Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis. BMJ. 2013;346:f1720.

Surgical Complications might Be Financially Advantageous for Hospitals

Clinical question: What is the impact of surgical complications on hospital finances?

Background: Surgical complications are common and lead to longer lengths of stay and higher costs. Strategies are available to reduce postsurgical complications but have not been universally adopted.

Study design: Observational study.

Setting: Twelve hospitals in one nonprofit Southern hospital system, which includes academic, nonacademic, and rural settings.

Synopsis: Researchers identified 34,526 patients who underwent surgery in 2010, excluding patients undergoing Caesarean section. Of those, 1,820 procedures (5.3%) were associated with at least one complication. The most frequent complications were surgical-site infection, other infections, pneumonia, and thromboembolic disease. The mortality rate for patients with complications was 12.3% compared with 0.6% for those without. Length of stay was four times longer for patients with complications.

Complications were associated with a higher total cost of hospitalization, with a differential of $37,917. This translated into a higher contribution to the margin. The cost differential varied by insurance type, with higher contributions under Medicare and private insurance but not with Medicaid.

The study had the benefit of using a large administrative database; however, this may have underestimated the actual rate of postoperative complications. The study supports the paradox in which quality-improvement (QI) programs that reduce surgical complications and improve postoperative mortality may negatively affect a hospital’s financial performance.

Bottom line: Surgical complications lead to higher mortality for patients but a financial benefit for hospitals.

Citation: Eappen S, Lane BH, Rosenberg B, et al. Relationship between occurrence of surgical complications and hospital finances. JAMA. 2013;309(5):1509-1606.

Showing Lab Test Fees May Decrease Frequency Of Test Ordering

Clinical question: Does information on the cost of a lab test lead to lowered ordering frequency among internal-medicine residents?

Background: Lab test overuse is common; some studies estimate that 70% of lab tests do not affect care. Strategies to reduce frequency of unnecessary lab tests are needed.

Study design: Randomized controlled trial.

Setting: Johns Hopkins Hospital, a 1,051-bed academic medical center in Baltimore.

Synopsis: Researchers used an administrative database to identify the 35 most frequently ordered and the 35 most expensive tests (each ordered at least 50 times). They randomized tests to an active arm, which displayed the Medicare allowable fee at the time of order entry within the computerized physician order entry, and a control arm. A total of 1,166,753 tests were ordered during the baseline and intervention period. Many more tests were ordered in the active group relative to the control group, a consequence of the randomization process. Relative to a six-month baseline period, tests in the active group were ordered 9.1% less frequently; control-group tests were ordered 5.1% more frequently. Charges decreased by $3.79 per patient-day in the active group and increased by $0.52 per patient-day in the control group.

This study reflects a low-cost strategy to reduce lab testing and associated costs. It is unknown whether only unnecessary tests were averted, or if there was any effect on the quality of care. The durability of the intervention and its applicability to other settings and with other types of providers is unclear.

Bottom line: Showing the fee associated with lab tests may decrease the frequency of ordering these tests and the resultant costs.

Citation: Feldman LS, Shihab HM, Thiemann D, et al. Impact of providing fee data on laboratory test ordering: a controlled clinical trial. JAMA Intern Med. 2013;173(10):903-908.

Inpatient Elderly Multidisciplinary-Team-Based Unit Reduces Readmissions

Clinical question: Can an inpatient unit that uses interdisciplinary rounds and a team approach reduce 30-day readmissions and lower cost compared with usual care?

Background: Elderly patients are at risk for adverse outcomes including delirium, deconditioning, and undernutrition. The Acute Care for Elders (ACE) model is designed as a team-based approach to improve communication between clinicians and to begin discharge planning soon after admission. ACE units have been shown to improve specific outcomes in older adults, but the impact on cost is less clear.

Study design: Retrospective cohort study.

Setting: University of Alabama at Birmingham Acute Care for Elders unit.

Synopsis: The analysis of cost data extrapolated from administrative sources indicated an average of $371 in variable cost savings per patient, and therefore an expected $148,400 savings for 400 patients admitted to this unit. The rate of 30-day readmissions was significantly lower in the ACE model: 7.9% versus 12.8% in patients receiving usual care.

Limitations of this study relate both to its design and single-center location. It is unclear which aspect of this ACE unit was helpful in the studied outcomes, and how this specific program would be reproduced at another institution. There were also some costs associated with the ACE-unit staffing, which may have resulted in an overestimation of the cost savings.

Bottom line: ACE units appear to improve outcomes and may lower cost, but further investigation is needed.

Citation: Flood KL, MacLennan PA, McGrew D, Green D, Dodd C, Brown CJ. Effects of an acute care for elders unit on costs and 30-day readmissions. JAMA. 2013 April 22 [Epub ahead of print].

Continue Beta-Blockers in High-Risk Patients During Noncardiac Surgery

Clinical question: Does exposure to a beta-blocker at the time of noncardiac surgery have an association with mortality, cardiac arrest, or Q-wave myocardial infarction (MI)?

Background: Exposure to beta-blockers perioperatively is controversial. The authors suggest that a randomized trial would be difficult, as one might need to withhold beta-blockers from stable patients. The American Heart Association and American College of Cardiology currently recommend continuation of pre-existing beta-blockades perioperatively.

Study design: Retrospective, propensity-matched cohort analysis.

Setting: One hundred four Veterans Affairs (VA) medical centers from January 2005 to August 2010.

Synopsis: Exposure for any reason to beta-blockers around nonvascular surgery appears to lower the risk of mortality and cardiac arrest, particularly in patients with higher revised cardiac risk index factors. Stopping beta-blockers in this same period was associated with increased mortality. The reasons for beta-blocker use in the exposed cohort were not well-established or -stratified.

Limitations include that the exposed cohort had a higher rate of cardiovascular disease and comorbidities and were generally older. Duration of exposure to beta-blockers was mixed, although more than 75% had a prescription for more than three months, with less than 2% for several days. Some of the matched cohort appears to have had beta-blocker exposure, thus diminishing the potential impact.

Bottom line: In this retrospective analysis, there is an association between beta-blocker use during noncardiac, nonvascular surgery and lower mortality, as well as lower rates of cardiac arrest and Q-wave MI, particularly among higher-risk patients.

Citation: London MJ, Hur K, Schwartz G, Henderson WG. Association of perioperative beta-blockade with mortality and cardiovascular morbidity following major noncardiac surgery. JAMA. 2013;309(16):1704-1713.

Patient-Centered Decision-Making and Health-Care Outcomes

Clinical question: Does recognition of contextual domains in the care plan lead to resolution of patients’ presenting problems?

Background: Patient-centered decision-making, or contextualization of care, adapts best evidence to the care of the individual patient. Examples of contextual domains include access to care, social support, and financial situation. Contextual errors (e.g. unrecognized domains) are, on average, more costly than errors in evidenced-based medicine.

Study design: Observational study.

Setting: VA ambulatory-care centers.

Synopsis: A total of 548 patient-derived audio recordings of physician encounters that included contextual red flags (e.g. missed appointments, HbA1c >8%) were reviewed at two VA hospital ambulatory-care centers using the content coding for contextualization of care (4C) method. Prospectively determined good and poor outcomes were derived from specific red flags (e.g. keeping next appointment, decrease in HbA1c). Of the 548 red flags, 208 were associated with contextual domains using the 4C method. Some 59% of physicians recognized contextual domains in care-plan development, leading to good outcomes in 71% of red flags. As many as 41% of physicians did not recognize contextual domains, leading to poor outcomes in 54% of red-flag instances.

Hospitalists should be aware of contextual domains and red flags (e.g. readmissions), and this study provides a method of evaluating patient-centered decision-making in the hospital setting. However, the inherently subjective 4C method may underestimate the number of contextual domains.

Bottom line: Recognition and incorporation of contextual domains in care-plan development in the ambulatory setting are associated with improved contextual red flag outcomes.

Citation: Weiner SJ, Schwartz A, Sharma G, et al. Patient-centered decision making and health care outcomes: an observational study. Ann Intern Med. 2013;158:573-579.

Adverse Surgical Outcomes in Schizophrenia Patients

Clinical question: What is the full spectrum of postoperative complications and mortality in schizophrenic patients receiving in-hospital major surgery?

Background: Schizophrenia affects an estimated 4 to 7 per 1,000 persons worldwide, and patients with schizophrenia are at increased risk of diabetes, cardiovascular disease, and stroke with subsequent increased mortality risk. The correlation between severity of mental illness and postoperative in-hospital mortality has not been validated in previous studies.

Study design: Population-based, cross-sectional study.

Setting: Taiwan hospitals.

Synopsis: Using the Taiwan National Health Insurance Research Database, researchers examined claims from 2004 to 2007 and retrospectively identified 8,967 schizophrenic patients who underwent major inpatient surgery and were hospitalized for more than one day. Primary outcomes included acute myocardial infarction, acute renal failure, stroke, and in-hospital mortality within 30 days. Postoperative complications and mortality rates were compared between schizophrenic patients and patients without mental illness.

Schizophrenic patients had higher rates of many primary outcomes, including 30-day postoperative mortality, compared with patients without mental illness, after adjusting for sex, age, surgery type, and hospital setting. The risk for 30-day mortality rose with the number of preoperative schizophrenia-related services provided. Limitations include the nature of retrospective analysis and generalizability.

Bottom line: Compared to patients without mental illness, schizophrenic patients have an increased risk of acute renal failure, pneumonia, septicemia, and 30-day mortality in the postoperative setting, with higher mortality rates in schizophrenic patients with more severe disease.

Citation: Liao CC, Shen WW, Chang CC, Chang H, Chen T. Surgical adverse outcomes in patients with schizophrenia. Ann Surg. 2013;257:433-438.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Steroids may increase VTE risk
2. Mortality rates rise at critical-care hospitals
3. Physicians don’t discuss advance-care planning with elderly, families
4. Ultrasound imaging for lumbar puncture, epidural catheterization
5. Financial impact of surgical complications on hospitals
6. Lab test fees and frequency of test ordering
7. Inpatient elderly multidisciplinary teams reduce readmissions
8. Use of beta-blockers in high-risk patients during noncardiac surgery
9. Patient-centered decision-making and health-care outcomes
10. Adverse surgical outcomes in patients with schizophrenia

Steroids May Increase VTE Risk

Clinical question: Is exogenous glucocorticoid administration associated with an increased risk of VTE?

Background: Endogenous hypercortisolism is linked to increased VTE rates, and pathophysiologic data exist to suggest glucocorticoids increase clotting, but few studies have measured the clinical link between glucocorticoid administration and VTE events.

Study design: Case-control study.

Setting: Denmark.

Synopsis: The authors analyzed Danish national registries, which include information on diagnoses and prescriptions. The study selection period was Jan. 1, 2005, to Dec. 31, 2011. During this period, 38,675 cases of VTE (both DVT and pulmonary embolism) were identified in the population of Denmark. These cases were matched with 387,650 controls. Three routes of glucocorticoid use were studied: systemic (oral and intravenous), inhaled, and intestinal-acting. Cases were classified as present (within 90 days of VTE event), recent (91 to 365 days), or former (over 365 days) users of glucocorticoids. Categories were also created for new versus continuous users.

Glucocorticoid use was associated with a significant increase in VTE occurrence. The strongest link was in new and recent users, and the effect diminished over time. Key limitations of the study included its reliance on registry data, as well as the fact that cases had more comorbid conditions than controls (e.g. recent infection, chronic illnesses).

Bottom line: Recipients of glucocorticoids had an increased risk of VTE; the effect was strongest in new and recent users.

