The frequency of drug-induced thrombocytopenia (DIT) in acutely ill patients is thought to be up to 25%, making it a common problem.1,2

Hundreds of drugs have been identified as causing DIT, due to either accelerated immune-mediated platelet destruction, decreased platelet production (bone marrow suppression), or platelet aggregation. The latter is the case in heparin-induced thrombocytopenia and thrombosis (HITT). DIT should be suspected in any patient who presents with acute thrombocytopenia from an unknown cause.3

Normal adult platelet counts usually are in the range of 140,000 to 450,000/mm3. A patient who presents with severe thrombocytopenia (less than 20,000 platelets/mm3) should strongly be suspected as having a drug-induced cause.

A patient also can present with moderate to severe thrombocytopenia (less than 50,000 platelets/mm3) and spontaneous bleeding from a drug-induced cause. The spontaneous bleeding can take the form of simple petechiae or ecchymoses, as well as mucosal bleeding or life-threatening intracranial or gastrointestinal hemorrhage. It may also present itself as bleeding around catheter insertion sites.

When DIT occurs, platelet count usually falls within two to three days of taking a drug that’s been taken before, or seven or more days after starting a drug the patient has not been exposed to. Once the offending drug is discontinued, platelet counts usually recover within 10 days.

Exclusions of other causes of thrombocytopenia, such as inflammatory processes and congenital disorders, as well as nondrug causes including sepsis, malignancy, extensive burns, chronic alcoholism, human immunodeficiency virus, splenomegaly, and disseminated intravascular coagulation, become part of the differential diagnosis.

Generally, the frequency and severity of bleeding manifestations correlate with the actual platelet count. Patients with a platelet count of less than 50,000/mm3 have an increased risk of spontaneous hemorrhage, but the severity may vary. Other risk factors include advanced age, bleeding history, and general bleeding diatheses.

A thorough physical examination and drug history are essential. Agents commonly associated with thrombocytopenia should be identified first followed by a more extensive review for other causes. A careful drug history should include prescriptions, over-the-counter medications (specifically quinine and acetaminophen), dietary supplements, folk remedies, other complementary and alternative therapies, and vaccinations.

The Agents

The top two suspects for DIT are antineoplastic agents and heparin. After these two, the agents most frequently associated with DIT development include:

• Quinine/quinidine;
• Phenytoin;
• Sulfonamide antibiotics;
• Cimetidine;
• Ranitidine;
• Rifampin/rifampicin;
• Carbamazepine;
• Thiazide diuretics;
• Penicillin;
• Oral antidiabetic drugs;
• Nonsteroidal anti-inflammatory drugs;
• Gold salts; and
• Procainamide.

A complete list of all case reports describing DIT, organized by generic

drug names, is available online at http://w3.ouhsc.edu/platelets/ditp.html.4

Management

Removal of the potentially offending agent, if known, is prudent before clinically significant bleeding occurs. If the offending agent is not discontinued, the platelet count will continue to decrease and bleeding will become more severe. If necessary, an alternate agent with a similar pharmacologic effect can be started. Daily platelet count monitoring is also recommended for management. Rare cases may require platelet transfusions, intravenous immunoglobulin therapy or plasmapheresis.

A complete blood count and peripheral blood smear may provide important indications into the mechanism of the disorder, but they’re not necessary for patient management. TH

Michele B Kaufman, PharmD, BSc, is a registere pharmacist based in New York City.

References

1. Visentin GP, Liu CY. Drug-induced thrombocytopenia. Hematol Oncol Clin N Am. 2007;21:685-696.
2. Wazny LD, Ariano RE. Evaluation and management of drug-induced thrombocytopenia in the acutely ill patient. Pharmacother. 2000;20(3):292-307.
3. Aster RH, Bougie DW. Drug-induced thrombocytopenia. N Engl J Med. 2007;357(6):580-587.
4. Majhail NS, Lichtin AE. What is the best way to determine if thrombocytopenia in a patient on multiple medications is drug-induced? Cleve Clin J Med. 2002;69(3):259-262.

The frequency of drug-induced thrombocytopenia (DIT) in acutely ill patients is thought to be up to 25%, making it a common problem.1,2

Hundreds of drugs have been identified as causing DIT, due to either accelerated immune-mediated platelet destruction, decreased platelet production (bone marrow suppression), or platelet aggregation. The latter is the case in heparin-induced thrombocytopenia and thrombosis (HITT). DIT should be suspected in any patient who presents with acute thrombocytopenia from an unknown cause.3

Normal adult platelet counts usually are in the range of 140,000 to 450,000/mm3. A patient who presents with severe thrombocytopenia (less than 20,000 platelets/mm3) should strongly be suspected as having a drug-induced cause.

A patient also can present with moderate to severe thrombocytopenia (less than 50,000 platelets/mm3) and spontaneous bleeding from a drug-induced cause. The spontaneous bleeding can take the form of simple petechiae or ecchymoses, as well as mucosal bleeding or life-threatening intracranial or gastrointestinal hemorrhage. It may also present itself as bleeding around catheter insertion sites.

When DIT occurs, platelet count usually falls within two to three days of taking a drug that’s been taken before, or seven or more days after starting a drug the patient has not been exposed to. Once the offending drug is discontinued, platelet counts usually recover within 10 days.

Exclusions of other causes of thrombocytopenia, such as inflammatory processes and congenital disorders, as well as nondrug causes including sepsis, malignancy, extensive burns, chronic alcoholism, human immunodeficiency virus, splenomegaly, and disseminated intravascular coagulation, become part of the differential diagnosis.

Generally, the frequency and severity of bleeding manifestations correlate with the actual platelet count. Patients with a platelet count of less than 50,000/mm3 have an increased risk of spontaneous hemorrhage, but the severity may vary. Other risk factors include advanced age, bleeding history, and general bleeding diatheses.

A thorough physical examination and drug history are essential. Agents commonly associated with thrombocytopenia should be identified first followed by a more extensive review for other causes. A careful drug history should include prescriptions, over-the-counter medications (specifically quinine and acetaminophen), dietary supplements, folk remedies, other complementary and alternative therapies, and vaccinations.

The Agents

The top two suspects for DIT are antineoplastic agents and heparin. After these two, the agents most frequently associated with DIT development include:

• Quinine/quinidine;
• Phenytoin;
• Sulfonamide antibiotics;
• Cimetidine;
• Ranitidine;
• Rifampin/rifampicin;
• Carbamazepine;
• Thiazide diuretics;
• Penicillin;
• Oral antidiabetic drugs;
• Nonsteroidal anti-inflammatory drugs;
• Gold salts; and
• Procainamide.

A complete list of all case reports describing DIT, organized by generic

drug names, is available online at http://w3.ouhsc.edu/platelets/ditp.html.4

Management

Removal of the potentially offending agent, if known, is prudent before clinically significant bleeding occurs. If the offending agent is not discontinued, the platelet count will continue to decrease and bleeding will become more severe. If necessary, an alternate agent with a similar pharmacologic effect can be started. Daily platelet count monitoring is also recommended for management. Rare cases may require platelet transfusions, intravenous immunoglobulin therapy or plasmapheresis.

A complete blood count and peripheral blood smear may provide important indications into the mechanism of the disorder, but they’re not necessary for patient management. TH

Michele B Kaufman, PharmD, BSc, is a registere pharmacist based in New York City.

References

1. Visentin GP, Liu CY. Drug-induced thrombocytopenia. Hematol Oncol Clin N Am. 2007;21:685-696.
2. Wazny LD, Ariano RE. Evaluation and management of drug-induced thrombocytopenia in the acutely ill patient. Pharmacother. 2000;20(3):292-307.
3. Aster RH, Bougie DW. Drug-induced thrombocytopenia. N Engl J Med. 2007;357(6):580-587.
4. Majhail NS, Lichtin AE. What is the best way to determine if thrombocytopenia in a patient on multiple medications is drug-induced? Cleve Clin J Med. 2002;69(3):259-262.

The frequency of drug-induced thrombocytopenia (DIT) in acutely ill patients is thought to be up to 25%, making it a common problem.1,2

Hundreds of drugs have been identified as causing DIT, due to either accelerated immune-mediated platelet destruction, decreased platelet production (bone marrow suppression), or platelet aggregation. The latter is the case in heparin-induced thrombocytopenia and thrombosis (HITT). DIT should be suspected in any patient who presents with acute thrombocytopenia from an unknown cause.3

Normal adult platelet counts usually are in the range of 140,000 to 450,000/mm3. A patient who presents with severe thrombocytopenia (less than 20,000 platelets/mm3) should strongly be suspected as having a drug-induced cause.

A patient also can present with moderate to severe thrombocytopenia (less than 50,000 platelets/mm3) and spontaneous bleeding from a drug-induced cause. The spontaneous bleeding can take the form of simple petechiae or ecchymoses, as well as mucosal bleeding or life-threatening intracranial or gastrointestinal hemorrhage. It may also present itself as bleeding around catheter insertion sites.

When DIT occurs, platelet count usually falls within two to three days of taking a drug that’s been taken before, or seven or more days after starting a drug the patient has not been exposed to. Once the offending drug is discontinued, platelet counts usually recover within 10 days.

Exclusions of other causes of thrombocytopenia, such as inflammatory processes and congenital disorders, as well as nondrug causes including sepsis, malignancy, extensive burns, chronic alcoholism, human immunodeficiency virus, splenomegaly, and disseminated intravascular coagulation, become part of the differential diagnosis.

Generally, the frequency and severity of bleeding manifestations correlate with the actual platelet count. Patients with a platelet count of less than 50,000/mm3 have an increased risk of spontaneous hemorrhage, but the severity may vary. Other risk factors include advanced age, bleeding history, and general bleeding diatheses.

A thorough physical examination and drug history are essential. Agents commonly associated with thrombocytopenia should be identified first followed by a more extensive review for other causes. A careful drug history should include prescriptions, over-the-counter medications (specifically quinine and acetaminophen), dietary supplements, folk remedies, other complementary and alternative therapies, and vaccinations.

The Agents

The top two suspects for DIT are antineoplastic agents and heparin. After these two, the agents most frequently associated with DIT development include:

• Quinine/quinidine;
• Phenytoin;
• Sulfonamide antibiotics;
• Cimetidine;
• Ranitidine;
• Rifampin/rifampicin;
• Carbamazepine;
• Thiazide diuretics;
• Penicillin;
• Oral antidiabetic drugs;
• Nonsteroidal anti-inflammatory drugs;
• Gold salts; and
• Procainamide.

A complete list of all case reports describing DIT, organized by generic

drug names, is available online at http://w3.ouhsc.edu/platelets/ditp.html.4

Management

Removal of the potentially offending agent, if known, is prudent before clinically significant bleeding occurs. If the offending agent is not discontinued, the platelet count will continue to decrease and bleeding will become more severe. If necessary, an alternate agent with a similar pharmacologic effect can be started. Daily platelet count monitoring is also recommended for management. Rare cases may require platelet transfusions, intravenous immunoglobulin therapy or plasmapheresis.

A complete blood count and peripheral blood smear may provide important indications into the mechanism of the disorder, but they’re not necessary for patient management. TH

Michele B Kaufman, PharmD, BSc, is a registere pharmacist based in New York City.

References

1. Visentin GP, Liu CY. Drug-induced thrombocytopenia. Hematol Oncol Clin N Am. 2007;21:685-696.
2. Wazny LD, Ariano RE. Evaluation and management of drug-induced thrombocytopenia in the acutely ill patient. Pharmacother. 2000;20(3):292-307.
3. Aster RH, Bougie DW. Drug-induced thrombocytopenia. N Engl J Med. 2007;357(6):580-587.
4. Majhail NS, Lichtin AE. What is the best way to determine if thrombocytopenia in a patient on multiple medications is drug-induced? Cleve Clin J Med. 2002;69(3):259-262.

Literature at a Glance

A guide to this month’s studies.

• Physiologic doses of corticosteroids provide no clear benefit to patients with septic shock.
• Endovascular vs. open repair of abdominal aortic aneurysms is associated with fewer short-term deaths but complications and higher late reinterventions.
• Neither intensive insulin nor use of colloid over crystalloid improves mortality or organ failure outcomes in sepsis.
• Surgical cure for diabetes shows promise at two-year follow-up.
• Delayed defibrillation negatively affects survival.
• Right-ventricular enlargement in patients with acute PE is not associated with increased mortality.
• Periprocedural interruption of warfarin therapy presents low risk of thromboembolism.
• Minor leg injury increases risk of developing venous thrombosis threefold.
• Oral vs. parenteral antibiotics for pediatric pyelonephritis.

Do Physiologic Doses of Hydrocortisone Benefit Patients With Septic Shock?

Background: Meta-analyses and guidelines advocate the use of physiologic dose steroids in patients exhibiting septic shock. However, recommendations are largely based on the results of a single trial where benefits were seen only in patients without a response to corticotropin.

Study design: Multicenter, randomized, double-blind, placebo-controlled study.

Setting: Fifty-two participating ICUs in nine countries.