Citation: Johannesdottir SA, Horvath-Puho E, Dekkers OM, et al. Use of glucocorticoids and risk of venous thromboembolism. JAMA Intern Med. 2013;173(9):743-752.

Mortality Rates Rise at Critical-Access Hospitals

Clinical question: How have trends in mortality changed in the past decade at critical-access hospitals when compared to other hospitals?

Background: Hospitals are designated as critical-access hospitals (CAH) by meeting certain requirements—namely, rural setting, small number of beds, and minimum distance from the nearest hospital. Because of the intrinsic challenges they face, CAHs are exempt from certain quality measures. Little data exist on patient outcomes at CAHs.

Study design: Retrospective observational study.

Setting: All nonfederal hospitals in the U.S. that provide acute care to Medicare beneficiaries.

Synopsis: Using Medicare data, risk-adjusted 30-day mortality rates were calculated at critical-access hospitals and non-critical-access hospitals from 2002 to 2010 for three conditions: acute myocardial infarction, congestive heart failure, and pneumonia. Mortality trends across these conditions were compared at baseline and over time. In 2002, CAHs had mortality rates comparable with non-CAHs. From 2002 to 2010, mortality rates increased by 0.1% per year at CAHs and decreased by 0.2% per year at non-CAHs, resulting in a mortality difference between these two hospital groups at the end of the study period. The authors postulate that differences in policy initiatives, enforcement of quality measures, and access to technology may play a role.

This study is limited in its ability to explain the findings. Notably, within the CAHs, the authors found that 48% did improve from 2002 to 2010; there were no significant differences in hospital characteristics between the CAHs that did and did not improve. The reasons for the overall widening gap between CAHs and non-CAHs, therefore, merit further investigation.

Bottom line: From 2002 to 2010, mortality rates at U.S. critical-access hospitals rose while rates fell at non-critical access hospitals.

Citation: Joynt KE, Orav EJ, Jha AK. Mortality rates for Medicare beneficiaries admitted to critical access and non-critical access hospitals, 2002-2010. JAMA. 2013;309(13):1379-1387.

Physicians Fail to Discuss Advance-Care Planning with Hospitalized Elderly, Relatives

Clinical question: Do elderly patients who are at high risk for death have documented advance-care plans, and do their physicians discuss goals of care with them?

Background: While studies indicate that most sick, elderly patients prefer a better quality of life to life-sustaining treatment, many patients still die in the hospital, often in the ICU. It is unclear whether this is due to the absence of advance-care planning or the lack of communicating goals of care.

Study design: Multicenter prospective cohort study.

Setting: Canada.

Synopsis: A validated questionnaire was used to evaluate advance-care planning both before hospitalization and on admission. Patients and their families were enrolled if they were considered at high risk for dying, including patients with advanced disease, or aged >80 years. Of the 278 patients enrolled, 76.3% had thought about advance-care planning. Approximately 47.9% of patients had written an advance-care plan, and 73.3% had formally documented a surrogate health-care decision-maker. Only a quarter of patients reported that they had been asked about advance-care planning on admission to the hospital. Patients’ stated preferences for end-of-life care were notably incongruent with goals-of-care orders documented in the hospital records. While 28% of patients preferred comfort-only care, this was documented in the hospital records for only 4.5% of patients.

In this study of mostly white, English-speaking hospitalized patients, many had considered and made advance-care plans but few had discussed this with their health-care providers. Not surprisingly, the goals-of-care orders that were documented did not match patients’ previously stated end-of-life preferences.

Bottom line: Physicians routinely fail to discuss patients’ advance-care planning, which may have profound effects on their inpatient care.

Citation: Heyland DK, Barwich D, Pichora D, et al. Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Intern Med. 2013;173(9):778-787.

Ultrasound Use Reduces Lumbar Puncture and Epidural Catheterization Failure

Clinical question: Does ultrasound imaging for lumbar puncture and epidural catheterization reduce risk of procedure failures?

Background: Numerous studies have compared ultrasound-guided lumbar puncture and epidural catheterization with standard techniques, but they have been underpowered to evaluate whether ultrasound use reduces lumbar puncture and epidural catheterization failure.

Study design: Systematic review and meta-analysis of randomized controlled trials.

Setting: Hospitals in North America, Europe, and Asia.

Synopsis: Among 14 trials, a total of 1,334 patients (including one pediatric study group) were randomly assigned either to receive ultrasound imaging or to a control group (using manual palpation or loss of resistance). Ultrasound imaging comprised a preprocedure marking approach, real-time visual guidance, or both. In the 12 trials in which the primary outcome was available, ultrasound imaging significantly reduced the risk of failed procedures with a risk ratio of 0.21 (95% confidence interval 0.10 to 0.43). A total of 16 ultrasound-guided procedures were needed to avoid one procedure failure. Ultrasound guidance also reduced the number of traumatic procedures, needle reinsertions, and needle redirections. These results were consistent across multiple subgroup analyses.

Only one of the studies included in the meta-analysis was double-blind, and in all of the studies, ultrasound imaging was performed by a clinician with high-level ultrasound experience. While this study suggests that ultrasound does reduce the frequency of procedure failure, the investigators did not include cost-effectiveness analyses.

Bottom line: Ultrasound imaging likely reduces the failure of lumbar puncture and epidural catheterization, but future research will be necessary to evaluate the cost-effectiveness of ultrasound use for these procedures.

Citation: Shaikh F, Brzezinski J, Alexander S, et al. Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis. BMJ. 2013;346:f1720.

Surgical Complications might Be Financially Advantageous for Hospitals

Clinical question: What is the impact of surgical complications on hospital finances?

Background: Surgical complications are common and lead to longer lengths of stay and higher costs. Strategies are available to reduce postsurgical complications but have not been universally adopted.

Study design: Observational study.

Setting: Twelve hospitals in one nonprofit Southern hospital system, which includes academic, nonacademic, and rural settings.

Synopsis: Researchers identified 34,526 patients who underwent surgery in 2010, excluding patients undergoing Caesarean section. Of those, 1,820 procedures (5.3%) were associated with at least one complication. The most frequent complications were surgical-site infection, other infections, pneumonia, and thromboembolic disease. The mortality rate for patients with complications was 12.3% compared with 0.6% for those without. Length of stay was four times longer for patients with complications.

Complications were associated with a higher total cost of hospitalization, with a differential of $37,917. This translated into a higher contribution to the margin. The cost differential varied by insurance type, with higher contributions under Medicare and private insurance but not with Medicaid.

The study had the benefit of using a large administrative database; however, this may have underestimated the actual rate of postoperative complications. The study supports the paradox in which quality-improvement (QI) programs that reduce surgical complications and improve postoperative mortality may negatively affect a hospital’s financial performance.

Bottom line: Surgical complications lead to higher mortality for patients but a financial benefit for hospitals.

Citation: Eappen S, Lane BH, Rosenberg B, et al. Relationship between occurrence of surgical complications and hospital finances. JAMA. 2013;309(5):1509-1606.

Showing Lab Test Fees May Decrease Frequency Of Test Ordering

Clinical question: Does information on the cost of a lab test lead to lowered ordering frequency among internal-medicine residents?

Background: Lab test overuse is common; some studies estimate that 70% of lab tests do not affect care. Strategies to reduce frequency of unnecessary lab tests are needed.

Study design: Randomized controlled trial.

Setting: Johns Hopkins Hospital, a 1,051-bed academic medical center in Baltimore.

Synopsis: Researchers used an administrative database to identify the 35 most frequently ordered and the 35 most expensive tests (each ordered at least 50 times). They randomized tests to an active arm, which displayed the Medicare allowable fee at the time of order entry within the computerized physician order entry, and a control arm. A total of 1,166,753 tests were ordered during the baseline and intervention period. Many more tests were ordered in the active group relative to the control group, a consequence of the randomization process. Relative to a six-month baseline period, tests in the active group were ordered 9.1% less frequently; control-group tests were ordered 5.1% more frequently. Charges decreased by $3.79 per patient-day in the active group and increased by $0.52 per patient-day in the control group.

This study reflects a low-cost strategy to reduce lab testing and associated costs. It is unknown whether only unnecessary tests were averted, or if there was any effect on the quality of care. The durability of the intervention and its applicability to other settings and with other types of providers is unclear.

Bottom line: Showing the fee associated with lab tests may decrease the frequency of ordering these tests and the resultant costs.

Citation: Feldman LS, Shihab HM, Thiemann D, et al. Impact of providing fee data on laboratory test ordering: a controlled clinical trial. JAMA Intern Med. 2013;173(10):903-908.

Inpatient Elderly Multidisciplinary-Team-Based Unit Reduces Readmissions

Clinical question: Can an inpatient unit that uses interdisciplinary rounds and a team approach reduce 30-day readmissions and lower cost compared with usual care?

Background: Elderly patients are at risk for adverse outcomes including delirium, deconditioning, and undernutrition. The Acute Care for Elders (ACE) model is designed as a team-based approach to improve communication between clinicians and to begin discharge planning soon after admission. ACE units have been shown to improve specific outcomes in older adults, but the impact on cost is less clear.

Study design: Retrospective cohort study.

Setting: University of Alabama at Birmingham Acute Care for Elders unit.

Synopsis: The analysis of cost data extrapolated from administrative sources indicated an average of $371 in variable cost savings per patient, and therefore an expected $148,400 savings for 400 patients admitted to this unit. The rate of 30-day readmissions was significantly lower in the ACE model: 7.9% versus 12.8% in patients receiving usual care.

Limitations of this study relate both to its design and single-center location. It is unclear which aspect of this ACE unit was helpful in the studied outcomes, and how this specific program would be reproduced at another institution. There were also some costs associated with the ACE-unit staffing, which may have resulted in an overestimation of the cost savings.

Bottom line: ACE units appear to improve outcomes and may lower cost, but further investigation is needed.

Citation: Flood KL, MacLennan PA, McGrew D, Green D, Dodd C, Brown CJ. Effects of an acute care for elders unit on costs and 30-day readmissions. JAMA. 2013 April 22 [Epub ahead of print].

Continue Beta-Blockers in High-Risk Patients During Noncardiac Surgery

Clinical question: Does exposure to a beta-blocker at the time of noncardiac surgery have an association with mortality, cardiac arrest, or Q-wave myocardial infarction (MI)?

Background: Exposure to beta-blockers perioperatively is controversial. The authors suggest that a randomized trial would be difficult, as one might need to withhold beta-blockers from stable patients. The American Heart Association and American College of Cardiology currently recommend continuation of pre-existing beta-blockades perioperatively.

Study design: Retrospective, propensity-matched cohort analysis.

Setting: One hundred four Veterans Affairs (VA) medical centers from January 2005 to August 2010.

Synopsis: Exposure for any reason to beta-blockers around nonvascular surgery appears to lower the risk of mortality and cardiac arrest, particularly in patients with higher revised cardiac risk index factors. Stopping beta-blockers in this same period was associated with increased mortality. The reasons for beta-blocker use in the exposed cohort were not well-established or -stratified.

Limitations include that the exposed cohort had a higher rate of cardiovascular disease and comorbidities and were generally older. Duration of exposure to beta-blockers was mixed, although more than 75% had a prescription for more than three months, with less than 2% for several days. Some of the matched cohort appears to have had beta-blocker exposure, thus diminishing the potential impact.

Bottom line: In this retrospective analysis, there is an association between beta-blocker use during noncardiac, nonvascular surgery and lower mortality, as well as lower rates of cardiac arrest and Q-wave MI, particularly among higher-risk patients.