Synopsis: A total of 499 patients with evidence of infection or a systemic inflammatory response characterized by refractory hypotension were randomly selected to receive either an 11-day tapering dose of hydrocortisone or a placebo. The primary outcome was death from any cause at 28 days. A corticotropin stimulation test was conducted on every patient to assess adrenal function. There were no differences in death rates or duration of hospitalization between study arms. Overall, there were 86 deaths in the hydrocortisone group and 78 deaths in the placebo group (p=0.51). Also, response to corticotropin appeared to have little bearing on outcomes.

The study was underpowered due to low enrollment and a lower-than-expected death rate. Nevertheless, this is the largest trial to date examining the role of steroids in the management of septic shock and calls into question the strength of prior data and published guidelines.

Bottom line: This study failed to demonstrate a clinically or statistically significant treatment effect from the administration of physiologic-dose steroids in patients with septic shock.

Citation: Sprung C, Annane D, Keh D, et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008;358(2):111-124.

Does Open or Endovascular Repair of Abdominal Aortic Aneurysm Benefit the Medicare Population?

Background: Randomized controlled trials (RCT) have shown a perioperative survival benefit of endovascular repair over open repair with fewer complications and shorter recovery. There is concern that late morbidity may be increased with endovascular repair. Patients enrolled in the trials were highly selected at specialty centers, so the results may not reflect actual practice.

Study design: Retrospective, propensity-matched, observational cohort study.

Synopsis: 22,830 patients were matched in each cohort. Patients were eligible if they had an abdominal aortic aneurysm repair without rupture and excluded if they were enrolled in health maintenance organizations.

Outcomes included death within 30 days and late survival, perioperative complications, aneurysm rupture, reintervention, and laparotomy-related complications. The average age was 76, and 20% were women. Perioperative mortality was lower after endovascular repair (1.2% vs. 4.8%, p<0.001), and older patients had a greater benefit. Late survival was similar. By four years, rupture was more likely in the endovascular group (1.8% vs. 0.5%, p<0.001), as was reintervention (9% vs. 1.7%, p<0.001).

In contrast, by four years, surgery for laparotomy-related complications was more likely in the open-repair group (9.7% v 4.1%, p<0.001), as was hospitalization for bowel obstruction or abdominal-wall hernia (14.2% v 8.1%, p<0.001). Limitations included the non-randomized design and use of administrative data for important categorical variables including medical co-morbidities.

Bottom line: As compared with open repair, endovascular repair of abdominal aortic aneurysm is associated with lower short-term death and complications and higher late reinterventions. This is balanced by an increase in laparotomy-related reinterventions after open repair.

Citation: Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med. 2008 Jan 31;358(5):464-474.

What Therapy Improves Outcomes in ICU Patients With Severe Sepsis or Septic Shock?

Background: Evidence suggests lower mortality with intensive insulin therapy in post-surgical cardiac patients. There is no proven benefit for non-surgical ICU patients. Despite lack of data, intensive insulin in severe sepsis has been widely advocated. Little is known to guide the use of colloid or crystalloid for fluid resuscitation in sepsis.

Study design: Multicenter, two-by-two factorial, open-label trial.

Setting: Multidisciplinary ICUs at 18 academic tertiary hospitals in Germany.

Synopsis: Data were analyzed for 537 patients with severe sepsis. They were randomly selected to receive intensive insulin therapy (n=247) or conventional insulin therapy (290), with either 10% hydroxyethyl starch (HES) (262) or modified Ringer’s lactate (LR) (275) for fluid resuscitation.

Co-primary endpoints were all-cause mortality at 28 days and morbidity as measured by the mean score on the Sequential Organ Failure Assessment (SOFA). The trial was stopped early for safety reasons. Intensive insulin therapy was terminated due to an increased number of hypoglycemic events in the intensive-therapy group compared with conventional therapy (12.1% vs. 2.1%, p<0.001), and there was no difference in mortality between groups at 28 and 90 days.

Interim analysis of 600 patients showed patients given HES had higher incidence of renal failure compared with LR (34.9% vs. 22.8%, p=0.002), required more days of renal replacement therapy, had lower median platelets and received more units of packed red cells. There was a trend toward higher rate of death at 90 days in those treated with HES (41% vs. 33.9%, p=0.09).

Bottom line: Intensive insulin therapy in ICU patients with severe sepsis and septic shock does not improve mortality and increases hypoglycemia and ICU length of stay. Use of colloid over crystalloid should be avoided, showing a trend toward increased death at 90 days, higher rates of acute renal failure, and need for renal replacement therapy..

Citation: Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med. 2008;358(2):125-139.

How Does Laparoscopic Adjustable Gastric Banding Affect Obese Adults With Type 2 Diabetes?

Background: Observational studies related surgical weight loss to improved glycemic control, but clinical trials did not test this relationship. The current trial examined this hypothesis.

Study design: Unmasked, randomized controlled trial.

Setting: University Obesity Research Center, Australia.

Synopsis: Sixty adults age 20-60 with body-mass index (BMI) of 30-40 and diagnosed with diabetes mellitus type 2 (DM2) within two years of recruitment were randomized into conventional therapy and surgical groups.

While both groups were treated similarly, only the surgical group received laparoscopic adjustable gastric banding. Primary outcome was remission of DM2 (a fasting glucose less than 126 mg/dl, HbA1C less than 6.2%, and off all hypoglycemic agents). At two years, 73% in the surgical group compared with 13% in the conventional group attained this outcome (relative risk [RR] 5.5, 95% confidence interval [CI] 2.2-14.0; p<0.001). Compared with the conventional group, the surgical group demonstrated statistically significant improvements in several secondary outcomes including mean body weight, waist circumference, insulin resistance, and lipids.

The limitations of the study are that it examined a small number of patients with shorter duration of DM2 and a shorter follow-up. The lower surgical complication rates cannot be generalized to other centers.

Bottom line: This study is a step forward in examining the relationship of surgical weight loss and remission of DM2. However, large multicenter trials with longer periods of follow-up in diverse group of patients would result in a better understanding of this relationship.

Citation: Dixon JB, O’Brien PE, Playfair J, et. al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA. 2008;299(3):316-323.

What is the Prevalence of Delayed Defibrillation and its Association With Survival to Discharge?

Background: Despite advances in resuscitation, survival rates following cardiac arrest remain low. Previous studies observed the effect of the timing of defibrillation on survival. This study examined the magnitude of delayed defibrillation and its association with survival in adults who sustained cardiac arrest specifically from ventricular fibrillation and pulseless ventricular tachycardia.

Study design: National Registry of Cardiopulmonary Resuscitation (NRCPR), a multicenter prospective cohort.

Setting: 369 U.S. hospitals providing acute care.

Synopsis: Data from NRCPR relating to 6,789 cardiac arrests secondary to ventricular fibrillation or pulseless ventricular tachycardia, at 369 hospitals in hospitalized adults were analyzed. Delayed defibrillation was defined as occurring more than two minutes from the identification of ventricular fibrillation or pulseless ventricular tachycardia to the administration of the first shock to the patient.

Delayed defibrillation occurred in 2,045 (30.1%) subjects. A lower proportion of subjects who received delayed defibrillation (22.2%) compared with those who received defibrillation in two minutes or less (39.3%) survived to hospital discharge. This was statistically significant (adjusted odds ratio [OR] 0.48, 95% CI 0.42 to 0.54; p<0.01).

Bottom line: This study not only reported that delayed defibrillation was prevalent in adult hospitalized patients, but also reinforced the importance of defibrillation within two minutes of identification of cardiac arrest secondary to ventricular fibrillation and pulseless ventricular tachycardia for better survival outcomes.

Citation: Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17.

Does Right-Ventricle Enlargement in Acute PE Increase In-hospital Death From PE or All-cause Mortality?

Background: Previous studies have shown conflicting results regarding the risk of death with right-ventricular enlargement in acute pulmonary embolism (PE). The role of thrombolysis in hemodynamically stable patients with acute PE and right-ventricular enlargement remains controversial.

Study design: Retrospective analysis of prospective cohort study.

Setting: Academic centers housing inpatients and outpatients in the United States and Canada.

Synopsis: Patients enrolled in PIOPED II who were diagnosed with acute PE and had multidetector computed tomographic (CT) angiography were retrospectively reviewed for the presence of right-ventricular enlargement. Study determined that 181 patients had PE and a CT, and 157 were adequate for measurement of right-ventricular size. PE treatment was anticoagulation in 138, anticoagulation and inferior vena cava filter in 15, inferior vena cava filter alone in two, and thrombolysis in two.

Right-ventricular enlargement was found in 78 (50%) patients; 76 were treated with anticoagulation alone or in combination with inferior vena cava filter. For patients with and without right-ventricular enlargement, there was no difference in in-hospital death from PE (0% vs. 1.3%) or all-cause mortality (2.6% vs. 2.5%). The results were unchanged when examined for septal motion abnormality and previous cardiopulmonary disease.

Bottom line: In hemodynamically stable patients with acute pulmonary embolism, right ventricular enlargement does not increase mortality. Further, thrombolytic therapy is unlikely to improve outcomes.

Citation: Stein PD, Beemath A, Matti F, et al. Enlarged right ventricle without shock in acute pulmonary embolus: prognosis. Am J Med. 2008;121:34-42.

What Are Short-term Thromboembolism, Hemorrhage Risks When Interrupting Warfarin Therapy for Procedures?

Background: The risks of thromboembolism and hemorrhage during the periprocedural interruption of warfarin therapy are not known. The risks and benefits of heparin bridging therapy are not well described.

Study design: Multicenter, prospective, observational cohort study.

Setting: Community-based physician practices.

Synopsis: Patients were eligible if they were on long-term warfarin and underwent outpatient procedures requiring interruption of therapy. The primary outcomes were thromboembolism or hemorrhage within 30 days of therapy interruption. In all, 1,024 eligible patients (7.1% considered high risk) had 1,293 interruptions of warfarin therapy. The most common procedures were colonoscopy (25.1%), oral or dental surgery (24.9%), and ophthalmologic surgery (8.9%). Warfarin interruption was five or fewer days in 83.8% of episodes.

Thromboembolism occurred in seven (0.7%) patients, and major or clinically significant bleeding occurred in 23 (0.6%, and 1.7%, respectively) patients. Periprocedural bridging with heparin was used in 88 (8.6%) patients. Of the patients who received periprocedural heparin therapy, none had thromboembolism, and 14 (13%) had bleeding episodes.

Bottom line: In patients whose warfarin therapy is interrupted to undergo outpatient procedures, the risk of thromboembolism is low and the hemorrhagic risk of heparin bridging therapy is significant.

Citation: Garcia DA, Regan S, Henault LE, et al. Risk of thromboembolism with short-term interruption of warfarin therapy. Arch Intern Med. 2008;168(1):63-69.

Are Minor Injuries an Independent Risk Factor For Development of DVT?

Background: Prior studies focus on major injuries as a risk factor for deep-vein thrombosis (DVT) and PE. However, major injury is often associated with other risks for venous thrombosis, such as surgery, plaster casting, hospitalization, and extended bed rest. Risk of DVT with minor injuries that don’t lead to these factors is unknown.

Study design: Large population-based case-control study.

Setting: Six anticoagulation clinics in the Netherlands.

Synopsis: 2,471 consecutive cases (patients with first episode of DVT or PE) and 3,534 controls (partners of cases or random digit dialing contacts) were enrolled. Participants were mailed a questionnaire, including a list of eight common injuries.

Participants with history of cast, surgery, recent hospitalization, extended bed rest, or prior history of cancer were excluded. A subset of patients and controls underwent DNA and blood collection to evaluate for presence of a hypercoagulable state. Of the cases, 289 (11.7%) had a minor injury within three months of the index date, compared with 154 (4.4%) of controls, representing a threefold increased risk of DVT/PE with minor injury (OR 3.1). Partial ruptures of muscles or ligaments in the leg (OR 10.9), multiple simultaneous injuries (OR 9.9), and injury within four weeks of presentation (OR 4.0), were associated with increased risk of DVT/PE.

Patients found to be Factor V Leiden carriers with injury had an almost 50-fold increased risk of venous thromboembolism (VTE) compared with non-carriers without injury (OR 49.7). Authors appropriately address possible limitations, including recall and referral bias.

Bottom line: Minor leg injury is associated with threefold risk of DVT/PE, especially in the four weeks following injury. Providers should consider short-term prophylactic treatment in patients with Factor V Leiden or high-risk injuries.

Citation: Van Stralen KJ, Rosendaal FR, Doggen CJ. Minor injuries as a risk factor for venous thrombosis. Arch Intern Med. 2008;168(1):21-26.

Is Oral Amox-Clav Non-inferior to IV Antibiotics in Pediatric Pyelonephritis?

Background: Present guidelines recommend initial treatment for pediatric pyelonephritis to be a parenteral third-generation cephalosporin followed by oral antibiotics. One prior randomly selected controlled trial compared oral antibiotics only with antibiotics started parenterally, but there was a higher-than-usual incidence of vesicoureteral reflux and female gender in the study.

Study design: Non-inferiority, multicenter, random, open label, controlled trial.

Setting: Twenty-eight pediatric units in northeast Italy from 2000-2005

Synopsis: 502 children age 1 month to less than 7 years with a clinical diagnosis of first occurrence of acute pyelonephritis according to urinalysis and urine culture (requiring two concordant consecutive tests) with at least two of the following conditions: fever of 38 degrees C or more or elevated erythrocyte sedimentation rate (ESR) or c-reactive protein (CRP), and elevated neutrophil count were randomized to receive oral amoxicillin-clavulanate (AC) or parenteral ceftriaxone followed by oral AC. Exclusion criteria were sepsis, dehydration, vomiting, and creatinine clearance of 70 ml/min or less.

Also, 400 children had dimercaptosuccinic acid (DMSA) scintigraphy within 10 days of study entry. Meantime, 223 had repeat DMSA at one year, and 177 had normal scans at study entry so were not repeated. At one year, 20% of patients were lost to follow-up. The primary outcome was renal scarring at one year. Secondary outcomes included time to fever defervescence, reduction in inflammatory indices, and percentage with sterile urine after 72 hours. Intention to treat analysis showed no significant differences between oral (n=244) and parenteral (n=258) treatment, both in the primary outcome 13.7% vs. 17.7% (95% CI, -11.1% to 3.1%), and secondary outcomes.

Bottom line: Treatment with oral antibiotics is as effective as parenteral then oral treatment for first episode of acute pediatric pyelonephritis.

Citation: Montini G, Toffolo A, Zucchetta P, et al. Antibiotic treatment for pyelonephritis in children: multicentre randomised controlled non-inferiority trial. BMJ. 2007 Aug 25;335(7616):386.

Literature at a Glance

A guide to this month’s studies.

• Physiologic doses of corticosteroids provide no clear benefit to patients with septic shock.
• Endovascular vs. open repair of abdominal aortic aneurysms is associated with fewer short-term deaths but complications and higher late reinterventions.
• Neither intensive insulin nor use of colloid over crystalloid improves mortality or organ failure outcomes in sepsis.
• Surgical cure for diabetes shows promise at two-year follow-up.
• Delayed defibrillation negatively affects survival.
• Right-ventricular enlargement in patients with acute PE is not associated with increased mortality.
• Periprocedural interruption of warfarin therapy presents low risk of thromboembolism.
• Minor leg injury increases risk of developing venous thrombosis threefold.
• Oral vs. parenteral antibiotics for pediatric pyelonephritis.

Do Physiologic Doses of Hydrocortisone Benefit Patients With Septic Shock?

Background: Meta-analyses and guidelines advocate the use of physiologic dose steroids in patients exhibiting septic shock. However, recommendations are largely based on the results of a single trial where benefits were seen only in patients without a response to corticotropin.

Study design: Multicenter, randomized, double-blind, placebo-controlled study.

Setting: Fifty-two participating ICUs in nine countries.

Synopsis: A total of 499 patients with evidence of infection or a systemic inflammatory response characterized by refractory hypotension were randomly selected to receive either an 11-day tapering dose of hydrocortisone or a placebo. The primary outcome was death from any cause at 28 days. A corticotropin stimulation test was conducted on every patient to assess adrenal function. There were no differences in death rates or duration of hospitalization between study arms. Overall, there were 86 deaths in the hydrocortisone group and 78 deaths in the placebo group (p=0.51). Also, response to corticotropin appeared to have little bearing on outcomes.

The study was underpowered due to low enrollment and a lower-than-expected death rate. Nevertheless, this is the largest trial to date examining the role of steroids in the management of septic shock and calls into question the strength of prior data and published guidelines.

Bottom line: This study failed to demonstrate a clinically or statistically significant treatment effect from the administration of physiologic-dose steroids in patients with septic shock.

Citation: Sprung C, Annane D, Keh D, et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008;358(2):111-124.

Does Open or Endovascular Repair of Abdominal Aortic Aneurysm Benefit the Medicare Population?

Background: Randomized controlled trials (RCT) have shown a perioperative survival benefit of endovascular repair over open repair with fewer complications and shorter recovery. There is concern that late morbidity may be increased with endovascular repair. Patients enrolled in the trials were highly selected at specialty centers, so the results may not reflect actual practice.

Study design: Retrospective, propensity-matched, observational cohort study.

Synopsis: 22,830 patients were matched in each cohort. Patients were eligible if they had an abdominal aortic aneurysm repair without rupture and excluded if they were enrolled in health maintenance organizations.

Outcomes included death within 30 days and late survival, perioperative complications, aneurysm rupture, reintervention, and laparotomy-related complications. The average age was 76, and 20% were women. Perioperative mortality was lower after endovascular repair (1.2% vs. 4.8%, p<0.001), and older patients had a greater benefit. Late survival was similar. By four years, rupture was more likely in the endovascular group (1.8% vs. 0.5%, p<0.001), as was reintervention (9% vs. 1.7%, p<0.001).

In contrast, by four years, surgery for laparotomy-related complications was more likely in the open-repair group (9.7% v 4.1%, p<0.001), as was hospitalization for bowel obstruction or abdominal-wall hernia (14.2% v 8.1%, p<0.001). Limitations included the non-randomized design and use of administrative data for important categorical variables including medical co-morbidities.

Bottom line: As compared with open repair, endovascular repair of abdominal aortic aneurysm is associated with lower short-term death and complications and higher late reinterventions. This is balanced by an increase in laparotomy-related reinterventions after open repair.

Citation: Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med. 2008 Jan 31;358(5):464-474.

What Therapy Improves Outcomes in ICU Patients With Severe Sepsis or Septic Shock?

Background: Evidence suggests lower mortality with intensive insulin therapy in post-surgical cardiac patients. There is no proven benefit for non-surgical ICU patients. Despite lack of data, intensive insulin in severe sepsis has been widely advocated. Little is known to guide the use of colloid or crystalloid for fluid resuscitation in sepsis.

Study design: Multicenter, two-by-two factorial, open-label trial.

Setting: Multidisciplinary ICUs at 18 academic tertiary hospitals in Germany.

Synopsis: Data were analyzed for 537 patients with severe sepsis. They were randomly selected to receive intensive insulin therapy (n=247) or conventional insulin therapy (290), with either 10% hydroxyethyl starch (HES) (262) or modified Ringer’s lactate (LR) (275) for fluid resuscitation.

Co-primary endpoints were all-cause mortality at 28 days and morbidity as measured by the mean score on the Sequential Organ Failure Assessment (SOFA). The trial was stopped early for safety reasons. Intensive insulin therapy was terminated due to an increased number of hypoglycemic events in the intensive-therapy group compared with conventional therapy (12.1% vs. 2.1%, p<0.001), and there was no difference in mortality between groups at 28 and 90 days.

Interim analysis of 600 patients showed patients given HES had higher incidence of renal failure compared with LR (34.9% vs. 22.8%, p=0.002), required more days of renal replacement therapy, had lower median platelets and received more units of packed red cells. There was a trend toward higher rate of death at 90 days in those treated with HES (41% vs. 33.9%, p=0.09).

Bottom line: Intensive insulin therapy in ICU patients with severe sepsis and septic shock does not improve mortality and increases hypoglycemia and ICU length of stay. Use of colloid over crystalloid should be avoided, showing a trend toward increased death at 90 days, higher rates of acute renal failure, and need for renal replacement therapy..

Citation: Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med. 2008;358(2):125-139.

How Does Laparoscopic Adjustable Gastric Banding Affect Obese Adults With Type 2 Diabetes?

Background: Observational studies related surgical weight loss to improved glycemic control, but clinical trials did not test this relationship. The current trial examined this hypothesis.

Study design: Unmasked, randomized controlled trial.

Setting: University Obesity Research Center, Australia.

Synopsis: Sixty adults age 20-60 with body-mass index (BMI) of 30-40 and diagnosed with diabetes mellitus type 2 (DM2) within two years of recruitment were randomized into conventional therapy and surgical groups.

While both groups were treated similarly, only the surgical group received laparoscopic adjustable gastric banding. Primary outcome was remission of DM2 (a fasting glucose less than 126 mg/dl, HbA1C less than 6.2%, and off all hypoglycemic agents). At two years, 73% in the surgical group compared with 13% in the conventional group attained this outcome (relative risk [RR] 5.5, 95% confidence interval [CI] 2.2-14.0; p<0.001). Compared with the conventional group, the surgical group demonstrated statistically significant improvements in several secondary outcomes including mean body weight, waist circumference, insulin resistance, and lipids.

The limitations of the study are that it examined a small number of patients with shorter duration of DM2 and a shorter follow-up. The lower surgical complication rates cannot be generalized to other centers.

Bottom line: This study is a step forward in examining the relationship of surgical weight loss and remission of DM2. However, large multicenter trials with longer periods of follow-up in diverse group of patients would result in a better understanding of this relationship.

Citation: Dixon JB, O’Brien PE, Playfair J, et. al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA. 2008;299(3):316-323.

What is the Prevalence of Delayed Defibrillation and its Association With Survival to Discharge?

Background: Despite advances in resuscitation, survival rates following cardiac arrest remain low. Previous studies observed the effect of the timing of defibrillation on survival. This study examined the magnitude of delayed defibrillation and its association with survival in adults who sustained cardiac arrest specifically from ventricular fibrillation and pulseless ventricular tachycardia.

Study design: National Registry of Cardiopulmonary Resuscitation (NRCPR), a multicenter prospective cohort.

Setting: 369 U.S. hospitals providing acute care.

Synopsis: Data from NRCPR relating to 6,789 cardiac arrests secondary to ventricular fibrillation or pulseless ventricular tachycardia, at 369 hospitals in hospitalized adults were analyzed. Delayed defibrillation was defined as occurring more than two minutes from the identification of ventricular fibrillation or pulseless ventricular tachycardia to the administration of the first shock to the patient.

Delayed defibrillation occurred in 2,045 (30.1%) subjects. A lower proportion of subjects who received delayed defibrillation (22.2%) compared with those who received defibrillation in two minutes or less (39.3%) survived to hospital discharge. This was statistically significant (adjusted odds ratio [OR] 0.48, 95% CI 0.42 to 0.54; p<0.01).

Bottom line: This study not only reported that delayed defibrillation was prevalent in adult hospitalized patients, but also reinforced the importance of defibrillation within two minutes of identification of cardiac arrest secondary to ventricular fibrillation and pulseless ventricular tachycardia for better survival outcomes.

Citation: Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17.

Does Right-Ventricle Enlargement in Acute PE Increase In-hospital Death From PE or All-cause Mortality?

Background: Previous studies have shown conflicting results regarding the risk of death with right-ventricular enlargement in acute pulmonary embolism (PE). The role of thrombolysis in hemodynamically stable patients with acute PE and right-ventricular enlargement remains controversial.

Study design: Retrospective analysis of prospective cohort study.

Setting: Academic centers housing inpatients and outpatients in the United States and Canada.

Synopsis: Patients enrolled in PIOPED II who were diagnosed with acute PE and had multidetector computed tomographic (CT) angiography were retrospectively reviewed for the presence of right-ventricular enlargement. Study determined that 181 patients had PE and a CT, and 157 were adequate for measurement of right-ventricular size. PE treatment was anticoagulation in 138, anticoagulation and inferior vena cava filter in 15, inferior vena cava filter alone in two, and thrombolysis in two.

Right-ventricular enlargement was found in 78 (50%) patients; 76 were treated with anticoagulation alone or in combination with inferior vena cava filter. For patients with and without right-ventricular enlargement, there was no difference in in-hospital death from PE (0% vs. 1.3%) or all-cause mortality (2.6% vs. 2.5%). The results were unchanged when examined for septal motion abnormality and previous cardiopulmonary disease.

Bottom line: In hemodynamically stable patients with acute pulmonary embolism, right ventricular enlargement does not increase mortality. Further, thrombolytic therapy is unlikely to improve outcomes.

Citation: Stein PD, Beemath A, Matti F, et al. Enlarged right ventricle without shock in acute pulmonary embolus: prognosis. Am J Med. 2008;121:34-42.

What Are Short-term Thromboembolism, Hemorrhage Risks When Interrupting Warfarin Therapy for Procedures?

Background: The risks of thromboembolism and hemorrhage during the periprocedural interruption of warfarin therapy are not known. The risks and benefits of heparin bridging therapy are not well described.

Study design: Multicenter, prospective, observational cohort study.

Setting: Community-based physician practices.

Synopsis: Patients were eligible if they were on long-term warfarin and underwent outpatient procedures requiring interruption of therapy. The primary outcomes were thromboembolism or hemorrhage within 30 days of therapy interruption. In all, 1,024 eligible patients (7.1% considered high risk) had 1,293 interruptions of warfarin therapy. The most common procedures were colonoscopy (25.1%), oral or dental surgery (24.9%), and ophthalmologic surgery (8.9%). Warfarin interruption was five or fewer days in 83.8% of episodes.

Thromboembolism occurred in seven (0.7%) patients, and major or clinically significant bleeding occurred in 23 (0.6%, and 1.7%, respectively) patients. Periprocedural bridging with heparin was used in 88 (8.6%) patients. Of the patients who received periprocedural heparin therapy, none had thromboembolism, and 14 (13%) had bleeding episodes.

Bottom line: In patients whose warfarin therapy is interrupted to undergo outpatient procedures, the risk of thromboembolism is low and the hemorrhagic risk of heparin bridging therapy is significant.