Citation: London MJ, Hur K, Schwartz G, Henderson WG. Association of perioperative beta-blockade with mortality and cardiovascular morbidity following major noncardiac surgery. JAMA. 2013;309(16):1704-1713.

Patient-Centered Decision-Making and Health-Care Outcomes

Clinical question: Does recognition of contextual domains in the care plan lead to resolution of patients’ presenting problems?

Background: Patient-centered decision-making, or contextualization of care, adapts best evidence to the care of the individual patient. Examples of contextual domains include access to care, social support, and financial situation. Contextual errors (e.g. unrecognized domains) are, on average, more costly than errors in evidenced-based medicine.

Study design: Observational study.

Setting: VA ambulatory-care centers.

Synopsis: A total of 548 patient-derived audio recordings of physician encounters that included contextual red flags (e.g. missed appointments, HbA1c >8%) were reviewed at two VA hospital ambulatory-care centers using the content coding for contextualization of care (4C) method. Prospectively determined good and poor outcomes were derived from specific red flags (e.g. keeping next appointment, decrease in HbA1c). Of the 548 red flags, 208 were associated with contextual domains using the 4C method. Some 59% of physicians recognized contextual domains in care-plan development, leading to good outcomes in 71% of red flags. As many as 41% of physicians did not recognize contextual domains, leading to poor outcomes in 54% of red-flag instances.

Hospitalists should be aware of contextual domains and red flags (e.g. readmissions), and this study provides a method of evaluating patient-centered decision-making in the hospital setting. However, the inherently subjective 4C method may underestimate the number of contextual domains.

Bottom line: Recognition and incorporation of contextual domains in care-plan development in the ambulatory setting are associated with improved contextual red flag outcomes.

Citation: Weiner SJ, Schwartz A, Sharma G, et al. Patient-centered decision making and health care outcomes: an observational study. Ann Intern Med. 2013;158:573-579.

Adverse Surgical Outcomes in Schizophrenia Patients

Clinical question: What is the full spectrum of postoperative complications and mortality in schizophrenic patients receiving in-hospital major surgery?

Background: Schizophrenia affects an estimated 4 to 7 per 1,000 persons worldwide, and patients with schizophrenia are at increased risk of diabetes, cardiovascular disease, and stroke with subsequent increased mortality risk. The correlation between severity of mental illness and postoperative in-hospital mortality has not been validated in previous studies.

Study design: Population-based, cross-sectional study.

Setting: Taiwan hospitals.

Synopsis: Using the Taiwan National Health Insurance Research Database, researchers examined claims from 2004 to 2007 and retrospectively identified 8,967 schizophrenic patients who underwent major inpatient surgery and were hospitalized for more than one day. Primary outcomes included acute myocardial infarction, acute renal failure, stroke, and in-hospital mortality within 30 days. Postoperative complications and mortality rates were compared between schizophrenic patients and patients without mental illness.

Schizophrenic patients had higher rates of many primary outcomes, including 30-day postoperative mortality, compared with patients without mental illness, after adjusting for sex, age, surgery type, and hospital setting. The risk for 30-day mortality rose with the number of preoperative schizophrenia-related services provided. Limitations include the nature of retrospective analysis and generalizability.

Bottom line: Compared to patients without mental illness, schizophrenic patients have an increased risk of acute renal failure, pneumonia, septicemia, and 30-day mortality in the postoperative setting, with higher mortality rates in schizophrenic patients with more severe disease.

Citation: Liao CC, Shen WW, Chang CC, Chang H, Chen T. Surgical adverse outcomes in patients with schizophrenia. Ann Surg. 2013;257:433-438.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Steroids may increase VTE risk
2. Mortality rates rise at critical-care hospitals
3. Physicians don’t discuss advance-care planning with elderly, families
4. Ultrasound imaging for lumbar puncture, epidural catheterization
5. Financial impact of surgical complications on hospitals
6. Lab test fees and frequency of test ordering
7. Inpatient elderly multidisciplinary teams reduce readmissions
8. Use of beta-blockers in high-risk patients during noncardiac surgery
9. Patient-centered decision-making and health-care outcomes
10. Adverse surgical outcomes in patients with schizophrenia

Steroids May Increase VTE Risk

Clinical question: Is exogenous glucocorticoid administration associated with an increased risk of VTE?

Background: Endogenous hypercortisolism is linked to increased VTE rates, and pathophysiologic data exist to suggest glucocorticoids increase clotting, but few studies have measured the clinical link between glucocorticoid administration and VTE events.

Study design: Case-control study.

Setting: Denmark.

Synopsis: The authors analyzed Danish national registries, which include information on diagnoses and prescriptions. The study selection period was Jan. 1, 2005, to Dec. 31, 2011. During this period, 38,675 cases of VTE (both DVT and pulmonary embolism) were identified in the population of Denmark. These cases were matched with 387,650 controls. Three routes of glucocorticoid use were studied: systemic (oral and intravenous), inhaled, and intestinal-acting. Cases were classified as present (within 90 days of VTE event), recent (91 to 365 days), or former (over 365 days) users of glucocorticoids. Categories were also created for new versus continuous users.

Glucocorticoid use was associated with a significant increase in VTE occurrence. The strongest link was in new and recent users, and the effect diminished over time. Key limitations of the study included its reliance on registry data, as well as the fact that cases had more comorbid conditions than controls (e.g. recent infection, chronic illnesses).

Bottom line: Recipients of glucocorticoids had an increased risk of VTE; the effect was strongest in new and recent users.

Citation: Johannesdottir SA, Horvath-Puho E, Dekkers OM, et al. Use of glucocorticoids and risk of venous thromboembolism. JAMA Intern Med. 2013;173(9):743-752.

Mortality Rates Rise at Critical-Access Hospitals

Clinical question: How have trends in mortality changed in the past decade at critical-access hospitals when compared to other hospitals?

Background: Hospitals are designated as critical-access hospitals (CAH) by meeting certain requirements—namely, rural setting, small number of beds, and minimum distance from the nearest hospital. Because of the intrinsic challenges they face, CAHs are exempt from certain quality measures. Little data exist on patient outcomes at CAHs.

Study design: Retrospective observational study.

Setting: All nonfederal hospitals in the U.S. that provide acute care to Medicare beneficiaries.

Synopsis: Using Medicare data, risk-adjusted 30-day mortality rates were calculated at critical-access hospitals and non-critical-access hospitals from 2002 to 2010 for three conditions: acute myocardial infarction, congestive heart failure, and pneumonia. Mortality trends across these conditions were compared at baseline and over time. In 2002, CAHs had mortality rates comparable with non-CAHs. From 2002 to 2010, mortality rates increased by 0.1% per year at CAHs and decreased by 0.2% per year at non-CAHs, resulting in a mortality difference between these two hospital groups at the end of the study period. The authors postulate that differences in policy initiatives, enforcement of quality measures, and access to technology may play a role.

This study is limited in its ability to explain the findings. Notably, within the CAHs, the authors found that 48% did improve from 2002 to 2010; there were no significant differences in hospital characteristics between the CAHs that did and did not improve. The reasons for the overall widening gap between CAHs and non-CAHs, therefore, merit further investigation.

Bottom line: From 2002 to 2010, mortality rates at U.S. critical-access hospitals rose while rates fell at non-critical access hospitals.

Citation: Joynt KE, Orav EJ, Jha AK. Mortality rates for Medicare beneficiaries admitted to critical access and non-critical access hospitals, 2002-2010. JAMA. 2013;309(13):1379-1387.

Physicians Fail to Discuss Advance-Care Planning with Hospitalized Elderly, Relatives

Clinical question: Do elderly patients who are at high risk for death have documented advance-care plans, and do their physicians discuss goals of care with them?

Background: While studies indicate that most sick, elderly patients prefer a better quality of life to life-sustaining treatment, many patients still die in the hospital, often in the ICU. It is unclear whether this is due to the absence of advance-care planning or the lack of communicating goals of care.

Study design: Multicenter prospective cohort study.

Setting: Canada.

Synopsis: A validated questionnaire was used to evaluate advance-care planning both before hospitalization and on admission. Patients and their families were enrolled if they were considered at high risk for dying, including patients with advanced disease, or aged >80 years. Of the 278 patients enrolled, 76.3% had thought about advance-care planning. Approximately 47.9% of patients had written an advance-care plan, and 73.3% had formally documented a surrogate health-care decision-maker. Only a quarter of patients reported that they had been asked about advance-care planning on admission to the hospital. Patients’ stated preferences for end-of-life care were notably incongruent with goals-of-care orders documented in the hospital records. While 28% of patients preferred comfort-only care, this was documented in the hospital records for only 4.5% of patients.

In this study of mostly white, English-speaking hospitalized patients, many had considered and made advance-care plans but few had discussed this with their health-care providers. Not surprisingly, the goals-of-care orders that were documented did not match patients’ previously stated end-of-life preferences.

Bottom line: Physicians routinely fail to discuss patients’ advance-care planning, which may have profound effects on their inpatient care.

Citation: Heyland DK, Barwich D, Pichora D, et al. Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Intern Med. 2013;173(9):778-787.

Ultrasound Use Reduces Lumbar Puncture and Epidural Catheterization Failure

Clinical question: Does ultrasound imaging for lumbar puncture and epidural catheterization reduce risk of procedure failures?

Background: Numerous studies have compared ultrasound-guided lumbar puncture and epidural catheterization with standard techniques, but they have been underpowered to evaluate whether ultrasound use reduces lumbar puncture and epidural catheterization failure.

Study design: Systematic review and meta-analysis of randomized controlled trials.

Setting: Hospitals in North America, Europe, and Asia.

Synopsis: Among 14 trials, a total of 1,334 patients (including one pediatric study group) were randomly assigned either to receive ultrasound imaging or to a control group (using manual palpation or loss of resistance). Ultrasound imaging comprised a preprocedure marking approach, real-time visual guidance, or both. In the 12 trials in which the primary outcome was available, ultrasound imaging significantly reduced the risk of failed procedures with a risk ratio of 0.21 (95% confidence interval 0.10 to 0.43). A total of 16 ultrasound-guided procedures were needed to avoid one procedure failure. Ultrasound guidance also reduced the number of traumatic procedures, needle reinsertions, and needle redirections. These results were consistent across multiple subgroup analyses.

Only one of the studies included in the meta-analysis was double-blind, and in all of the studies, ultrasound imaging was performed by a clinician with high-level ultrasound experience. While this study suggests that ultrasound does reduce the frequency of procedure failure, the investigators did not include cost-effectiveness analyses.

Bottom line: Ultrasound imaging likely reduces the failure of lumbar puncture and epidural catheterization, but future research will be necessary to evaluate the cost-effectiveness of ultrasound use for these procedures.

Citation: Shaikh F, Brzezinski J, Alexander S, et al. Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis. BMJ. 2013;346:f1720.

Surgical Complications might Be Financially Advantageous for Hospitals

Clinical question: What is the impact of surgical complications on hospital finances?

Background: Surgical complications are common and lead to longer lengths of stay and higher costs. Strategies are available to reduce postsurgical complications but have not been universally adopted.

Study design: Observational study.

Setting: Twelve hospitals in one nonprofit Southern hospital system, which includes academic, nonacademic, and rural settings.

Synopsis: Researchers identified 34,526 patients who underwent surgery in 2010, excluding patients undergoing Caesarean section. Of those, 1,820 procedures (5.3%) were associated with at least one complication. The most frequent complications were surgical-site infection, other infections, pneumonia, and thromboembolic disease. The mortality rate for patients with complications was 12.3% compared with 0.6% for those without. Length of stay was four times longer for patients with complications.