Citation: Garcia DA, Regan S, Henault LE, et al. Risk of thromboembolism with short-term interruption of warfarin therapy. Arch Intern Med. 2008;168(1):63-69.

Are Minor Injuries an Independent Risk Factor For Development of DVT?

Background: Prior studies focus on major injuries as a risk factor for deep-vein thrombosis (DVT) and PE. However, major injury is often associated with other risks for venous thrombosis, such as surgery, plaster casting, hospitalization, and extended bed rest. Risk of DVT with minor injuries that don’t lead to these factors is unknown.

Study design: Large population-based case-control study.

Setting: Six anticoagulation clinics in the Netherlands.

Synopsis: 2,471 consecutive cases (patients with first episode of DVT or PE) and 3,534 controls (partners of cases or random digit dialing contacts) were enrolled. Participants were mailed a questionnaire, including a list of eight common injuries.

Participants with history of cast, surgery, recent hospitalization, extended bed rest, or prior history of cancer were excluded. A subset of patients and controls underwent DNA and blood collection to evaluate for presence of a hypercoagulable state. Of the cases, 289 (11.7%) had a minor injury within three months of the index date, compared with 154 (4.4%) of controls, representing a threefold increased risk of DVT/PE with minor injury (OR 3.1). Partial ruptures of muscles or ligaments in the leg (OR 10.9), multiple simultaneous injuries (OR 9.9), and injury within four weeks of presentation (OR 4.0), were associated with increased risk of DVT/PE.

Patients found to be Factor V Leiden carriers with injury had an almost 50-fold increased risk of venous thromboembolism (VTE) compared with non-carriers without injury (OR 49.7). Authors appropriately address possible limitations, including recall and referral bias.

Bottom line: Minor leg injury is associated with threefold risk of DVT/PE, especially in the four weeks following injury. Providers should consider short-term prophylactic treatment in patients with Factor V Leiden or high-risk injuries.

Citation: Van Stralen KJ, Rosendaal FR, Doggen CJ. Minor injuries as a risk factor for venous thrombosis. Arch Intern Med. 2008;168(1):21-26.

Is Oral Amox-Clav Non-inferior to IV Antibiotics in Pediatric Pyelonephritis?

Background: Present guidelines recommend initial treatment for pediatric pyelonephritis to be a parenteral third-generation cephalosporin followed by oral antibiotics. One prior randomly selected controlled trial compared oral antibiotics only with antibiotics started parenterally, but there was a higher-than-usual incidence of vesicoureteral reflux and female gender in the study.

Study design: Non-inferiority, multicenter, random, open label, controlled trial.

Setting: Twenty-eight pediatric units in northeast Italy from 2000-2005

Synopsis: 502 children age 1 month to less than 7 years with a clinical diagnosis of first occurrence of acute pyelonephritis according to urinalysis and urine culture (requiring two concordant consecutive tests) with at least two of the following conditions: fever of 38 degrees C or more or elevated erythrocyte sedimentation rate (ESR) or c-reactive protein (CRP), and elevated neutrophil count were randomized to receive oral amoxicillin-clavulanate (AC) or parenteral ceftriaxone followed by oral AC. Exclusion criteria were sepsis, dehydration, vomiting, and creatinine clearance of 70 ml/min or less.

Also, 400 children had dimercaptosuccinic acid (DMSA) scintigraphy within 10 days of study entry. Meantime, 223 had repeat DMSA at one year, and 177 had normal scans at study entry so were not repeated. At one year, 20% of patients were lost to follow-up. The primary outcome was renal scarring at one year. Secondary outcomes included time to fever defervescence, reduction in inflammatory indices, and percentage with sterile urine after 72 hours. Intention to treat analysis showed no significant differences between oral (n=244) and parenteral (n=258) treatment, both in the primary outcome 13.7% vs. 17.7% (95% CI, -11.1% to 3.1%), and secondary outcomes.

Bottom line: Treatment with oral antibiotics is as effective as parenteral then oral treatment for first episode of acute pediatric pyelonephritis.

Citation: Montini G, Toffolo A, Zucchetta P, et al. Antibiotic treatment for pyelonephritis in children: multicentre randomised controlled non-inferiority trial. BMJ. 2007 Aug 25;335(7616):386.

Literature at a Glance

A guide to this month’s studies.

• Physiologic doses of corticosteroids provide no clear benefit to patients with septic shock.
• Endovascular vs. open repair of abdominal aortic aneurysms is associated with fewer short-term deaths but complications and higher late reinterventions.
• Neither intensive insulin nor use of colloid over crystalloid improves mortality or organ failure outcomes in sepsis.
• Surgical cure for diabetes shows promise at two-year follow-up.
• Delayed defibrillation negatively affects survival.
• Right-ventricular enlargement in patients with acute PE is not associated with increased mortality.
• Periprocedural interruption of warfarin therapy presents low risk of thromboembolism.
• Minor leg injury increases risk of developing venous thrombosis threefold.
• Oral vs. parenteral antibiotics for pediatric pyelonephritis.

Do Physiologic Doses of Hydrocortisone Benefit Patients With Septic Shock?

Background: Meta-analyses and guidelines advocate the use of physiologic dose steroids in patients exhibiting septic shock. However, recommendations are largely based on the results of a single trial where benefits were seen only in patients without a response to corticotropin.

Study design: Multicenter, randomized, double-blind, placebo-controlled study.

Setting: Fifty-two participating ICUs in nine countries.

Synopsis: A total of 499 patients with evidence of infection or a systemic inflammatory response characterized by refractory hypotension were randomly selected to receive either an 11-day tapering dose of hydrocortisone or a placebo. The primary outcome was death from any cause at 28 days. A corticotropin stimulation test was conducted on every patient to assess adrenal function. There were no differences in death rates or duration of hospitalization between study arms. Overall, there were 86 deaths in the hydrocortisone group and 78 deaths in the placebo group (p=0.51). Also, response to corticotropin appeared to have little bearing on outcomes.

The study was underpowered due to low enrollment and a lower-than-expected death rate. Nevertheless, this is the largest trial to date examining the role of steroids in the management of septic shock and calls into question the strength of prior data and published guidelines.

Bottom line: This study failed to demonstrate a clinically or statistically significant treatment effect from the administration of physiologic-dose steroids in patients with septic shock.

Citation: Sprung C, Annane D, Keh D, et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008;358(2):111-124.

Does Open or Endovascular Repair of Abdominal Aortic Aneurysm Benefit the Medicare Population?

Background: Randomized controlled trials (RCT) have shown a perioperative survival benefit of endovascular repair over open repair with fewer complications and shorter recovery. There is concern that late morbidity may be increased with endovascular repair. Patients enrolled in the trials were highly selected at specialty centers, so the results may not reflect actual practice.

Study design: Retrospective, propensity-matched, observational cohort study.

Synopsis: 22,830 patients were matched in each cohort. Patients were eligible if they had an abdominal aortic aneurysm repair without rupture and excluded if they were enrolled in health maintenance organizations.

Outcomes included death within 30 days and late survival, perioperative complications, aneurysm rupture, reintervention, and laparotomy-related complications. The average age was 76, and 20% were women. Perioperative mortality was lower after endovascular repair (1.2% vs. 4.8%, p<0.001), and older patients had a greater benefit. Late survival was similar. By four years, rupture was more likely in the endovascular group (1.8% vs. 0.5%, p<0.001), as was reintervention (9% vs. 1.7%, p<0.001).

In contrast, by four years, surgery for laparotomy-related complications was more likely in the open-repair group (9.7% v 4.1%, p<0.001), as was hospitalization for bowel obstruction or abdominal-wall hernia (14.2% v 8.1%, p<0.001). Limitations included the non-randomized design and use of administrative data for important categorical variables including medical co-morbidities.

Bottom line: As compared with open repair, endovascular repair of abdominal aortic aneurysm is associated with lower short-term death and complications and higher late reinterventions. This is balanced by an increase in laparotomy-related reinterventions after open repair.

Citation: Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med. 2008 Jan 31;358(5):464-474.

What Therapy Improves Outcomes in ICU Patients With Severe Sepsis or Septic Shock?

Background: Evidence suggests lower mortality with intensive insulin therapy in post-surgical cardiac patients. There is no proven benefit for non-surgical ICU patients. Despite lack of data, intensive insulin in severe sepsis has been widely advocated. Little is known to guide the use of colloid or crystalloid for fluid resuscitation in sepsis.

Study design: Multicenter, two-by-two factorial, open-label trial.

Setting: Multidisciplinary ICUs at 18 academic tertiary hospitals in Germany.

Synopsis: Data were analyzed for 537 patients with severe sepsis. They were randomly selected to receive intensive insulin therapy (n=247) or conventional insulin therapy (290), with either 10% hydroxyethyl starch (HES) (262) or modified Ringer’s lactate (LR) (275) for fluid resuscitation.

Co-primary endpoints were all-cause mortality at 28 days and morbidity as measured by the mean score on the Sequential Organ Failure Assessment (SOFA). The trial was stopped early for safety reasons. Intensive insulin therapy was terminated due to an increased number of hypoglycemic events in the intensive-therapy group compared with conventional therapy (12.1% vs. 2.1%, p<0.001), and there was no difference in mortality between groups at 28 and 90 days.

Interim analysis of 600 patients showed patients given HES had higher incidence of renal failure compared with LR (34.9% vs. 22.8%, p=0.002), required more days of renal replacement therapy, had lower median platelets and received more units of packed red cells. There was a trend toward higher rate of death at 90 days in those treated with HES (41% vs. 33.9%, p=0.09).

Bottom line: Intensive insulin therapy in ICU patients with severe sepsis and septic shock does not improve mortality and increases hypoglycemia and ICU length of stay. Use of colloid over crystalloid should be avoided, showing a trend toward increased death at 90 days, higher rates of acute renal failure, and need for renal replacement therapy..

Citation: Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med. 2008;358(2):125-139.

How Does Laparoscopic Adjustable Gastric Banding Affect Obese Adults With Type 2 Diabetes?

Background: Observational studies related surgical weight loss to improved glycemic control, but clinical trials did not test this relationship. The current trial examined this hypothesis.

Study design: Unmasked, randomized controlled trial.

Setting: University Obesity Research Center, Australia.

Synopsis: Sixty adults age 20-60 with body-mass index (BMI) of 30-40 and diagnosed with diabetes mellitus type 2 (DM2) within two years of recruitment were randomized into conventional therapy and surgical groups.

While both groups were treated similarly, only the surgical group received laparoscopic adjustable gastric banding. Primary outcome was remission of DM2 (a fasting glucose less than 126 mg/dl, HbA1C less than 6.2%, and off all hypoglycemic agents). At two years, 73% in the surgical group compared with 13% in the conventional group attained this outcome (relative risk [RR] 5.5, 95% confidence interval [CI] 2.2-14.0; p<0.001). Compared with the conventional group, the surgical group demonstrated statistically significant improvements in several secondary outcomes including mean body weight, waist circumference, insulin resistance, and lipids.

The limitations of the study are that it examined a small number of patients with shorter duration of DM2 and a shorter follow-up. The lower surgical complication rates cannot be generalized to other centers.

Bottom line: This study is a step forward in examining the relationship of surgical weight loss and remission of DM2. However, large multicenter trials with longer periods of follow-up in diverse group of patients would result in a better understanding of this relationship.

Citation: Dixon JB, O’Brien PE, Playfair J, et. al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA. 2008;299(3):316-323.

What is the Prevalence of Delayed Defibrillation and its Association With Survival to Discharge?

Background: Despite advances in resuscitation, survival rates following cardiac arrest remain low. Previous studies observed the effect of the timing of defibrillation on survival. This study examined the magnitude of delayed defibrillation and its association with survival in adults who sustained cardiac arrest specifically from ventricular fibrillation and pulseless ventricular tachycardia.

Study design: National Registry of Cardiopulmonary Resuscitation (NRCPR), a multicenter prospective cohort.

Setting: 369 U.S. hospitals providing acute care.

Synopsis: Data from NRCPR relating to 6,789 cardiac arrests secondary to ventricular fibrillation or pulseless ventricular tachycardia, at 369 hospitals in hospitalized adults were analyzed. Delayed defibrillation was defined as occurring more than two minutes from the identification of ventricular fibrillation or pulseless ventricular tachycardia to the administration of the first shock to the patient.

Delayed defibrillation occurred in 2,045 (30.1%) subjects. A lower proportion of subjects who received delayed defibrillation (22.2%) compared with those who received defibrillation in two minutes or less (39.3%) survived to hospital discharge. This was statistically significant (adjusted odds ratio [OR] 0.48, 95% CI 0.42 to 0.54; p<0.01).

Bottom line: This study not only reported that delayed defibrillation was prevalent in adult hospitalized patients, but also reinforced the importance of defibrillation within two minutes of identification of cardiac arrest secondary to ventricular fibrillation and pulseless ventricular tachycardia for better survival outcomes.

Citation: Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17.

Does Right-Ventricle Enlargement in Acute PE Increase In-hospital Death From PE or All-cause Mortality?

Background: Previous studies have shown conflicting results regarding the risk of death with right-ventricular enlargement in acute pulmonary embolism (PE). The role of thrombolysis in hemodynamically stable patients with acute PE and right-ventricular enlargement remains controversial.

Study design: Retrospective analysis of prospective cohort study.

Setting: Academic centers housing inpatients and outpatients in the United States and Canada.

Synopsis: Patients enrolled in PIOPED II who were diagnosed with acute PE and had multidetector computed tomographic (CT) angiography were retrospectively reviewed for the presence of right-ventricular enlargement. Study determined that 181 patients had PE and a CT, and 157 were adequate for measurement of right-ventricular size. PE treatment was anticoagulation in 138, anticoagulation and inferior vena cava filter in 15, inferior vena cava filter alone in two, and thrombolysis in two.

Right-ventricular enlargement was found in 78 (50%) patients; 76 were treated with anticoagulation alone or in combination with inferior vena cava filter. For patients with and without right-ventricular enlargement, there was no difference in in-hospital death from PE (0% vs. 1.3%) or all-cause mortality (2.6% vs. 2.5%). The results were unchanged when examined for septal motion abnormality and previous cardiopulmonary disease.

Bottom line: In hemodynamically stable patients with acute pulmonary embolism, right ventricular enlargement does not increase mortality. Further, thrombolytic therapy is unlikely to improve outcomes.

Citation: Stein PD, Beemath A, Matti F, et al. Enlarged right ventricle without shock in acute pulmonary embolus: prognosis. Am J Med. 2008;121:34-42.

What Are Short-term Thromboembolism, Hemorrhage Risks When Interrupting Warfarin Therapy for Procedures?

Background: The risks of thromboembolism and hemorrhage during the periprocedural interruption of warfarin therapy are not known. The risks and benefits of heparin bridging therapy are not well described.

Study design: Multicenter, prospective, observational cohort study.

Setting: Community-based physician practices.

Synopsis: Patients were eligible if they were on long-term warfarin and underwent outpatient procedures requiring interruption of therapy. The primary outcomes were thromboembolism or hemorrhage within 30 days of therapy interruption. In all, 1,024 eligible patients (7.1% considered high risk) had 1,293 interruptions of warfarin therapy. The most common procedures were colonoscopy (25.1%), oral or dental surgery (24.9%), and ophthalmologic surgery (8.9%). Warfarin interruption was five or fewer days in 83.8% of episodes.

Thromboembolism occurred in seven (0.7%) patients, and major or clinically significant bleeding occurred in 23 (0.6%, and 1.7%, respectively) patients. Periprocedural bridging with heparin was used in 88 (8.6%) patients. Of the patients who received periprocedural heparin therapy, none had thromboembolism, and 14 (13%) had bleeding episodes.

Bottom line: In patients whose warfarin therapy is interrupted to undergo outpatient procedures, the risk of thromboembolism is low and the hemorrhagic risk of heparin bridging therapy is significant.

Citation: Garcia DA, Regan S, Henault LE, et al. Risk of thromboembolism with short-term interruption of warfarin therapy. Arch Intern Med. 2008;168(1):63-69.

Are Minor Injuries an Independent Risk Factor For Development of DVT?

Background: Prior studies focus on major injuries as a risk factor for deep-vein thrombosis (DVT) and PE. However, major injury is often associated with other risks for venous thrombosis, such as surgery, plaster casting, hospitalization, and extended bed rest. Risk of DVT with minor injuries that don’t lead to these factors is unknown.

Study design: Large population-based case-control study.

Setting: Six anticoagulation clinics in the Netherlands.

Synopsis: 2,471 consecutive cases (patients with first episode of DVT or PE) and 3,534 controls (partners of cases or random digit dialing contacts) were enrolled. Participants were mailed a questionnaire, including a list of eight common injuries.

Participants with history of cast, surgery, recent hospitalization, extended bed rest, or prior history of cancer were excluded. A subset of patients and controls underwent DNA and blood collection to evaluate for presence of a hypercoagulable state. Of the cases, 289 (11.7%) had a minor injury within three months of the index date, compared with 154 (4.4%) of controls, representing a threefold increased risk of DVT/PE with minor injury (OR 3.1). Partial ruptures of muscles or ligaments in the leg (OR 10.9), multiple simultaneous injuries (OR 9.9), and injury within four weeks of presentation (OR 4.0), were associated with increased risk of DVT/PE.

Patients found to be Factor V Leiden carriers with injury had an almost 50-fold increased risk of venous thromboembolism (VTE) compared with non-carriers without injury (OR 49.7). Authors appropriately address possible limitations, including recall and referral bias.

Bottom line: Minor leg injury is associated with threefold risk of DVT/PE, especially in the four weeks following injury. Providers should consider short-term prophylactic treatment in patients with Factor V Leiden or high-risk injuries.

Citation: Van Stralen KJ, Rosendaal FR, Doggen CJ. Minor injuries as a risk factor for venous thrombosis. Arch Intern Med. 2008;168(1):21-26.

Is Oral Amox-Clav Non-inferior to IV Antibiotics in Pediatric Pyelonephritis?

Background: Present guidelines recommend initial treatment for pediatric pyelonephritis to be a parenteral third-generation cephalosporin followed by oral antibiotics. One prior randomly selected controlled trial compared oral antibiotics only with antibiotics started parenterally, but there was a higher-than-usual incidence of vesicoureteral reflux and female gender in the study.

Study design: Non-inferiority, multicenter, random, open label, controlled trial.

Setting: Twenty-eight pediatric units in northeast Italy from 2000-2005

Synopsis: 502 children age 1 month to less than 7 years with a clinical diagnosis of first occurrence of acute pyelonephritis according to urinalysis and urine culture (requiring two concordant consecutive tests) with at least two of the following conditions: fever of 38 degrees C or more or elevated erythrocyte sedimentation rate (ESR) or c-reactive protein (CRP), and elevated neutrophil count were randomized to receive oral amoxicillin-clavulanate (AC) or parenteral ceftriaxone followed by oral AC. Exclusion criteria were sepsis, dehydration, vomiting, and creatinine clearance of 70 ml/min or less.

Also, 400 children had dimercaptosuccinic acid (DMSA) scintigraphy within 10 days of study entry. Meantime, 223 had repeat DMSA at one year, and 177 had normal scans at study entry so were not repeated. At one year, 20% of patients were lost to follow-up. The primary outcome was renal scarring at one year. Secondary outcomes included time to fever defervescence, reduction in inflammatory indices, and percentage with sterile urine after 72 hours. Intention to treat analysis showed no significant differences between oral (n=244) and parenteral (n=258) treatment, both in the primary outcome 13.7% vs. 17.7% (95% CI, -11.1% to 3.1%), and secondary outcomes.

Bottom line: Treatment with oral antibiotics is as effective as parenteral then oral treatment for first episode of acute pediatric pyelonephritis.

Citation: Montini G, Toffolo A, Zucchetta P, et al. Antibiotic treatment for pyelonephritis in children: multicentre randomised controlled non-inferiority trial. BMJ. 2007 Aug 25;335(7616):386.

The best and brightest thinking from today’s hospitalists was on display in the poster presentations in San Diego. Of 265 abstracts submitted to the Research, Innovations and Clinical Vignettes (RIV) Competition, 195 were accepted for poster presentations.

“The quality and quantity of abstract submissions increases every year,” said Sylvia McKean, MD, course director of Hospital Medicine 2008.

Best in Show

“It’s been a banner year for the poster presentations,” said Jeffrey Greenwald, MD, hospital medicine unit director, Boston Medical Center, as he announced the winning abstracts during the President’s Lunch on April 5:

• Research: “Prevention of Hospital-Acquired Venous Thromboembolism: Prospective Validation of a VTE Risk Assessment Model and Protocol, Greg Maynard, MD, MSc, professor of clinical medicine and chief of the division of hospital medicine at the University of California, San Diego.
• Innovations: “Can Tissue Models Be Used to Teach Central Line Placement? Phase II of the Procedure Patient Safety Initiative (PPSI), Annie R. Harrington, MD, Cedars-Sinai Medical Center, Los Angeles; and
• Clinical Vignettes: “A Case of Salty Voluminous Urine, Twylla Tassava, MD, Saint Joseph Mercy Hospital, Ann Arbor, Mich.

Other Notable Works

Param Dedhia, MD, presented research he conducted with colleagues from Johns Hopkins Bayview Medical Center titled “Safe STEPS: Safe and Successful Transition of Elderly Patients.” The group developed an interdisciplinary, multifaceted intervention in this area, which included:

• A history and physical exam tailored to geriatric patients;
• A “fast facts fax” to communicate with the primary care physician;
• An interdisciplinary team worksheet for centralized input;
• A medical evaluation including a detailed review with the pharmacist; and?
• A pre-discharge appointment.

The results: A 15-question survey showed a 60% to 90% jump in patient satisfaction. A health assessment by self-report showed improvement as well, and the number of revisits and readmissions dropped from 10% to 3%.

“The Impact of Fragmentation of Hospitalist Care on Length of Stay and Post-Discharge Issues” was presented by Kenneth R. Epstein, MD, MBA, of IPC-The Hospitalist Company. Dr. Epstein and his colleagues used an observational study of data from IPC’s billing and clinical database on inpatient admissions with pneumonia with complications and heart failure and shock. They wanted to see if fragmented hospitalist care—care provided by more than one hospitalist—affected outcomes for these patients.

Using a fragmentation formula that included the number of days as an inpatient and the number of hospitalists who provided care, they found that for every 10% increase in fragmentation, the length of stay increased 0.45 days for pneumonia patients and 0.38 days for heart failure patients.

The country’s first fellowship for physician assistants (PA) specializing in hospital medicine was detailed in “The Mayo Clinic Arizona Post-Graduate PA Fellowship in Hospital Internal Medicine.” Kristen K. Will, MHPE, PA-C, co-program director of clinic’s PA Fellowship Program, outlined how her institution initiated the fellowship in October. The program will train one PA using hospital medicine-specific clinical rotations, didactic instruction, and teaching modules.

The best and brightest thinking from today’s hospitalists was on display in the poster presentations in San Diego. Of 265 abstracts submitted to the Research, Innovations and Clinical Vignettes (RIV) Competition, 195 were accepted for poster presentations.

“The quality and quantity of abstract submissions increases every year,” said Sylvia McKean, MD, course director of Hospital Medicine 2008.

Best in Show

“It’s been a banner year for the poster presentations,” said Jeffrey Greenwald, MD, hospital medicine unit director, Boston Medical Center, as he announced the winning abstracts during the President’s Lunch on April 5:

• Research: “Prevention of Hospital-Acquired Venous Thromboembolism: Prospective Validation of a VTE Risk Assessment Model and Protocol, Greg Maynard, MD, MSc, professor of clinical medicine and chief of the division of hospital medicine at the University of California, San Diego.
• Innovations: “Can Tissue Models Be Used to Teach Central Line Placement? Phase II of the Procedure Patient Safety Initiative (PPSI), Annie R. Harrington, MD, Cedars-Sinai Medical Center, Los Angeles; and
• Clinical Vignettes: “A Case of Salty Voluminous Urine, Twylla Tassava, MD, Saint Joseph Mercy Hospital, Ann Arbor, Mich.

Other Notable Works

Param Dedhia, MD, presented research he conducted with colleagues from Johns Hopkins Bayview Medical Center titled “Safe STEPS: Safe and Successful Transition of Elderly Patients.” The group developed an interdisciplinary, multifaceted intervention in this area, which included:

• A history and physical exam tailored to geriatric patients;
• A “fast facts fax” to communicate with the primary care physician;
• An interdisciplinary team worksheet for centralized input;
• A medical evaluation including a detailed review with the pharmacist; and?
• A pre-discharge appointment.

The results: A 15-question survey showed a 60% to 90% jump in patient satisfaction. A health assessment by self-report showed improvement as well, and the number of revisits and readmissions dropped from 10% to 3%.

“The Impact of Fragmentation of Hospitalist Care on Length of Stay and Post-Discharge Issues” was presented by Kenneth R. Epstein, MD, MBA, of IPC-The Hospitalist Company. Dr. Epstein and his colleagues used an observational study of data from IPC’s billing and clinical database on inpatient admissions with pneumonia with complications and heart failure and shock. They wanted to see if fragmented hospitalist care—care provided by more than one hospitalist—affected outcomes for these patients.

Using a fragmentation formula that included the number of days as an inpatient and the number of hospitalists who provided care, they found that for every 10% increase in fragmentation, the length of stay increased 0.45 days for pneumonia patients and 0.38 days for heart failure patients.

The country’s first fellowship for physician assistants (PA) specializing in hospital medicine was detailed in “The Mayo Clinic Arizona Post-Graduate PA Fellowship in Hospital Internal Medicine.” Kristen K. Will, MHPE, PA-C, co-program director of clinic’s PA Fellowship Program, outlined how her institution initiated the fellowship in October. The program will train one PA using hospital medicine-specific clinical rotations, didactic instruction, and teaching modules.

The best and brightest thinking from today’s hospitalists was on display in the poster presentations in San Diego. Of 265 abstracts submitted to the Research, Innovations and Clinical Vignettes (RIV) Competition, 195 were accepted for poster presentations.

“The quality and quantity of abstract submissions increases every year,” said Sylvia McKean, MD, course director of Hospital Medicine 2008.