Complications were associated with a higher total cost of hospitalization, with a differential of $37,917. This translated into a higher contribution to the margin. The cost differential varied by insurance type, with higher contributions under Medicare and private insurance but not with Medicaid.

The study had the benefit of using a large administrative database; however, this may have underestimated the actual rate of postoperative complications. The study supports the paradox in which quality-improvement (QI) programs that reduce surgical complications and improve postoperative mortality may negatively affect a hospital’s financial performance.

Bottom line: Surgical complications lead to higher mortality for patients but a financial benefit for hospitals.

Citation: Eappen S, Lane BH, Rosenberg B, et al. Relationship between occurrence of surgical complications and hospital finances. JAMA. 2013;309(5):1509-1606.

Showing Lab Test Fees May Decrease Frequency Of Test Ordering

Clinical question: Does information on the cost of a lab test lead to lowered ordering frequency among internal-medicine residents?

Background: Lab test overuse is common; some studies estimate that 70% of lab tests do not affect care. Strategies to reduce frequency of unnecessary lab tests are needed.

Study design: Randomized controlled trial.

Setting: Johns Hopkins Hospital, a 1,051-bed academic medical center in Baltimore.

Synopsis: Researchers used an administrative database to identify the 35 most frequently ordered and the 35 most expensive tests (each ordered at least 50 times). They randomized tests to an active arm, which displayed the Medicare allowable fee at the time of order entry within the computerized physician order entry, and a control arm. A total of 1,166,753 tests were ordered during the baseline and intervention period. Many more tests were ordered in the active group relative to the control group, a consequence of the randomization process. Relative to a six-month baseline period, tests in the active group were ordered 9.1% less frequently; control-group tests were ordered 5.1% more frequently. Charges decreased by $3.79 per patient-day in the active group and increased by $0.52 per patient-day in the control group.

This study reflects a low-cost strategy to reduce lab testing and associated costs. It is unknown whether only unnecessary tests were averted, or if there was any effect on the quality of care. The durability of the intervention and its applicability to other settings and with other types of providers is unclear.

Bottom line: Showing the fee associated with lab tests may decrease the frequency of ordering these tests and the resultant costs.

Citation: Feldman LS, Shihab HM, Thiemann D, et al. Impact of providing fee data on laboratory test ordering: a controlled clinical trial. JAMA Intern Med. 2013;173(10):903-908.

Inpatient Elderly Multidisciplinary-Team-Based Unit Reduces Readmissions

Clinical question: Can an inpatient unit that uses interdisciplinary rounds and a team approach reduce 30-day readmissions and lower cost compared with usual care?

Background: Elderly patients are at risk for adverse outcomes including delirium, deconditioning, and undernutrition. The Acute Care for Elders (ACE) model is designed as a team-based approach to improve communication between clinicians and to begin discharge planning soon after admission. ACE units have been shown to improve specific outcomes in older adults, but the impact on cost is less clear.

Study design: Retrospective cohort study.

Setting: University of Alabama at Birmingham Acute Care for Elders unit.

Synopsis: The analysis of cost data extrapolated from administrative sources indicated an average of $371 in variable cost savings per patient, and therefore an expected $148,400 savings for 400 patients admitted to this unit. The rate of 30-day readmissions was significantly lower in the ACE model: 7.9% versus 12.8% in patients receiving usual care.

Limitations of this study relate both to its design and single-center location. It is unclear which aspect of this ACE unit was helpful in the studied outcomes, and how this specific program would be reproduced at another institution. There were also some costs associated with the ACE-unit staffing, which may have resulted in an overestimation of the cost savings.

Bottom line: ACE units appear to improve outcomes and may lower cost, but further investigation is needed.

Citation: Flood KL, MacLennan PA, McGrew D, Green D, Dodd C, Brown CJ. Effects of an acute care for elders unit on costs and 30-day readmissions. JAMA. 2013 April 22 [Epub ahead of print].

Continue Beta-Blockers in High-Risk Patients During Noncardiac Surgery

Clinical question: Does exposure to a beta-blocker at the time of noncardiac surgery have an association with mortality, cardiac arrest, or Q-wave myocardial infarction (MI)?

Background: Exposure to beta-blockers perioperatively is controversial. The authors suggest that a randomized trial would be difficult, as one might need to withhold beta-blockers from stable patients. The American Heart Association and American College of Cardiology currently recommend continuation of pre-existing beta-blockades perioperatively.

Study design: Retrospective, propensity-matched cohort analysis.

Setting: One hundred four Veterans Affairs (VA) medical centers from January 2005 to August 2010.

Synopsis: Exposure for any reason to beta-blockers around nonvascular surgery appears to lower the risk of mortality and cardiac arrest, particularly in patients with higher revised cardiac risk index factors. Stopping beta-blockers in this same period was associated with increased mortality. The reasons for beta-blocker use in the exposed cohort were not well-established or -stratified.

Limitations include that the exposed cohort had a higher rate of cardiovascular disease and comorbidities and were generally older. Duration of exposure to beta-blockers was mixed, although more than 75% had a prescription for more than three months, with less than 2% for several days. Some of the matched cohort appears to have had beta-blocker exposure, thus diminishing the potential impact.

Bottom line: In this retrospective analysis, there is an association between beta-blocker use during noncardiac, nonvascular surgery and lower mortality, as well as lower rates of cardiac arrest and Q-wave MI, particularly among higher-risk patients.

Citation: London MJ, Hur K, Schwartz G, Henderson WG. Association of perioperative beta-blockade with mortality and cardiovascular morbidity following major noncardiac surgery. JAMA. 2013;309(16):1704-1713.

Patient-Centered Decision-Making and Health-Care Outcomes

Clinical question: Does recognition of contextual domains in the care plan lead to resolution of patients’ presenting problems?

Background: Patient-centered decision-making, or contextualization of care, adapts best evidence to the care of the individual patient. Examples of contextual domains include access to care, social support, and financial situation. Contextual errors (e.g. unrecognized domains) are, on average, more costly than errors in evidenced-based medicine.

Study design: Observational study.

Setting: VA ambulatory-care centers.

Synopsis: A total of 548 patient-derived audio recordings of physician encounters that included contextual red flags (e.g. missed appointments, HbA1c >8%) were reviewed at two VA hospital ambulatory-care centers using the content coding for contextualization of care (4C) method. Prospectively determined good and poor outcomes were derived from specific red flags (e.g. keeping next appointment, decrease in HbA1c). Of the 548 red flags, 208 were associated with contextual domains using the 4C method. Some 59% of physicians recognized contextual domains in care-plan development, leading to good outcomes in 71% of red flags. As many as 41% of physicians did not recognize contextual domains, leading to poor outcomes in 54% of red-flag instances.

Hospitalists should be aware of contextual domains and red flags (e.g. readmissions), and this study provides a method of evaluating patient-centered decision-making in the hospital setting. However, the inherently subjective 4C method may underestimate the number of contextual domains.

Bottom line: Recognition and incorporation of contextual domains in care-plan development in the ambulatory setting are associated with improved contextual red flag outcomes.

Citation: Weiner SJ, Schwartz A, Sharma G, et al. Patient-centered decision making and health care outcomes: an observational study. Ann Intern Med. 2013;158:573-579.

Adverse Surgical Outcomes in Schizophrenia Patients

Clinical question: What is the full spectrum of postoperative complications and mortality in schizophrenic patients receiving in-hospital major surgery?

Background: Schizophrenia affects an estimated 4 to 7 per 1,000 persons worldwide, and patients with schizophrenia are at increased risk of diabetes, cardiovascular disease, and stroke with subsequent increased mortality risk. The correlation between severity of mental illness and postoperative in-hospital mortality has not been validated in previous studies.

Study design: Population-based, cross-sectional study.

Setting: Taiwan hospitals.

Synopsis: Using the Taiwan National Health Insurance Research Database, researchers examined claims from 2004 to 2007 and retrospectively identified 8,967 schizophrenic patients who underwent major inpatient surgery and were hospitalized for more than one day. Primary outcomes included acute myocardial infarction, acute renal failure, stroke, and in-hospital mortality within 30 days. Postoperative complications and mortality rates were compared between schizophrenic patients and patients without mental illness.

Schizophrenic patients had higher rates of many primary outcomes, including 30-day postoperative mortality, compared with patients without mental illness, after adjusting for sex, age, surgery type, and hospital setting. The risk for 30-day mortality rose with the number of preoperative schizophrenia-related services provided. Limitations include the nature of retrospective analysis and generalizability.

Bottom line: Compared to patients without mental illness, schizophrenic patients have an increased risk of acute renal failure, pneumonia, septicemia, and 30-day mortality in the postoperative setting, with higher mortality rates in schizophrenic patients with more severe disease.

Citation: Liao CC, Shen WW, Chang CC, Chang H, Chen T. Surgical adverse outcomes in patients with schizophrenia. Ann Surg. 2013;257:433-438.

Clinical question: What are the costs associated with observation-status hospital stays compared to inpatient-status stays in pediatric hospitals?

Background: Observation status is a designation for hospitalizations that are typically shorter than 48 hours and do not meet criteria for inpatient status. It is considered to be outpatient for evaluation and management (E/M) coding. A designation of observation status for a hospital stay can have significant effects on out-of-pocket costs for patients and reimbursements to physicians and hospitals. It also can affect readmission and length-of-stay data, as observation-status hospital stays are often excluded from a hospital’s inpatient data.

Study design: Multicenter retrospective cohort study.

Setting: Thirty-three freestanding children’s hospitals.

Synopsis: Researchers reviewed data obtained from the Pediatric Health Information System (PHIS), which contains demographic and resource utilization date from 43 freestanding children’s hospitals in the U.S. Resource utilization data were reviewed from 33 of 43 hospitals in PHIS that reported data regarding observation- versus inpatient-status stays. Data were then limited to observation-status stays £2 days, which made up 97.8% of all observation-status stays. These were then compared to a corresponding cohort of inpatient-status stays of £2 days (47.5% of inpatient-status stays), excluding any patient who had spent time in an ICU.

Hospitalization costs were analyzed and separated into room and nonroom costs, as well as in aggregate. These were further subdivided into costs for four common diagnoses (asthma, gastroenteritis, bronchiolitis, and seizure) and were risk-adjusted.

Observation status was used variably between hospitals (2% to 45%) and within hospitals. There was significant overlap in costs of observation-status and inpatient-status stays, which persisted when accounting for nonroom costs and within the diagnosis subgroups. Although average severity-adjusted costs for observation-status stays were consistently less than those for inpatient-status stays, the dollar amounts were small.

Bottom line: Observation-status designation is used inconsistently in pediatric hospitals, and their costs overlap substantially with inpatient-status stays.

Citation: Fieldston ES, Shah SS, Hall M. Resource utilization for observation-status stays at children’s hospitals. Pediatrics. 2013;131;1050-1058.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FACP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What are the costs associated with observation-status hospital stays compared to inpatient-status stays in pediatric hospitals?

Background: Observation status is a designation for hospitalizations that are typically shorter than 48 hours and do not meet criteria for inpatient status. It is considered to be outpatient for evaluation and management (E/M) coding. A designation of observation status for a hospital stay can have significant effects on out-of-pocket costs for patients and reimbursements to physicians and hospitals. It also can affect readmission and length-of-stay data, as observation-status hospital stays are often excluded from a hospital’s inpatient data.

Study design: Multicenter retrospective cohort study.