Best in Show

“It’s been a banner year for the poster presentations,” said Jeffrey Greenwald, MD, hospital medicine unit director, Boston Medical Center, as he announced the winning abstracts during the President’s Lunch on April 5:

• Research: “Prevention of Hospital-Acquired Venous Thromboembolism: Prospective Validation of a VTE Risk Assessment Model and Protocol, Greg Maynard, MD, MSc, professor of clinical medicine and chief of the division of hospital medicine at the University of California, San Diego.
• Innovations: “Can Tissue Models Be Used to Teach Central Line Placement? Phase II of the Procedure Patient Safety Initiative (PPSI), Annie R. Harrington, MD, Cedars-Sinai Medical Center, Los Angeles; and
• Clinical Vignettes: “A Case of Salty Voluminous Urine, Twylla Tassava, MD, Saint Joseph Mercy Hospital, Ann Arbor, Mich.

Other Notable Works

Param Dedhia, MD, presented research he conducted with colleagues from Johns Hopkins Bayview Medical Center titled “Safe STEPS: Safe and Successful Transition of Elderly Patients.” The group developed an interdisciplinary, multifaceted intervention in this area, which included:

• A history and physical exam tailored to geriatric patients;
• A “fast facts fax” to communicate with the primary care physician;
• An interdisciplinary team worksheet for centralized input;
• A medical evaluation including a detailed review with the pharmacist; and?
• A pre-discharge appointment.

The results: A 15-question survey showed a 60% to 90% jump in patient satisfaction. A health assessment by self-report showed improvement as well, and the number of revisits and readmissions dropped from 10% to 3%.

“The Impact of Fragmentation of Hospitalist Care on Length of Stay and Post-Discharge Issues” was presented by Kenneth R. Epstein, MD, MBA, of IPC-The Hospitalist Company. Dr. Epstein and his colleagues used an observational study of data from IPC’s billing and clinical database on inpatient admissions with pneumonia with complications and heart failure and shock. They wanted to see if fragmented hospitalist care—care provided by more than one hospitalist—affected outcomes for these patients.

Using a fragmentation formula that included the number of days as an inpatient and the number of hospitalists who provided care, they found that for every 10% increase in fragmentation, the length of stay increased 0.45 days for pneumonia patients and 0.38 days for heart failure patients.

The country’s first fellowship for physician assistants (PA) specializing in hospital medicine was detailed in “The Mayo Clinic Arizona Post-Graduate PA Fellowship in Hospital Internal Medicine.” Kristen K. Will, MHPE, PA-C, co-program director of clinic’s PA Fellowship Program, outlined how her institution initiated the fellowship in October. The program will train one PA using hospital medicine-specific clinical rotations, didactic instruction, and teaching modules.

Those responsible for teaching hospital medicine to residents and medical students had an unprecedented opportunity to become students for the day and learn from top teachers in the field.

An important new addition to the all-day precourses was the “Teaching Hospitalist Educators (THE) Course: What Clinical Teachers in Hospital Medicine Need to Know.” The session was presented by Jeffrey Wiese, MD, FACP, associate professor of medicine at Tulane University Health Sciences Center in New Orleans, and Mark Williams, MD, director of the hospital medicine program at Northwestern University’s Feinberg School of Medicine in Chicago.

“This pre-course was developed in response to requests from [SHM’s] Education Committee,” said Sylvia McKean, MD, chair of SHM’s Annual Meeting Committee. “It fold[s] in the best suggestions for hospitalist educators. It’s designed to shift those hospitalists who are responsible for education away from knowledge-only [teaching] and toward a performance-based focus.”

The pre-course used SHM’s The Core Competencies in Hospital Medicine as a framework to provide a competency-based model of physician education, one that emphasizes performance-based competencies such as procedures, practice-based learning, and “people skills.” This model can be adapted to teaching residents and students at the bedside as well as in conference rooms and large lecture halls.

“It went beyond curriculum,” said attendee Kevin O’Leary, MD. “It inspired people to think creatively about their own curriculum at home … it was an enlightened teaching model.”

The more than 85 hospitalist educators who attended the pre-course were asked to start a networking group to be called the SHM Educator Network, which will exchange resources and curriculum.

“The goal is for people to share talking points and generate additional tools,” Dr. Williams said. “There are lots of new faculty” teaching hospital medicine across the country. “They need training and they need resources.”

Those responsible for teaching hospital medicine to residents and medical students had an unprecedented opportunity to become students for the day and learn from top teachers in the field.

An important new addition to the all-day precourses was the “Teaching Hospitalist Educators (THE) Course: What Clinical Teachers in Hospital Medicine Need to Know.” The session was presented by Jeffrey Wiese, MD, FACP, associate professor of medicine at Tulane University Health Sciences Center in New Orleans, and Mark Williams, MD, director of the hospital medicine program at Northwestern University’s Feinberg School of Medicine in Chicago.

“This pre-course was developed in response to requests from [SHM’s] Education Committee,” said Sylvia McKean, MD, chair of SHM’s Annual Meeting Committee. “It fold[s] in the best suggestions for hospitalist educators. It’s designed to shift those hospitalists who are responsible for education away from knowledge-only [teaching] and toward a performance-based focus.”

The pre-course used SHM’s The Core Competencies in Hospital Medicine as a framework to provide a competency-based model of physician education, one that emphasizes performance-based competencies such as procedures, practice-based learning, and “people skills.” This model can be adapted to teaching residents and students at the bedside as well as in conference rooms and large lecture halls.

“It went beyond curriculum,” said attendee Kevin O’Leary, MD. “It inspired people to think creatively about their own curriculum at home … it was an enlightened teaching model.”

The more than 85 hospitalist educators who attended the pre-course were asked to start a networking group to be called the SHM Educator Network, which will exchange resources and curriculum.

“The goal is for people to share talking points and generate additional tools,” Dr. Williams said. “There are lots of new faculty” teaching hospital medicine across the country. “They need training and they need resources.”

Those responsible for teaching hospital medicine to residents and medical students had an unprecedented opportunity to become students for the day and learn from top teachers in the field.

An important new addition to the all-day precourses was the “Teaching Hospitalist Educators (THE) Course: What Clinical Teachers in Hospital Medicine Need to Know.” The session was presented by Jeffrey Wiese, MD, FACP, associate professor of medicine at Tulane University Health Sciences Center in New Orleans, and Mark Williams, MD, director of the hospital medicine program at Northwestern University’s Feinberg School of Medicine in Chicago.

“This pre-course was developed in response to requests from [SHM’s] Education Committee,” said Sylvia McKean, MD, chair of SHM’s Annual Meeting Committee. “It fold[s] in the best suggestions for hospitalist educators. It’s designed to shift those hospitalists who are responsible for education away from knowledge-only [teaching] and toward a performance-based focus.”

The pre-course used SHM’s The Core Competencies in Hospital Medicine as a framework to provide a competency-based model of physician education, one that emphasizes performance-based competencies such as procedures, practice-based learning, and “people skills.” This model can be adapted to teaching residents and students at the bedside as well as in conference rooms and large lecture halls.

“It went beyond curriculum,” said attendee Kevin O’Leary, MD. “It inspired people to think creatively about their own curriculum at home … it was an enlightened teaching model.”

The more than 85 hospitalist educators who attended the pre-course were asked to start a networking group to be called the SHM Educator Network, which will exchange resources and curriculum.

“The goal is for people to share talking points and generate additional tools,” Dr. Williams said. “There are lots of new faculty” teaching hospital medicine across the country. “They need training and they need resources.”

Couldn’t make it to a session you wanted to attend? Missed the meeting entirely?

This at-a-glance wrap-up provides some highlights from several key sessions:

Clinical Tracks

Key session: “The How, When and Why of Comanagement” presented by Eric M. Siegal, MD, regional medical director, Cogent Healthcare, Madison, Wis.

Take-away points: Co-management does not always result in better or more efficient care. Common arguments in favor of having hospitalists involved, such as improved outcomes and leveraging scarce specialist resources, each have a counter-argument that should be carefully considered.

In assuming co-management of orthopedic or neurosurgical patients, Dr. Siegal points out: “We’re managing patients we were never trained to manage. Subspecialties know how to do this type of care. Why step in, learn new skills, and practice them on living patients?”

Dr. Siegal summarized his concerns with some clear caveats: “Be rigorous about defining your co-management responsibilities; admit that some patients don’t need us; concentrate on leveraging your own scarce resources; and recognize that it’s sometimes better for a surgeon to see his or her patient.”

If and when you do assume co-management responsibilities, he advised, ask questions, including “Why are we being asked to participate?” “Will we make a difference?” and “What might we screw up?”

Key session: “Nosocomial Infections and Resistant Organisms” presented by James Pile, MD, FACP, Case Western Reserve University/MetroHealth Medical Center, Cleveland, Ohio

Take-away points: Dr. Pile’s presentation began with the evolving topic of methicillin-resistant Staph aureus (MRSA). He traced the evolution of nosocomial and community-associated strains of MRSA and detailed the ongoing shifts in the distribution of community-associated MRSA (CA-MRSA). Particular attention was given to the ongoing movement of CA-MRSA out of the community and into the hospital setting, the recent emergence of multidrug resistant CA-MRSA on the East and West coasts, and MRSA colonization.

He also touched on the emerging understanding that vancomycin is a less-than-ideal treatment for serious MRSA infections, and outlined the potential utility of alternative agents old and new. He then addressed catheter-related bloodstream infections, including optimal diagnostic methods, evidence-based methods of prevention, and treatment strategies.

He stressed that the still-underutilized therapeutic modality of antibiotic lock therapy clearly appears to increase the likelihood of successfully salvaging infected catheters, and discussed the fact the responsible pathogen helps inform the decision to remove or retain an infected catheter. He closed by pointing out that revised guidelines for the treatment of catheter-related bloodstream infections from the Infectious Diseases Society of America should be released shortly.

Operational Track

Key session: “Designing Compensation and Bonus Plans to Drive Desired Behaviors” presented by Rachel M. George, MD, MBA, Cogent Healthcare, Department of Pediatrics at SUNY Downstate Medical Center, Brooklyn, N.Y.; Winthrop Whitcomb, MD, Mercy Medical Center in Springfield, Mass.; and John Bulger DO, FACOI, FACP, Geisinger Health System in Pennsylvania.

Take-away points: Dr. Whitcomb discussed compensation for community-based hospital medicine programs that reward both an individual’s productivity—based on RVUs, charges or cash—and quality measures met, which will directly improve quality.

Dr. Bolger believes hospitalists at a large academic teaching center should have the ability to affect their compensation; therefore, those who contribute more should be compensated more. His institution uses a base-incentive plan that rewards for core values including teaching, innovation, and quality.

Dr. George of the multistate hospital medicine program Cogent Healthcare discussed her organization’s compensation plan of a base salary plus a bonus of approximately 20% of salary for incentives.

Academic Track

Key session: “Keys to a Successful Academic Hospitalist Program” presented by Robert M. Wachter, MD, University of California, San Francisco; Brian P. Lucas, MD, MS, Cook County Hospital, Chicago; and Adrienne L. Bennett, MD, PhD, Ohio State University Medical Center, Columbus.

Take-away points: These academic hospitalist leaders stressed research in this session. Research is critical to the success of hospital medicine. You can support research by building research expertise among your staff and creating (or borrowing) an infrastructure for research. Get your entire group involved, with the goal of producing at least two scholarly works a year. Invite other subspecialists and institutions to participate in your research. You also must offer salary support for dedicated scholarship time.

Quality Track

Key session: “Improving Quality and Safety during Transitions of Care” presented by Eric Coleman, MD, MPH, University of Colorado, Denver; Jeffrey Greenwald, MD, Boston University Medical Campus; Lakshmi Halasyamani, MD, St. Joseph Mercy Medical Center, Ann Arbor, Mich.; and Mark V. Williams, MD, Northwestern University’s Feinberg School of Medicine in Chicago.

Take-away points: Retitled “BOOSTing Care Transitions,” this session focused on problems with discharging patients and outlined Project BOOST: Better Outcomes for Older adults through Safe Transitions. The BOOST toolkit includes resources for identifying high-risk patients; preparation for the patient and caregiver including follow-up plans; and a discharge summary communication. Specific tools include GRATE, a Geriatric Risk Adjusted Transition Evaluation; a 6P Risk Scale to be used on admit and discharge; a Risk Adjusted Checklist; and GAP, Geriatric Assessment of Preparedness for on admit, near discharge and at discharge. The toolkit is available online in the SHM Resource Rooms at www.hospitalmedicine.org.

Pediatric Track

Key session: “Surveys Say ... Current Reports on Pediatric Hospitalist Workload and Compensation” presented by Jack Percelay, MD, MPH, FAAP, ELMO Pediatrics, Livingston, N.J., and David Zipes, MD, FAAP, St. Vincent Children’s Hospital, Indianapolis, Ind.

Take-away points: Relevant data from the “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement” were reviewed, with many caveats noted as the pediatric portion still is being analyzed. Pediatric hospitalists make less money than their adult-patient counterparts, with a total compensation of $144,600 compared with $183,900. They reported fewer patient encounters and work fewer hours overall. These differences are subject to closer examination. “Is this really a decrease in productivity and the work that we do, or does this reflect the fact that virtually no ‘private practice hospitalists’ responded?” Dr. Percelay asked.