Setting: Thirty-three freestanding children’s hospitals.

Synopsis: Researchers reviewed data obtained from the Pediatric Health Information System (PHIS), which contains demographic and resource utilization date from 43 freestanding children’s hospitals in the U.S. Resource utilization data were reviewed from 33 of 43 hospitals in PHIS that reported data regarding observation- versus inpatient-status stays. Data were then limited to observation-status stays £2 days, which made up 97.8% of all observation-status stays. These were then compared to a corresponding cohort of inpatient-status stays of £2 days (47.5% of inpatient-status stays), excluding any patient who had spent time in an ICU.

Hospitalization costs were analyzed and separated into room and nonroom costs, as well as in aggregate. These were further subdivided into costs for four common diagnoses (asthma, gastroenteritis, bronchiolitis, and seizure) and were risk-adjusted.

Observation status was used variably between hospitals (2% to 45%) and within hospitals. There was significant overlap in costs of observation-status and inpatient-status stays, which persisted when accounting for nonroom costs and within the diagnosis subgroups. Although average severity-adjusted costs for observation-status stays were consistently less than those for inpatient-status stays, the dollar amounts were small.

Bottom line: Observation-status designation is used inconsistently in pediatric hospitals, and their costs overlap substantially with inpatient-status stays.

Citation: Fieldston ES, Shah SS, Hall M. Resource utilization for observation-status stays at children’s hospitals. Pediatrics. 2013;131;1050-1058.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FACP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What are the costs associated with observation-status hospital stays compared to inpatient-status stays in pediatric hospitals?

Background: Observation status is a designation for hospitalizations that are typically shorter than 48 hours and do not meet criteria for inpatient status. It is considered to be outpatient for evaluation and management (E/M) coding. A designation of observation status for a hospital stay can have significant effects on out-of-pocket costs for patients and reimbursements to physicians and hospitals. It also can affect readmission and length-of-stay data, as observation-status hospital stays are often excluded from a hospital’s inpatient data.

Study design: Multicenter retrospective cohort study.

Setting: Thirty-three freestanding children’s hospitals.

Synopsis: Researchers reviewed data obtained from the Pediatric Health Information System (PHIS), which contains demographic and resource utilization date from 43 freestanding children’s hospitals in the U.S. Resource utilization data were reviewed from 33 of 43 hospitals in PHIS that reported data regarding observation- versus inpatient-status stays. Data were then limited to observation-status stays £2 days, which made up 97.8% of all observation-status stays. These were then compared to a corresponding cohort of inpatient-status stays of £2 days (47.5% of inpatient-status stays), excluding any patient who had spent time in an ICU.

Hospitalization costs were analyzed and separated into room and nonroom costs, as well as in aggregate. These were further subdivided into costs for four common diagnoses (asthma, gastroenteritis, bronchiolitis, and seizure) and were risk-adjusted.

Observation status was used variably between hospitals (2% to 45%) and within hospitals. There was significant overlap in costs of observation-status and inpatient-status stays, which persisted when accounting for nonroom costs and within the diagnosis subgroups. Although average severity-adjusted costs for observation-status stays were consistently less than those for inpatient-status stays, the dollar amounts were small.

Bottom line: Observation-status designation is used inconsistently in pediatric hospitals, and their costs overlap substantially with inpatient-status stays.

Citation: Fieldston ES, Shah SS, Hall M. Resource utilization for observation-status stays at children’s hospitals. Pediatrics. 2013;131;1050-1058.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FACP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

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Case

A 70-year-old male with ESRD on hemodialysis presents with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and ankle pain after a fall. An MRI of his ankle is negative, and he is started on acetaminophen and lidocaine patches, which result in adequate pain relief of the ankle. He later develops significant neuropathic pain in both arms, and a CT scan of the cervical spine reveals a cervical abscess and osteomyelitis. The patient desires pain relief but adamantly refuses narcotics, stating: “I don’t want to get addicted.” How can his pain be managed?

Overview

Pain is a common problem in patients with renal insufficiency and end-stage renal disease (ESRD) and can have a significant effect on the patient’s quality of life.¹ When assessing a patient’s pain, assess both the severity of the pain (such as on an analogue scale, 0-10) and the characteristics of the pain. Pain is most commonly characterized as nociceptive, neuropathic, or both. Nociceptive pain can be further classified as arising from either somatic or visceral sources, and is often described as dull, throbbing, cramping, and/or pressurelike.¹ Neuropathic pain is often described as tingling, numbing, burning, and/or stabbing.

It is a challenge to manage pain in patients with renal insufficiency and dialysis. Renal insufficiency affects the pharmacokinetic properties of most pain medications, including their distribution, clearance, and excretion. The magnitude of the effect of renal insufficiency on drug metabolism varies depending on the agent itself, its metabolite, and the extent of renal failure.³ Multiple factors should be considered when prescribing pain medications for patients on dialysis, including the properties of the parent drug and its metabolites; the physical properties of the dialysis equipment, such as the filter pore size, the flow rate, and the efficiency of the technique used; and the dialysis method (intermittent versus continuous).³ Table 1 provides the recommended dosing of the most commonly prescribed agents, based on the degree of renal impairment. A modified World Health Organization (WHO) ladder has been suggested to treat pain in patients with ESRD, which can lead to effective pain relief in as many as 96% of patients (see Figure 1).²

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Review of Data

Nonopioid options. Nonopioids, such as acetaminophen and NSAIDs, have no associated tolerance but have a ceiling effect for analgesia, and NSAIDs are associated with dose-dependent acute renal failure, gastrointestinal ulceration and bleeding, and cardiac events. The nonopioids that are considered safe options in patients with renal insufficiency include acetaminophen, ibuprofen, and fenoprofen (Nalfon). However, in the elderly, American Geriatric Society (AGS) guidelines currently recommend avoiding all NSAIDs due to their safety profile in the geriatric population.⁴ Although all NSAIDs can potentially be used for pain, selected NSAIDs with an FDA indication for acute or chronic pain were included for this review.

Acetaminophen (APAP) is a dialyzable compound that is metabolized in the liver to five inactive metabolites. The terminal elimination half-life of its sulfate and glucuronide metabolites are prolonged in patients with renal failure; therefore, the dosing interval of APAP should be increased to six to eight hours in renally impaired patients.^5,6,7 Overall, acetaminophen is considered one of the safest agents to use for the treatment of pain, in renal patients and otherwise, as long as dosing is below the minimal daily dose (see Table 1).

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Ibuprofen is metabolized in the liver to inactive compounds. It does not accumulate in renal insufficiency, and two of the inactive compounds are dialyzable.⁸ It is considered a safe option for the treatment of pain in patients with renal insufficiency or dialysis.⁹

Fenoprofen is metabolized in the liver to inactive compounds. Renal impairment is likely to cause the accumulation of the inactive metabolites but not the parent compound, so dose reduction is not necessary with the use of this agent in renal insufficiency or dialysis.⁶

Mefenamic acid (Ponstel) is metabolized in the liver. Mefenamic acid can further deteriorate renal function in patients with underlying renal disease.12 However, the nephrotoxic potential of this agent is of little consideration in ESRD patients on dialysis, and therefore no dosage adjustments are necessary in these patients.⁶

Ketoprofen is metabolized in the liver, where approximately 80% of the dose is excreted in the urine as a glucuronide metabolite. Dose reduction is recommended in renal insufficiency and dialysis, as it not dialyzable.⁸

Ketorolac accumulates in renal insufficiency; therefore, it is contraindicated in these patients and in patients at risk for renal failure, including those with volume depletion.¹⁰ Ketorolac is unlikely to be removed by dialysis and so should be avoided.^10,11

Naproxen is metabolized in the liver to inactive compounds. Use of naproxen is not recommended in patients with moderate to severe renal impairment. If therapy must be initiated, close monitoring of the patient’s renal function is recommended.¹³

Celecoxib is the only cyclooxygenase-2 (COX-2) inhibitor available in the U.S. It is metabolized extensively by the liver and is unlikely to be removed by dialysis. Therefore, use of COX-2 inhibitors should be avoided in severe renal impairment and in those on dialysis.^14,15

Opioid options. The use of opioids in the renally impaired population is challenging, as one must balance opioid-related adverse events with adequate pain control. As such, it is recommended to start with lower-than-recommended doses and slowly titrate up the dose while extending the dosing interval. This will help limit adverse effects, such as respiratory depression and hypotension.³

Hydrocodone is metabolized to hydromorphone (Dilaudid), which is then metabolized to its major metabolite hydromorphine-3-glucuronide (H3G) and minor metabolite hydromorphine-6-hydroxy, all of which are excreted renally along with the parent compound. H3G has no analgesic properties, but it can potentially cause neuroexcitation, agitation, confusion, and hallucination. Hydromorphone has been used safely in patients with renal insufficiency and dialysis, as it is expected to be dialyzable. ^16,17

Tramadol is metabolized in the liver, producing one active compound. Approximately 30% of the tramadol dose is excreted unchanged in the urine, whereas 60% of the dose is excreted as metabolites. It is recommended to reduce the dose and increase the dosing interval in patients with renal insufficiency, but tramadol is generally well-tolerated in patients with renal insufficiency and dialysis. It is significantly removed by hemodialysis; therefore, redosing after a session may be necessary.^18,19

Oxycodone can be used in patients with mild to moderate renal insufficiency but should be used at reduced dosing; it has been associated with significant sedation with usual doses in renal failure patients.¹⁶ Its use is generally not recommended in dialysis patients due to lack of data.³

Methadone and its metabolites are excreted in the urine and feces. Methadone has been used safely in patients with renal insufficiency, but it is poorly removed by dialysis and no specific recommendations are available regarding its dosing in dialysis.^3,16

Fentanyl is primarily metabolized in the liver to inactive metabolites. Fentanyl clearance is reduced in patients with moderate to severe uremia (BUN >60 mg/dL). It is not expected that fentanyl be dialyzable because of its pharmacokinetic properties (high protein-binding, low water solubility, high molecular weight, and high volume of distribution). Data suggests that fentanyl can be used at usual doses in mild to moderate renal insufficiency and in dialysis patients, although reduced doses may be prudent. Such patients should be monitored for signs of gradual accumulation of the parent drug.^3,16

Morphine is metabolized in the liver to morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G), all of which are excreted renally, along with the parent compound. Only M6G has analgesic properties, and when it accumulates, it can lead to CNS depression. M3G is associated with behavioral excitation, a side effect that is further magnified in patients with renal insufficiency. Although morphine is dialyzable, it should generally be avoided in patients with any level of renal insufficiency.^16,17,20,21

Codeine is metabolized to several active metabolites, all of which are renally excreted. Lower-than-usual doses are recommended in patients with renal insufficiency, and it should be avoided altogether in dialysis patients.^3,16

Meperidine is metabolized in the liver to various metabolites, primarily normeperidine, which is toxic and has a long half-life, five to 10 times longer then meperidine. Meperidine should not be used in patients with renal insufficiency or dialysis.³

Adjunctive therapeutic options. Lidocaine patches currently are only FDA-indicated for postherpetic neuralgia but are used for a wide variety of local pain syndromes. Absorption of lidocaine is determined by the duration of application and the surface area over which it is applied. There is no appreciable accumulation of lidocaine or its metabolites in renal insufficiency; therefore, dose adjustments are not required.^22,23

Gabapentin is FDA-indicated for partial seizures and postherpetic neuralgia but is also used for a wide variety of neuropathic pain syndromes, including postoperative pain.²⁴ Gabapentin is not metabolized and is excreted in the urine unchanged. Renal clearance of gabapentin is reduced by 40% and the elimination half-life is increased up to 52 hours in renal insufficiency, but it is dialyzable. Therefore, dose adjustments are required with gabapentin in patients with moderate to severe renal insufficiency, and supplemental doses should be administered in patients after receiving dialysis.^25-27

Pregabalin is structurally related to gabapentin and is indicated for a variety of neuropathic pain conditions. Pregabalin is 90% excreted unchanged in the urine, and approximately 50% of drug is removed after four hours of hemodialysis. Dose adjustments are required in patients with moderate to severe renal insufficiency, and supplemental doses should be administered in patients after receiving dialysis.²⁸

Antidepressant options. Amitriptyline, nortryptiline, and desipramine are the tricyclic antidepressants (TCAs) commonly used for neuropathic pain. TCAs are metabolized in the liver to inactive metabolites, with the exception of amitriptyline, which is metabolized to nortryptiline. Common side effects reported with TCAs include postural hypotension and anticholinergic side effects, such as constipation, urinary retention, blurred vision, dry mouth, delirium, and sedation. It is unlikely that the TCAs can be removed by dialysis. It is suggested that the dosage be reduced in renal insufficiency and that anticholinergic side effects be monitored.²⁹

Back to the Case

The patient’s ankle pain was controlled with acetaminophen and lidocaine patches. For the neuropathic pain in his upper extremities, tramadol was started at 25 mg oral every 12 hours and increased to 50 mg oral every eight hours (below the maximum of 200 mg a day). The tramadol did not result in adequate pain relief, so gabapentin 100 mg at bedtime was initiated, then increased to twice daily over three days with some relief.