Key session: “Clinical Pathways on a Budget” presented by Steve Narang, MD, Our Lady of the Lake Regional Medical Center, Baton Rouge, La.

Take-away points: To help fill the gap in information on pediatric care, Dr. Narang designed a clinical pathway for admitting an increasing number of pediatric patients with skin and soft-tissue infection (abscess) based on evidence and expert opinion. This pathway was shared with 100 pediatric providers in Louisiana. The results of implementing the pathway in his institution showed a reduction in other, less efficient treatments and tests, a 25% decrease in length of stay for these patients and a 20% decrease in cost—both in three years.

Couldn’t make it to a session you wanted to attend? Missed the meeting entirely?

This at-a-glance wrap-up provides some highlights from several key sessions:

Clinical Tracks

Key session: “The How, When and Why of Comanagement” presented by Eric M. Siegal, MD, regional medical director, Cogent Healthcare, Madison, Wis.

Take-away points: Co-management does not always result in better or more efficient care. Common arguments in favor of having hospitalists involved, such as improved outcomes and leveraging scarce specialist resources, each have a counter-argument that should be carefully considered.

In assuming co-management of orthopedic or neurosurgical patients, Dr. Siegal points out: “We’re managing patients we were never trained to manage. Subspecialties know how to do this type of care. Why step in, learn new skills, and practice them on living patients?”

Dr. Siegal summarized his concerns with some clear caveats: “Be rigorous about defining your co-management responsibilities; admit that some patients don’t need us; concentrate on leveraging your own scarce resources; and recognize that it’s sometimes better for a surgeon to see his or her patient.”

If and when you do assume co-management responsibilities, he advised, ask questions, including “Why are we being asked to participate?” “Will we make a difference?” and “What might we screw up?”

Key session: “Nosocomial Infections and Resistant Organisms” presented by James Pile, MD, FACP, Case Western Reserve University/MetroHealth Medical Center, Cleveland, Ohio

Take-away points: Dr. Pile’s presentation began with the evolving topic of methicillin-resistant Staph aureus (MRSA). He traced the evolution of nosocomial and community-associated strains of MRSA and detailed the ongoing shifts in the distribution of community-associated MRSA (CA-MRSA). Particular attention was given to the ongoing movement of CA-MRSA out of the community and into the hospital setting, the recent emergence of multidrug resistant CA-MRSA on the East and West coasts, and MRSA colonization.

He also touched on the emerging understanding that vancomycin is a less-than-ideal treatment for serious MRSA infections, and outlined the potential utility of alternative agents old and new. He then addressed catheter-related bloodstream infections, including optimal diagnostic methods, evidence-based methods of prevention, and treatment strategies.

He stressed that the still-underutilized therapeutic modality of antibiotic lock therapy clearly appears to increase the likelihood of successfully salvaging infected catheters, and discussed the fact the responsible pathogen helps inform the decision to remove or retain an infected catheter. He closed by pointing out that revised guidelines for the treatment of catheter-related bloodstream infections from the Infectious Diseases Society of America should be released shortly.

Operational Track

Key session: “Designing Compensation and Bonus Plans to Drive Desired Behaviors” presented by Rachel M. George, MD, MBA, Cogent Healthcare, Department of Pediatrics at SUNY Downstate Medical Center, Brooklyn, N.Y.; Winthrop Whitcomb, MD, Mercy Medical Center in Springfield, Mass.; and John Bulger DO, FACOI, FACP, Geisinger Health System in Pennsylvania.

Take-away points: Dr. Whitcomb discussed compensation for community-based hospital medicine programs that reward both an individual’s productivity—based on RVUs, charges or cash—and quality measures met, which will directly improve quality.

Dr. Bolger believes hospitalists at a large academic teaching center should have the ability to affect their compensation; therefore, those who contribute more should be compensated more. His institution uses a base-incentive plan that rewards for core values including teaching, innovation, and quality.

Dr. George of the multistate hospital medicine program Cogent Healthcare discussed her organization’s compensation plan of a base salary plus a bonus of approximately 20% of salary for incentives.

Academic Track

Key session: “Keys to a Successful Academic Hospitalist Program” presented by Robert M. Wachter, MD, University of California, San Francisco; Brian P. Lucas, MD, MS, Cook County Hospital, Chicago; and Adrienne L. Bennett, MD, PhD, Ohio State University Medical Center, Columbus.

Take-away points: These academic hospitalist leaders stressed research in this session. Research is critical to the success of hospital medicine. You can support research by building research expertise among your staff and creating (or borrowing) an infrastructure for research. Get your entire group involved, with the goal of producing at least two scholarly works a year. Invite other subspecialists and institutions to participate in your research. You also must offer salary support for dedicated scholarship time.

Quality Track

Key session: “Improving Quality and Safety during Transitions of Care” presented by Eric Coleman, MD, MPH, University of Colorado, Denver; Jeffrey Greenwald, MD, Boston University Medical Campus; Lakshmi Halasyamani, MD, St. Joseph Mercy Medical Center, Ann Arbor, Mich.; and Mark V. Williams, MD, Northwestern University’s Feinberg School of Medicine in Chicago.

Take-away points: Retitled “BOOSTing Care Transitions,” this session focused on problems with discharging patients and outlined Project BOOST: Better Outcomes for Older adults through Safe Transitions. The BOOST toolkit includes resources for identifying high-risk patients; preparation for the patient and caregiver including follow-up plans; and a discharge summary communication. Specific tools include GRATE, a Geriatric Risk Adjusted Transition Evaluation; a 6P Risk Scale to be used on admit and discharge; a Risk Adjusted Checklist; and GAP, Geriatric Assessment of Preparedness for on admit, near discharge and at discharge. The toolkit is available online in the SHM Resource Rooms at www.hospitalmedicine.org.

Pediatric Track

Key session: “Surveys Say ... Current Reports on Pediatric Hospitalist Workload and Compensation” presented by Jack Percelay, MD, MPH, FAAP, ELMO Pediatrics, Livingston, N.J., and David Zipes, MD, FAAP, St. Vincent Children’s Hospital, Indianapolis, Ind.

Take-away points: Relevant data from the “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement” were reviewed, with many caveats noted as the pediatric portion still is being analyzed. Pediatric hospitalists make less money than their adult-patient counterparts, with a total compensation of $144,600 compared with $183,900. They reported fewer patient encounters and work fewer hours overall. These differences are subject to closer examination. “Is this really a decrease in productivity and the work that we do, or does this reflect the fact that virtually no ‘private practice hospitalists’ responded?” Dr. Percelay asked.

Key session: “Clinical Pathways on a Budget” presented by Steve Narang, MD, Our Lady of the Lake Regional Medical Center, Baton Rouge, La.

Take-away points: To help fill the gap in information on pediatric care, Dr. Narang designed a clinical pathway for admitting an increasing number of pediatric patients with skin and soft-tissue infection (abscess) based on evidence and expert opinion. This pathway was shared with 100 pediatric providers in Louisiana. The results of implementing the pathway in his institution showed a reduction in other, less efficient treatments and tests, a 25% decrease in length of stay for these patients and a 20% decrease in cost—both in three years.

Couldn’t make it to a session you wanted to attend? Missed the meeting entirely?

This at-a-glance wrap-up provides some highlights from several key sessions:

Clinical Tracks

Key session: “The How, When and Why of Comanagement” presented by Eric M. Siegal, MD, regional medical director, Cogent Healthcare, Madison, Wis.

Take-away points: Co-management does not always result in better or more efficient care. Common arguments in favor of having hospitalists involved, such as improved outcomes and leveraging scarce specialist resources, each have a counter-argument that should be carefully considered.

In assuming co-management of orthopedic or neurosurgical patients, Dr. Siegal points out: “We’re managing patients we were never trained to manage. Subspecialties know how to do this type of care. Why step in, learn new skills, and practice them on living patients?”

Dr. Siegal summarized his concerns with some clear caveats: “Be rigorous about defining your co-management responsibilities; admit that some patients don’t need us; concentrate on leveraging your own scarce resources; and recognize that it’s sometimes better for a surgeon to see his or her patient.”

If and when you do assume co-management responsibilities, he advised, ask questions, including “Why are we being asked to participate?” “Will we make a difference?” and “What might we screw up?”

Key session: “Nosocomial Infections and Resistant Organisms” presented by James Pile, MD, FACP, Case Western Reserve University/MetroHealth Medical Center, Cleveland, Ohio

Take-away points: Dr. Pile’s presentation began with the evolving topic of methicillin-resistant Staph aureus (MRSA). He traced the evolution of nosocomial and community-associated strains of MRSA and detailed the ongoing shifts in the distribution of community-associated MRSA (CA-MRSA). Particular attention was given to the ongoing movement of CA-MRSA out of the community and into the hospital setting, the recent emergence of multidrug resistant CA-MRSA on the East and West coasts, and MRSA colonization.

He also touched on the emerging understanding that vancomycin is a less-than-ideal treatment for serious MRSA infections, and outlined the potential utility of alternative agents old and new. He then addressed catheter-related bloodstream infections, including optimal diagnostic methods, evidence-based methods of prevention, and treatment strategies.

He stressed that the still-underutilized therapeutic modality of antibiotic lock therapy clearly appears to increase the likelihood of successfully salvaging infected catheters, and discussed the fact the responsible pathogen helps inform the decision to remove or retain an infected catheter. He closed by pointing out that revised guidelines for the treatment of catheter-related bloodstream infections from the Infectious Diseases Society of America should be released shortly.

Operational Track

Key session: “Designing Compensation and Bonus Plans to Drive Desired Behaviors” presented by Rachel M. George, MD, MBA, Cogent Healthcare, Department of Pediatrics at SUNY Downstate Medical Center, Brooklyn, N.Y.; Winthrop Whitcomb, MD, Mercy Medical Center in Springfield, Mass.; and John Bulger DO, FACOI, FACP, Geisinger Health System in Pennsylvania.

Take-away points: Dr. Whitcomb discussed compensation for community-based hospital medicine programs that reward both an individual’s productivity—based on RVUs, charges or cash—and quality measures met, which will directly improve quality.

Dr. Bolger believes hospitalists at a large academic teaching center should have the ability to affect their compensation; therefore, those who contribute more should be compensated more. His institution uses a base-incentive plan that rewards for core values including teaching, innovation, and quality.

Dr. George of the multistate hospital medicine program Cogent Healthcare discussed her organization’s compensation plan of a base salary plus a bonus of approximately 20% of salary for incentives.

Academic Track

Key session: “Keys to a Successful Academic Hospitalist Program” presented by Robert M. Wachter, MD, University of California, San Francisco; Brian P. Lucas, MD, MS, Cook County Hospital, Chicago; and Adrienne L. Bennett, MD, PhD, Ohio State University Medical Center, Columbus.

Take-away points: These academic hospitalist leaders stressed research in this session. Research is critical to the success of hospital medicine. You can support research by building research expertise among your staff and creating (or borrowing) an infrastructure for research. Get your entire group involved, with the goal of producing at least two scholarly works a year. Invite other subspecialists and institutions to participate in your research. You also must offer salary support for dedicated scholarship time.

Quality Track

Key session: “Improving Quality and Safety during Transitions of Care” presented by Eric Coleman, MD, MPH, University of Colorado, Denver; Jeffrey Greenwald, MD, Boston University Medical Campus; Lakshmi Halasyamani, MD, St. Joseph Mercy Medical Center, Ann Arbor, Mich.; and Mark V. Williams, MD, Northwestern University’s Feinberg School of Medicine in Chicago.

Take-away points: Retitled “BOOSTing Care Transitions,” this session focused on problems with discharging patients and outlined Project BOOST: Better Outcomes for Older adults through Safe Transitions. The BOOST toolkit includes resources for identifying high-risk patients; preparation for the patient and caregiver including follow-up plans; and a discharge summary communication. Specific tools include GRATE, a Geriatric Risk Adjusted Transition Evaluation; a 6P Risk Scale to be used on admit and discharge; a Risk Adjusted Checklist; and GAP, Geriatric Assessment of Preparedness for on admit, near discharge and at discharge. The toolkit is available online in the SHM Resource Rooms at www.hospitalmedicine.org.

Pediatric Track

Key session: “Surveys Say ... Current Reports on Pediatric Hospitalist Workload and Compensation” presented by Jack Percelay, MD, MPH, FAAP, ELMO Pediatrics, Livingston, N.J., and David Zipes, MD, FAAP, St. Vincent Children’s Hospital, Indianapolis, Ind.

Take-away points: Relevant data from the “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement” were reviewed, with many caveats noted as the pediatric portion still is being analyzed. Pediatric hospitalists make less money than their adult-patient counterparts, with a total compensation of $144,600 compared with $183,900. They reported fewer patient encounters and work fewer hours overall. These differences are subject to closer examination. “Is this really a decrease in productivity and the work that we do, or does this reflect the fact that virtually no ‘private practice hospitalists’ responded?” Dr. Percelay asked.

Key session: “Clinical Pathways on a Budget” presented by Steve Narang, MD, Our Lady of the Lake Regional Medical Center, Baton Rouge, La.