A geriatric consult was obtained to help educate him regarding addiction to opioids, as well as to explore goals of care, but he continued to insist on the use of a non-narcotic regimen for his pain.

Bottom Line

Pain management in patients with renal insufficiency and dialysis can be challenging, but there are a number of safe non-narcotic and narcotic pain regimens that can be safely used in this patient population.

Dr. Harisingani is a board-certified hospitalist at Long Island Jewish Medical Center in New Hyde Park, N.Y., and Drs. Saad and Cassagnol are assistant clinical professors at St. Johns University College of Pharmacy and Health Sciences in Jamaica, N.Y., and clinical pharmacy coordinators at Long Island Jewish Medical Center.

References

1. Mid-Atlantic Renal Coalition and the Kidney End-of-Life Coalition. Clinical algorithm & preferred medications to treat pain in dialysis patients. Coalition for Supportive Care of Kidney Patients website. Available at: http://www.kidneysupportivecare.org/Physicians-Clinicians/Pain—Symptom-Management.aspx. Accessed Nov. 18, 2012.
2. Barakzoy AS, Moss AH. Efficacy of the World Health Organization analgesic ladder to treat pain in end-stage renal disease. J Am Soc Nephrol. 2006;17(11):3198-3203.
3. Johnson SJ. Opioid safety in patients with renal or hepatic dysfunction. Pain Treatment Topics website. Available at: http://pain-topics.org/pdf/Opioids-Renal-Hepatic-Dysfunction.pdf. Accessed Nov. 28, 2012.
4. Ferrell B, Argoff CE, Epplin J, et al. American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57(8):1331-1346.
5. Prescott LF, Speirs GC, Critchley JA, Temple RM, Winney RJ. Paracetamol disposition and metabolite kinetics in patients with chronic renal failure. Eur J Clin Pharmacol. 1989;36(3):291-297.
6. Launay-Vacher V, Karie S, Fau JB, Izzedine H, Deray G. Treatment of pain in patients with renal insufficiency: the World Health Organization three-step ladder adapted. J Pain. 2006;6(3):137-148.
7. Berg KJ, Djøseland O, Gjellan A, et al. Acute effects of paracetamol on prostaglandin synthesis and renal function in normal man and in patients with renal failure. Clin Nephrol. 1990;34:255-262.
8. Delbarre F, Roucayrol JC, Amor B, et al. Pharmacokinetic study of ketoprofen (19.583 R.P.) in man using the tritiated compound. Scand J Rheumatol Suppl. 1976;1976(0):45-52.
9. Shen CH, Hung CJ, Wu CC, Huang HW, Ho WM. Rhabdomyolysis-induced acute renal failure after morphine overdose—a case report. Acta Anaesthesiol Sin. 1999;37(3):159-162.
10. Ketorolac tromethamine oral tablets [package insert]. St. Louis: Ethex Corp.: 2008.
11. Brocks DR, Jamali F. Clinical pharmacokinetics of ketorolac tromethamine. Clin Pharmacokinet. 1992;23:415-427. Erratum in: Clin Pharmacokinet. 1999;24(3):270.
12. Ponstel [package insert]. Alpharetta, GA: First Horizon Pharmaceutical Corp.; 2006.
13. Naprosyn [package insert]. Nutley, NJ: Roche Laboratories Inc.; 2008.
14. Celebrex [package insert]. New York: G.D. Searle LLC; 2011.
15. Catella-Lawson F, McAdam B, Morrison BW, et al. Effects of specific inhibition of cyclooygenase-2 on sodium balance, hemodynamics, and vasoactive eicosanoids. J Pharmacol Exp Ther. 1999;289:735-741.
16. Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage. 2004;28(5):497-504.
17. Lee MA, Leng ME, Tiernan EJ. Retrospective study of the use of hydromorphone in palliative care patients with normal and abnormal urea and creatinine. Palliat Med. 2001;15(1):26-34.
18. Gibson TP. Pharmacokinetics, efficacy, and safety of analgesia with a focus on tramadol HCI. Am J. Med. 1996;101(1A):47S-53S.
19. Izzedine H, Launay-Vacher V, Abbara C, Aymard G, Bassilios N, Deray G. Pharmacokinetics of tramadol in a hemodialysis patient. Nephron. 2002;92(3):755-756.
20. Hasselström J, Säwe J. Morphine pharmacokinetics and metabolism in humans. Enterohepatic cycling and relative contribution of metabolites to active opioid concentrations. Clin Pharmacokinet. 1993;24(4):344-354.
21. Andersen G, Christrup L, Sjøgren P. Relationships among morphine metabolism, pain and side effects during long-term treatment: an update. J Pain Symptom Manage. 2003;25(1):74-91.
22. Lidoderm [package insert]. Chadds Ford, PA: Endo Pharmaceuticals Inc.; 2010.
23. Carter GT, Galer BS. Advances in the management of neuropathic pain. Phys Med Rehabil Clin N Am. 2001;12(2):447-459.
24. Ho KY, Gan TJ, Habib AS. Gabapentin and postoperative pain—a systematic review of randomized controlled trials. Pain. 2006;15:126(1-3):91-101.
25. Neurontin [package insert]. New York: Parke-Davis; 2010.
26. Pandey CK, Priye S, Singh S, et al. Preemptive use of gabapentin significantly decreases postoperative pain and rescue analgesic requirements in laparoscopic cholecystectomy. Can J Anaesth. 2004;51(4):358-363.
27. Srivastava U, Kumar A, Saxena S, et al: Effect of preoperative gabapentin on postoperative pain and tramadol consumption after minilap open cholecystectomy: a randomized double-blind, placebo-controlled trial. Eur J Anaesthesiol. 2010;27(N4):331-335.
28. Lyrica [package insert]. New York: Pfizer Inc.; 2012.
29. Broadbent A, Khor K, Heaney A. Palliation and chronic renal failure: opioid and other palliative medications—dosage guidelines. Progress in Palliative Care. 2003;11(4):183-190(8).
30. Nayak-Rao S. Achieving effective pain relief in patients with chronic kidney disease: a review of analgesics in renal failure. J Nephrol. 2011;24(1):35-40.
31. Wolters Kluwer Health. Facts & comparisons. Wolters Kluwer Health website. Available at: http://www.factsandcomparisons.com. Accessed Jan. 14, 2013.
32. Lexicomp. Lexicomp Online. Lexicomp website. Available at: http://www.lexi.com/institutions/products/online/.

click for large version

Case

A 70-year-old male with ESRD on hemodialysis presents with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and ankle pain after a fall. An MRI of his ankle is negative, and he is started on acetaminophen and lidocaine patches, which result in adequate pain relief of the ankle. He later develops significant neuropathic pain in both arms, and a CT scan of the cervical spine reveals a cervical abscess and osteomyelitis. The patient desires pain relief but adamantly refuses narcotics, stating: “I don’t want to get addicted.” How can his pain be managed?

Overview

Pain is a common problem in patients with renal insufficiency and end-stage renal disease (ESRD) and can have a significant effect on the patient’s quality of life.¹ When assessing a patient’s pain, assess both the severity of the pain (such as on an analogue scale, 0-10) and the characteristics of the pain. Pain is most commonly characterized as nociceptive, neuropathic, or both. Nociceptive pain can be further classified as arising from either somatic or visceral sources, and is often described as dull, throbbing, cramping, and/or pressurelike.¹ Neuropathic pain is often described as tingling, numbing, burning, and/or stabbing.

It is a challenge to manage pain in patients with renal insufficiency and dialysis. Renal insufficiency affects the pharmacokinetic properties of most pain medications, including their distribution, clearance, and excretion. The magnitude of the effect of renal insufficiency on drug metabolism varies depending on the agent itself, its metabolite, and the extent of renal failure.³ Multiple factors should be considered when prescribing pain medications for patients on dialysis, including the properties of the parent drug and its metabolites; the physical properties of the dialysis equipment, such as the filter pore size, the flow rate, and the efficiency of the technique used; and the dialysis method (intermittent versus continuous).³ Table 1 provides the recommended dosing of the most commonly prescribed agents, based on the degree of renal impairment. A modified World Health Organization (WHO) ladder has been suggested to treat pain in patients with ESRD, which can lead to effective pain relief in as many as 96% of patients (see Figure 1).²

click for large version

click for large version

Review of Data

Nonopioid options. Nonopioids, such as acetaminophen and NSAIDs, have no associated tolerance but have a ceiling effect for analgesia, and NSAIDs are associated with dose-dependent acute renal failure, gastrointestinal ulceration and bleeding, and cardiac events. The nonopioids that are considered safe options in patients with renal insufficiency include acetaminophen, ibuprofen, and fenoprofen (Nalfon). However, in the elderly, American Geriatric Society (AGS) guidelines currently recommend avoiding all NSAIDs due to their safety profile in the geriatric population.⁴ Although all NSAIDs can potentially be used for pain, selected NSAIDs with an FDA indication for acute or chronic pain were included for this review.

Acetaminophen (APAP) is a dialyzable compound that is metabolized in the liver to five inactive metabolites. The terminal elimination half-life of its sulfate and glucuronide metabolites are prolonged in patients with renal failure; therefore, the dosing interval of APAP should be increased to six to eight hours in renally impaired patients.^5,6,7 Overall, acetaminophen is considered one of the safest agents to use for the treatment of pain, in renal patients and otherwise, as long as dosing is below the minimal daily dose (see Table 1).

click for large version

Ibuprofen is metabolized in the liver to inactive compounds. It does not accumulate in renal insufficiency, and two of the inactive compounds are dialyzable.⁸ It is considered a safe option for the treatment of pain in patients with renal insufficiency or dialysis.⁹

Fenoprofen is metabolized in the liver to inactive compounds. Renal impairment is likely to cause the accumulation of the inactive metabolites but not the parent compound, so dose reduction is not necessary with the use of this agent in renal insufficiency or dialysis.⁶

Mefenamic acid (Ponstel) is metabolized in the liver. Mefenamic acid can further deteriorate renal function in patients with underlying renal disease.12 However, the nephrotoxic potential of this agent is of little consideration in ESRD patients on dialysis, and therefore no dosage adjustments are necessary in these patients.⁶

Ketoprofen is metabolized in the liver, where approximately 80% of the dose is excreted in the urine as a glucuronide metabolite. Dose reduction is recommended in renal insufficiency and dialysis, as it not dialyzable.⁸

Ketorolac accumulates in renal insufficiency; therefore, it is contraindicated in these patients and in patients at risk for renal failure, including those with volume depletion.¹⁰ Ketorolac is unlikely to be removed by dialysis and so should be avoided.^10,11

Naproxen is metabolized in the liver to inactive compounds. Use of naproxen is not recommended in patients with moderate to severe renal impairment. If therapy must be initiated, close monitoring of the patient’s renal function is recommended.¹³

Celecoxib is the only cyclooxygenase-2 (COX-2) inhibitor available in the U.S. It is metabolized extensively by the liver and is unlikely to be removed by dialysis. Therefore, use of COX-2 inhibitors should be avoided in severe renal impairment and in those on dialysis.^14,15

Opioid options. The use of opioids in the renally impaired population is challenging, as one must balance opioid-related adverse events with adequate pain control. As such, it is recommended to start with lower-than-recommended doses and slowly titrate up the dose while extending the dosing interval. This will help limit adverse effects, such as respiratory depression and hypotension.³

Hydrocodone is metabolized to hydromorphone (Dilaudid), which is then metabolized to its major metabolite hydromorphine-3-glucuronide (H3G) and minor metabolite hydromorphine-6-hydroxy, all of which are excreted renally along with the parent compound. H3G has no analgesic properties, but it can potentially cause neuroexcitation, agitation, confusion, and hallucination. Hydromorphone has been used safely in patients with renal insufficiency and dialysis, as it is expected to be dialyzable. ^16,17

Tramadol is metabolized in the liver, producing one active compound. Approximately 30% of the tramadol dose is excreted unchanged in the urine, whereas 60% of the dose is excreted as metabolites. It is recommended to reduce the dose and increase the dosing interval in patients with renal insufficiency, but tramadol is generally well-tolerated in patients with renal insufficiency and dialysis. It is significantly removed by hemodialysis; therefore, redosing after a session may be necessary.^18,19

Oxycodone can be used in patients with mild to moderate renal insufficiency but should be used at reduced dosing; it has been associated with significant sedation with usual doses in renal failure patients.¹⁶ Its use is generally not recommended in dialysis patients due to lack of data.³

Methadone and its metabolites are excreted in the urine and feces. Methadone has been used safely in patients with renal insufficiency, but it is poorly removed by dialysis and no specific recommendations are available regarding its dosing in dialysis.^3,16

Fentanyl is primarily metabolized in the liver to inactive metabolites. Fentanyl clearance is reduced in patients with moderate to severe uremia (BUN >60 mg/dL). It is not expected that fentanyl be dialyzable because of its pharmacokinetic properties (high protein-binding, low water solubility, high molecular weight, and high volume of distribution). Data suggests that fentanyl can be used at usual doses in mild to moderate renal insufficiency and in dialysis patients, although reduced doses may be prudent. Such patients should be monitored for signs of gradual accumulation of the parent drug.^3,16

Morphine is metabolized in the liver to morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G), all of which are excreted renally, along with the parent compound. Only M6G has analgesic properties, and when it accumulates, it can lead to CNS depression. M3G is associated with behavioral excitation, a side effect that is further magnified in patients with renal insufficiency. Although morphine is dialyzable, it should generally be avoided in patients with any level of renal insufficiency.^16,17,20,21

Codeine is metabolized to several active metabolites, all of which are renally excreted. Lower-than-usual doses are recommended in patients with renal insufficiency, and it should be avoided altogether in dialysis patients.^3,16

Meperidine is metabolized in the liver to various metabolites, primarily normeperidine, which is toxic and has a long half-life, five to 10 times longer then meperidine. Meperidine should not be used in patients with renal insufficiency or dialysis.³

Adjunctive therapeutic options. Lidocaine patches currently are only FDA-indicated for postherpetic neuralgia but are used for a wide variety of local pain syndromes. Absorption of lidocaine is determined by the duration of application and the surface area over which it is applied. There is no appreciable accumulation of lidocaine or its metabolites in renal insufficiency; therefore, dose adjustments are not required.^22,23

Gabapentin is FDA-indicated for partial seizures and postherpetic neuralgia but is also used for a wide variety of neuropathic pain syndromes, including postoperative pain.²⁴ Gabapentin is not metabolized and is excreted in the urine unchanged. Renal clearance of gabapentin is reduced by 40% and the elimination half-life is increased up to 52 hours in renal insufficiency, but it is dialyzable. Therefore, dose adjustments are required with gabapentin in patients with moderate to severe renal insufficiency, and supplemental doses should be administered in patients after receiving dialysis.^25-27

Pregabalin is structurally related to gabapentin and is indicated for a variety of neuropathic pain conditions. Pregabalin is 90% excreted unchanged in the urine, and approximately 50% of drug is removed after four hours of hemodialysis. Dose adjustments are required in patients with moderate to severe renal insufficiency, and supplemental doses should be administered in patients after receiving dialysis.²⁸

Antidepressant options. Amitriptyline, nortryptiline, and desipramine are the tricyclic antidepressants (TCAs) commonly used for neuropathic pain. TCAs are metabolized in the liver to inactive metabolites, with the exception of amitriptyline, which is metabolized to nortryptiline. Common side effects reported with TCAs include postural hypotension and anticholinergic side effects, such as constipation, urinary retention, blurred vision, dry mouth, delirium, and sedation. It is unlikely that the TCAs can be removed by dialysis. It is suggested that the dosage be reduced in renal insufficiency and that anticholinergic side effects be monitored.²⁹

Back to the Case

The patient’s ankle pain was controlled with acetaminophen and lidocaine patches. For the neuropathic pain in his upper extremities, tramadol was started at 25 mg oral every 12 hours and increased to 50 mg oral every eight hours (below the maximum of 200 mg a day). The tramadol did not result in adequate pain relief, so gabapentin 100 mg at bedtime was initiated, then increased to twice daily over three days with some relief.

A geriatric consult was obtained to help educate him regarding addiction to opioids, as well as to explore goals of care, but he continued to insist on the use of a non-narcotic regimen for his pain.

Bottom Line

Pain management in patients with renal insufficiency and dialysis can be challenging, but there are a number of safe non-narcotic and narcotic pain regimens that can be safely used in this patient population.

Dr. Harisingani is a board-certified hospitalist at Long Island Jewish Medical Center in New Hyde Park, N.Y., and Drs. Saad and Cassagnol are assistant clinical professors at St. Johns University College of Pharmacy and Health Sciences in Jamaica, N.Y., and clinical pharmacy coordinators at Long Island Jewish Medical Center.

References

1. Mid-Atlantic Renal Coalition and the Kidney End-of-Life Coalition. Clinical algorithm & preferred medications to treat pain in dialysis patients. Coalition for Supportive Care of Kidney Patients website. Available at: http://www.kidneysupportivecare.org/Physicians-Clinicians/Pain—Symptom-Management.aspx. Accessed Nov. 18, 2012.
2. Barakzoy AS, Moss AH. Efficacy of the World Health Organization analgesic ladder to treat pain in end-stage renal disease. J Am Soc Nephrol. 2006;17(11):3198-3203.
3. Johnson SJ. Opioid safety in patients with renal or hepatic dysfunction. Pain Treatment Topics website. Available at: http://pain-topics.org/pdf/Opioids-Renal-Hepatic-Dysfunction.pdf. Accessed Nov. 28, 2012.
4. Ferrell B, Argoff CE, Epplin J, et al. American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57(8):1331-1346.
5. Prescott LF, Speirs GC, Critchley JA, Temple RM, Winney RJ. Paracetamol disposition and metabolite kinetics in patients with chronic renal failure. Eur J Clin Pharmacol. 1989;36(3):291-297.
6. Launay-Vacher V, Karie S, Fau JB, Izzedine H, Deray G. Treatment of pain in patients with renal insufficiency: the World Health Organization three-step ladder adapted. J Pain. 2006;6(3):137-148.
7. Berg KJ, Djøseland O, Gjellan A, et al. Acute effects of paracetamol on prostaglandin synthesis and renal function in normal man and in patients with renal failure. Clin Nephrol. 1990;34:255-262.
8. Delbarre F, Roucayrol JC, Amor B, et al. Pharmacokinetic study of ketoprofen (19.583 R.P.) in man using the tritiated compound. Scand J Rheumatol Suppl. 1976;1976(0):45-52.
9. Shen CH, Hung CJ, Wu CC, Huang HW, Ho WM. Rhabdomyolysis-induced acute renal failure after morphine overdose—a case report. Acta Anaesthesiol Sin. 1999;37(3):159-162.
10. Ketorolac tromethamine oral tablets [package insert]. St. Louis: Ethex Corp.: 2008.
11. Brocks DR, Jamali F. Clinical pharmacokinetics of ketorolac tromethamine. Clin Pharmacokinet. 1992;23:415-427. Erratum in: Clin Pharmacokinet. 1999;24(3):270.
12. Ponstel [package insert]. Alpharetta, GA: First Horizon Pharmaceutical Corp.; 2006.
13. Naprosyn [package insert]. Nutley, NJ: Roche Laboratories Inc.; 2008.
14. Celebrex [package insert]. New York: G.D. Searle LLC; 2011.
15. Catella-Lawson F, McAdam B, Morrison BW, et al. Effects of specific inhibition of cyclooygenase-2 on sodium balance, hemodynamics, and vasoactive eicosanoids. J Pharmacol Exp Ther. 1999;289:735-741.
16. Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage. 2004;28(5):497-504.
17. Lee MA, Leng ME, Tiernan EJ. Retrospective study of the use of hydromorphone in palliative care patients with normal and abnormal urea and creatinine. Palliat Med. 2001;15(1):26-34.
18. Gibson TP. Pharmacokinetics, efficacy, and safety of analgesia with a focus on tramadol HCI. Am J. Med. 1996;101(1A):47S-53S.
19. Izzedine H, Launay-Vacher V, Abbara C, Aymard G, Bassilios N, Deray G. Pharmacokinetics of tramadol in a hemodialysis patient. Nephron. 2002;92(3):755-756.
20. Hasselström J, Säwe J. Morphine pharmacokinetics and metabolism in humans. Enterohepatic cycling and relative contribution of metabolites to active opioid concentrations. Clin Pharmacokinet. 1993;24(4):344-354.
21. Andersen G, Christrup L, Sjøgren P. Relationships among morphine metabolism, pain and side effects during long-term treatment: an update. J Pain Symptom Manage. 2003;25(1):74-91.
22. Lidoderm [package insert]. Chadds Ford, PA: Endo Pharmaceuticals Inc.; 2010.
23. Carter GT, Galer BS. Advances in the management of neuropathic pain. Phys Med Rehabil Clin N Am. 2001;12(2):447-459.
24. Ho KY, Gan TJ, Habib AS. Gabapentin and postoperative pain—a systematic review of randomized controlled trials. Pain. 2006;15:126(1-3):91-101.
25. Neurontin [package insert]. New York: Parke-Davis; 2010.
26. Pandey CK, Priye S, Singh S, et al. Preemptive use of gabapentin significantly decreases postoperative pain and rescue analgesic requirements in laparoscopic cholecystectomy. Can J Anaesth. 2004;51(4):358-363.
27. Srivastava U, Kumar A, Saxena S, et al: Effect of preoperative gabapentin on postoperative pain and tramadol consumption after minilap open cholecystectomy: a randomized double-blind, placebo-controlled trial. Eur J Anaesthesiol. 2010;27(N4):331-335.
28. Lyrica [package insert]. New York: Pfizer Inc.; 2012.
29. Broadbent A, Khor K, Heaney A. Palliation and chronic renal failure: opioid and other palliative medications—dosage guidelines. Progress in Palliative Care. 2003;11(4):183-190(8).
30. Nayak-Rao S. Achieving effective pain relief in patients with chronic kidney disease: a review of analgesics in renal failure. J Nephrol. 2011;24(1):35-40.
31. Wolters Kluwer Health. Facts & comparisons. Wolters Kluwer Health website. Available at: http://www.factsandcomparisons.com. Accessed Jan. 14, 2013.
32. Lexicomp. Lexicomp Online. Lexicomp website. Available at: http://www.lexi.com/institutions/products/online/.

click for large version

Case

A 70-year-old male with ESRD on hemodialysis presents with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and ankle pain after a fall. An MRI of his ankle is negative, and he is started on acetaminophen and lidocaine patches, which result in adequate pain relief of the ankle. He later develops significant neuropathic pain in both arms, and a CT scan of the cervical spine reveals a cervical abscess and osteomyelitis. The patient desires pain relief but adamantly refuses narcotics, stating: “I don’t want to get addicted.” How can his pain be managed?

Overview

Pain is a common problem in patients with renal insufficiency and end-stage renal disease (ESRD) and can have a significant effect on the patient’s quality of life.¹ When assessing a patient’s pain, assess both the severity of the pain (such as on an analogue scale, 0-10) and the characteristics of the pain. Pain is most commonly characterized as nociceptive, neuropathic, or both. Nociceptive pain can be further classified as arising from either somatic or visceral sources, and is often described as dull, throbbing, cramping, and/or pressurelike.¹ Neuropathic pain is often described as tingling, numbing, burning, and/or stabbing.

It is a challenge to manage pain in patients with renal insufficiency and dialysis. Renal insufficiency affects the pharmacokinetic properties of most pain medications, including their distribution, clearance, and excretion. The magnitude of the effect of renal insufficiency on drug metabolism varies depending on the agent itself, its metabolite, and the extent of renal failure.³ Multiple factors should be considered when prescribing pain medications for patients on dialysis, including the properties of the parent drug and its metabolites; the physical properties of the dialysis equipment, such as the filter pore size, the flow rate, and the efficiency of the technique used; and the dialysis method (intermittent versus continuous).³ Table 1 provides the recommended dosing of the most commonly prescribed agents, based on the degree of renal impairment. A modified World Health Organization (WHO) ladder has been suggested to treat pain in patients with ESRD, which can lead to effective pain relief in as many as 96% of patients (see Figure 1).²

click for large version

click for large version

Review of Data

Nonopioid options. Nonopioids, such as acetaminophen and NSAIDs, have no associated tolerance but have a ceiling effect for analgesia, and NSAIDs are associated with dose-dependent acute renal failure, gastrointestinal ulceration and bleeding, and cardiac events. The nonopioids that are considered safe options in patients with renal insufficiency include acetaminophen, ibuprofen, and fenoprofen (Nalfon). However, in the elderly, American Geriatric Society (AGS) guidelines currently recommend avoiding all NSAIDs due to their safety profile in the geriatric population.⁴ Although all NSAIDs can potentially be used for pain, selected NSAIDs with an FDA indication for acute or chronic pain were included for this review.

Acetaminophen (APAP) is a dialyzable compound that is metabolized in the liver to five inactive metabolites. The terminal elimination half-life of its sulfate and glucuronide metabolites are prolonged in patients with renal failure; therefore, the dosing interval of APAP should be increased to six to eight hours in renally impaired patients.^5,6,7 Overall, acetaminophen is considered one of the safest agents to use for the treatment of pain, in renal patients and otherwise, as long as dosing is below the minimal daily dose (see Table 1).

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Ibuprofen is metabolized in the liver to inactive compounds. It does not accumulate in renal insufficiency, and two of the inactive compounds are dialyzable.⁸ It is considered a safe option for the treatment of pain in patients with renal insufficiency or dialysis.⁹

Fenoprofen is metabolized in the liver to inactive compounds. Renal impairment is likely to cause the accumulation of the inactive metabolites but not the parent compound, so dose reduction is not necessary with the use of this agent in renal insufficiency or dialysis.⁶

Mefenamic acid (Ponstel) is metabolized in the liver. Mefenamic acid can further deteriorate renal function in patients with underlying renal disease.12 However, the nephrotoxic potential of this agent is of little consideration in ESRD patients on dialysis, and therefore no dosage adjustments are necessary in these patients.⁶

Ketoprofen is metabolized in the liver, where approximately 80% of the dose is excreted in the urine as a glucuronide metabolite. Dose reduction is recommended in renal insufficiency and dialysis, as it not dialyzable.⁸

Ketorolac accumulates in renal insufficiency; therefore, it is contraindicated in these patients and in patients at risk for renal failure, including those with volume depletion.¹⁰ Ketorolac is unlikely to be removed by dialysis and so should be avoided.^10,11

Naproxen is metabolized in the liver to inactive compounds. Use of naproxen is not recommended in patients with moderate to severe renal impairment. If therapy must be initiated, close monitoring of the patient’s renal function is recommended.¹³

Celecoxib is the only cyclooxygenase-2 (COX-2) inhibitor available in the U.S. It is metabolized extensively by the liver and is unlikely to be removed by dialysis. Therefore, use of COX-2 inhibitors should be avoided in severe renal impairment and in those on dialysis.^14,15

Opioid options. The use of opioids in the renally impaired population is challenging, as one must balance opioid-related adverse events with adequate pain control. As such, it is recommended to start with lower-than-recommended doses and slowly titrate up the dose while extending the dosing interval. This will help limit adverse effects, such as respiratory depression and hypotension.³

Hydrocodone is metabolized to hydromorphone (Dilaudid), which is then metabolized to its major metabolite hydromorphine-3-glucuronide (H3G) and minor metabolite hydromorphine-6-hydroxy, all of which are excreted renally along with the parent compound. H3G has no analgesic properties, but it can potentially cause neuroexcitation, agitation, confusion, and hallucination. Hydromorphone has been used safely in patients with renal insufficiency and dialysis, as it is expected to be dialyzable. ^16,17

Tramadol is metabolized in the liver, producing one active compound. Approximately 30% of the tramadol dose is excreted unchanged in the urine, whereas 60% of the dose is excreted as metabolites. It is recommended to reduce the dose and increase the dosing interval in patients with renal insufficiency, but tramadol is generally well-tolerated in patients with renal insufficiency and dialysis. It is significantly removed by hemodialysis; therefore, redosing after a session may be necessary.^18,19

Oxycodone can be used in patients with mild to moderate renal insufficiency but should be used at reduced dosing; it has been associated with significant sedation with usual doses in renal failure patients.¹⁶ Its use is generally not recommended in dialysis patients due to lack of data.³

Methadone and its metabolites are excreted in the urine and feces. Methadone has been used safely in patients with renal insufficiency, but it is poorly removed by dialysis and no specific recommendations are available regarding its dosing in dialysis.^3,16

Fentanyl is primarily metabolized in the liver to inactive metabolites. Fentanyl clearance is reduced in patients with moderate to severe uremia (BUN >60 mg/dL). It is not expected that fentanyl be dialyzable because of its pharmacokinetic properties (high protein-binding, low water solubility, high molecular weight, and high volume of distribution). Data suggests that fentanyl can be used at usual doses in mild to moderate renal insufficiency and in dialysis patients, although reduced doses may be prudent. Such patients should be monitored for signs of gradual accumulation of the parent drug.^3,16

Morphine is metabolized in the liver to morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G), all of which are excreted renally, along with the parent compound. Only M6G has analgesic properties, and when it accumulates, it can lead to CNS depression. M3G is associated with behavioral excitation, a side effect that is further magnified in patients with renal insufficiency. Although morphine is dialyzable, it should generally be avoided in patients with any level of renal insufficiency.^16,17,20,21

Codeine is metabolized to several active metabolites, all of which are renally excreted. Lower-than-usual doses are recommended in patients with renal insufficiency, and it should be avoided altogether in dialysis patients.^3,16

Meperidine is metabolized in the liver to various metabolites, primarily normeperidine, which is toxic and has a long half-life, five to 10 times longer then meperidine. Meperidine should not be used in patients with renal insufficiency or dialysis.³

Adjunctive therapeutic options. Lidocaine patches currently are only FDA-indicated for postherpetic neuralgia but are used for a wide variety of local pain syndromes. Absorption of lidocaine is determined by the duration of application and the surface area over which it is applied. There is no appreciable accumulation of lidocaine or its metabolites in renal insufficiency; therefore, dose adjustments are not required.^22,23

Gabapentin is FDA-indicated for partial seizures and postherpetic neuralgia but is also used for a wide variety of neuropathic pain syndromes, including postoperative pain.²⁴ Gabapentin is not metabolized and is excreted in the urine unchanged. Renal clearance of gabapentin is reduced by 40% and the elimination half-life is increased up to 52 hours in renal insufficiency, but it is dialyzable. Therefore, dose adjustments are required with gabapentin in patients with moderate to severe renal insufficiency, and supplemental doses should be administered in patients after receiving dialysis.^25-27

Pregabalin is structurally related to gabapentin and is indicated for a variety of neuropathic pain conditions. Pregabalin is 90% excreted unchanged in the urine, and approximately 50% of drug is removed after four hours of hemodialysis. Dose adjustments are required in patients with moderate to severe renal insufficiency, and supplemental doses should be administered in patients after receiving dialysis.²⁸

Antidepressant options. Amitriptyline, nortryptiline, and desipramine are the tricyclic antidepressants (TCAs) commonly used for neuropathic pain. TCAs are metabolized in the liver to inactive metabolites, with the exception of amitriptyline, which is metabolized to nortryptiline. Common side effects reported with TCAs include postural hypotension and anticholinergic side effects, such as constipation, urinary retention, blurred vision, dry mouth, delirium, and sedation. It is unlikely that the TCAs can be removed by dialysis. It is suggested that the dosage be reduced in renal insufficiency and that anticholinergic side effects be monitored.²⁹

Back to the Case

The patient’s ankle pain was controlled with acetaminophen and lidocaine patches. For the neuropathic pain in his upper extremities, tramadol was started at 25 mg oral every 12 hours and increased to 50 mg oral every eight hours (below the maximum of 200 mg a day). The tramadol did not result in adequate pain relief, so gabapentin 100 mg at bedtime was initiated, then increased to twice daily over three days with some relief.

A geriatric consult was obtained to help educate him regarding addiction to opioids, as well as to explore goals of care, but he continued to insist on the use of a non-narcotic regimen for his pain.

Bottom Line

Pain management in patients with renal insufficiency and dialysis can be challenging, but there are a number of safe non-narcotic and narcotic pain regimens that can be safely used in this patient population.

Dr. Harisingani is a board-certified hospitalist at Long Island Jewish Medical Center in New Hyde Park, N.Y., and Drs. Saad and Cassagnol are assistant clinical professors at St. Johns University College of Pharmacy and Health Sciences in Jamaica, N.Y., and clinical pharmacy coordinators at Long Island Jewish Medical Center.

References

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