Take-away points: To help fill the gap in information on pediatric care, Dr. Narang designed a clinical pathway for admitting an increasing number of pediatric patients with skin and soft-tissue infection (abscess) based on evidence and expert opinion. This pathway was shared with 100 pediatric providers in Louisiana. The results of implementing the pathway in his institution showed a reduction in other, less efficient treatments and tests, a 25% decrease in length of stay for these patients and a 20% decrease in cost—both in three years.

A new educational track at Hospital Medicine 2008 offered the latest evidence-based data on controversial issues hospitalists routinely face—all in a shortened time frame called Rapid Fire.

“The Rapid Fire track is very exciting,” said Sylvia McKean, MD, course director of the meeting. “The purpose is basically to help hospitalists when they’re on the front lines with the key questions that come up. The sessions are 35 minutes each, and they’re more direct, with applicable content that’s designed to provide attendees with rapid bursts of information and to address specific questions. Each course is very clinical and very relevant to [working hospitalists].”

The Rapid Fire track proved popular with attendees; each topic drew a packed house.

“This is a great idea—it’s like a mini-session,” said attendee Randy Hobbs, MD, of Aurora Hospital PC in Buffalo, N.Y. “They did a great job choosing the questions. These are things we use every day.”

Ten topics were covered in Rapid Fire, two per session hour. Each answered multiple questions submitted in advance by the Annual Meeting Committee, and each used the highest level of medical evidence available. Key points from each include:

“Controversies in Critical Care”: David Schulman, MD, MPH, chief of pulmonary and critical care medicine at Emory University Hospital in Atlanta, outlined treatment options for high-risk patients with ventilator-acquired pneumonia. His advise: Include a cephalosporin with antipseudomonal activity; imipenem or meropenem; beta-lactam and a beta-lactamase inhibitor plus anantipseudomonal fluoroquinolone or aminoglycoside; and add vancomycin or linezolid if methicillin-resistant staphylococcus aureus is of high incidence.

“Clot Controversies: Thrombolysis and VTE Prophylaxis”: “Prophylaxis has to do with diligence, not which drug we give them,” said Timothy Morris, MD, University of California, San Diego. “Declare the risk and contraindication for each patient and mark whether you’re going to prophylax, and it can make a huge difference” when a patient is admitted, he advised.

“Controversies in Transfusion Medicine”: Studies indicate careful assessment of the necessity of transfusion for each patient is crucial, said Jeffrey Carson, MD, Robert Wood Johnson Medical School in New Brunswick, N.J. Pending additional research, current data suggest that a restrictive transfusion trigger (7 g/dL) should be used.

“Acute Coronary Syndrome Trials and Tribulations”: Can you trust troponins? Will Southern, MD, MS, of Weiler Division Hospital of Montefiore Medical Center in New York City, said the following combinations have good outcomes:

• Prolonged chest pain and normal troponin;
• Normal ECG and normal troponin in a young nondiabetic patient without prior coronary artery disease; and
• Normal troponin and atypical symptoms in the same patient type.

“Management of Anticoagulant-Related Bleeding Complications”: Amir Jaffer, MD, University of Miami Hospital, cited a study that recommended the following treatment for unfractionated or low molecular weight heparin-related bleeding:

• 1 mg of protamine for every 100 units of heparin;
• No greater than 50 mg of protamine at one time; and
• Infusion should not exceed 5 mg/min.

“Acute Renal Failure Prophylaxis, Med Dosing and Acute Management”: James Paparello, MD, of Northwestern University, reviewed medications used in kidney disease. For example, nonsteroidal anti-inflammatory drugs (NSAIDS) can push a patient with marginal glomerular filtration rate into acute renal failure. In dialysis, NSAIDS carry a bleeding risk.

“Perioperative Cardiac Guide-lines”: “Preoperative evaluation should focus on the clinical presentation of disease, exercise tolerance, and extent of surgery,” said Lee Fleisher, MD, University of Pennsylvania Health System in Philadelphia. “Testing should be reserved for patients with a poor exercise tolerance undergoing vascular surgery with risk factors if the results may impact care.”

“Ischemic Stroke Diagnosis and Management”: All patients who suffer a transient ischemic attack or ischemic stroke should get the following, summarized Galen Henderson, MD, Brigham and Women’s Hospital:

• Brain and neurovascular imaging;
• Blood glucose and serum electrolytes;
• Complete blood count with platelets;
• Prothrombin time/partial thromboplastin/international normalized ratio;
• A 12-lead EKG and Holter monitoring;
• Transthoracic echocardiogram/ transesophageal echcardiogram; and
• Supplemental oxygen fever reduction and lipids.

“Common Endocrine Problems for the Hospitalist”: “Regardless of a prior history of diabetes, keep glucose at 80-110 mg/dl for better outcomes,” advised Jordan Geller, MD, of the Endocrinology Department at Cedars-Sinai Medical Center in Los Angeles.

“New Practices in ACLS”: Jason Persoff, MD, of the Mayo Clinic in Jacksonville, Fla., reviewed new studies showing that the best course for basic life support is to begin chest compressions immediately, pushing hard and pumping fast. Focus on this, not bag-valve-mask or intubation, to save more lives.

A new educational track at Hospital Medicine 2008 offered the latest evidence-based data on controversial issues hospitalists routinely face—all in a shortened time frame called Rapid Fire.

“The Rapid Fire track is very exciting,” said Sylvia McKean, MD, course director of the meeting. “The purpose is basically to help hospitalists when they’re on the front lines with the key questions that come up. The sessions are 35 minutes each, and they’re more direct, with applicable content that’s designed to provide attendees with rapid bursts of information and to address specific questions. Each course is very clinical and very relevant to [working hospitalists].”

The Rapid Fire track proved popular with attendees; each topic drew a packed house.

“This is a great idea—it’s like a mini-session,” said attendee Randy Hobbs, MD, of Aurora Hospital PC in Buffalo, N.Y. “They did a great job choosing the questions. These are things we use every day.”

Ten topics were covered in Rapid Fire, two per session hour. Each answered multiple questions submitted in advance by the Annual Meeting Committee, and each used the highest level of medical evidence available. Key points from each include:

“Controversies in Critical Care”: David Schulman, MD, MPH, chief of pulmonary and critical care medicine at Emory University Hospital in Atlanta, outlined treatment options for high-risk patients with ventilator-acquired pneumonia. His advise: Include a cephalosporin with antipseudomonal activity; imipenem or meropenem; beta-lactam and a beta-lactamase inhibitor plus anantipseudomonal fluoroquinolone or aminoglycoside; and add vancomycin or linezolid if methicillin-resistant staphylococcus aureus is of high incidence.

“Clot Controversies: Thrombolysis and VTE Prophylaxis”: “Prophylaxis has to do with diligence, not which drug we give them,” said Timothy Morris, MD, University of California, San Diego. “Declare the risk and contraindication for each patient and mark whether you’re going to prophylax, and it can make a huge difference” when a patient is admitted, he advised.

“Controversies in Transfusion Medicine”: Studies indicate careful assessment of the necessity of transfusion for each patient is crucial, said Jeffrey Carson, MD, Robert Wood Johnson Medical School in New Brunswick, N.J. Pending additional research, current data suggest that a restrictive transfusion trigger (7 g/dL) should be used.

“Acute Coronary Syndrome Trials and Tribulations”: Can you trust troponins? Will Southern, MD, MS, of Weiler Division Hospital of Montefiore Medical Center in New York City, said the following combinations have good outcomes:

• Prolonged chest pain and normal troponin;
• Normal ECG and normal troponin in a young nondiabetic patient without prior coronary artery disease; and
• Normal troponin and atypical symptoms in the same patient type.

“Management of Anticoagulant-Related Bleeding Complications”: Amir Jaffer, MD, University of Miami Hospital, cited a study that recommended the following treatment for unfractionated or low molecular weight heparin-related bleeding:

• 1 mg of protamine for every 100 units of heparin;
• No greater than 50 mg of protamine at one time; and
• Infusion should not exceed 5 mg/min.

“Acute Renal Failure Prophylaxis, Med Dosing and Acute Management”: James Paparello, MD, of Northwestern University, reviewed medications used in kidney disease. For example, nonsteroidal anti-inflammatory drugs (NSAIDS) can push a patient with marginal glomerular filtration rate into acute renal failure. In dialysis, NSAIDS carry a bleeding risk.

“Perioperative Cardiac Guide-lines”: “Preoperative evaluation should focus on the clinical presentation of disease, exercise tolerance, and extent of surgery,” said Lee Fleisher, MD, University of Pennsylvania Health System in Philadelphia. “Testing should be reserved for patients with a poor exercise tolerance undergoing vascular surgery with risk factors if the results may impact care.”

“Ischemic Stroke Diagnosis and Management”: All patients who suffer a transient ischemic attack or ischemic stroke should get the following, summarized Galen Henderson, MD, Brigham and Women’s Hospital:

• Brain and neurovascular imaging;
• Blood glucose and serum electrolytes;
• Complete blood count with platelets;
• Prothrombin time/partial thromboplastin/international normalized ratio;
• A 12-lead EKG and Holter monitoring;
• Transthoracic echocardiogram/ transesophageal echcardiogram; and
• Supplemental oxygen fever reduction and lipids.

“Common Endocrine Problems for the Hospitalist”: “Regardless of a prior history of diabetes, keep glucose at 80-110 mg/dl for better outcomes,” advised Jordan Geller, MD, of the Endocrinology Department at Cedars-Sinai Medical Center in Los Angeles.

“New Practices in ACLS”: Jason Persoff, MD, of the Mayo Clinic in Jacksonville, Fla., reviewed new studies showing that the best course for basic life support is to begin chest compressions immediately, pushing hard and pumping fast. Focus on this, not bag-valve-mask or intubation, to save more lives.

A new educational track at Hospital Medicine 2008 offered the latest evidence-based data on controversial issues hospitalists routinely face—all in a shortened time frame called Rapid Fire.

“The Rapid Fire track is very exciting,” said Sylvia McKean, MD, course director of the meeting. “The purpose is basically to help hospitalists when they’re on the front lines with the key questions that come up. The sessions are 35 minutes each, and they’re more direct, with applicable content that’s designed to provide attendees with rapid bursts of information and to address specific questions. Each course is very clinical and very relevant to [working hospitalists].”

The Rapid Fire track proved popular with attendees; each topic drew a packed house.

“This is a great idea—it’s like a mini-session,” said attendee Randy Hobbs, MD, of Aurora Hospital PC in Buffalo, N.Y. “They did a great job choosing the questions. These are things we use every day.”

Ten topics were covered in Rapid Fire, two per session hour. Each answered multiple questions submitted in advance by the Annual Meeting Committee, and each used the highest level of medical evidence available. Key points from each include:

“Controversies in Critical Care”: David Schulman, MD, MPH, chief of pulmonary and critical care medicine at Emory University Hospital in Atlanta, outlined treatment options for high-risk patients with ventilator-acquired pneumonia. His advise: Include a cephalosporin with antipseudomonal activity; imipenem or meropenem; beta-lactam and a beta-lactamase inhibitor plus anantipseudomonal fluoroquinolone or aminoglycoside; and add vancomycin or linezolid if methicillin-resistant staphylococcus aureus is of high incidence.

“Clot Controversies: Thrombolysis and VTE Prophylaxis”: “Prophylaxis has to do with diligence, not which drug we give them,” said Timothy Morris, MD, University of California, San Diego. “Declare the risk and contraindication for each patient and mark whether you’re going to prophylax, and it can make a huge difference” when a patient is admitted, he advised.

“Controversies in Transfusion Medicine”: Studies indicate careful assessment of the necessity of transfusion for each patient is crucial, said Jeffrey Carson, MD, Robert Wood Johnson Medical School in New Brunswick, N.J. Pending additional research, current data suggest that a restrictive transfusion trigger (7 g/dL) should be used.

“Acute Coronary Syndrome Trials and Tribulations”: Can you trust troponins? Will Southern, MD, MS, of Weiler Division Hospital of Montefiore Medical Center in New York City, said the following combinations have good outcomes:

• Prolonged chest pain and normal troponin;
• Normal ECG and normal troponin in a young nondiabetic patient without prior coronary artery disease; and
• Normal troponin and atypical symptoms in the same patient type.

“Management of Anticoagulant-Related Bleeding Complications”: Amir Jaffer, MD, University of Miami Hospital, cited a study that recommended the following treatment for unfractionated or low molecular weight heparin-related bleeding:

• 1 mg of protamine for every 100 units of heparin;
• No greater than 50 mg of protamine at one time; and
• Infusion should not exceed 5 mg/min.

“Acute Renal Failure Prophylaxis, Med Dosing and Acute Management”: James Paparello, MD, of Northwestern University, reviewed medications used in kidney disease. For example, nonsteroidal anti-inflammatory drugs (NSAIDS) can push a patient with marginal glomerular filtration rate into acute renal failure. In dialysis, NSAIDS carry a bleeding risk.

“Perioperative Cardiac Guide-lines”: “Preoperative evaluation should focus on the clinical presentation of disease, exercise tolerance, and extent of surgery,” said Lee Fleisher, MD, University of Pennsylvania Health System in Philadelphia. “Testing should be reserved for patients with a poor exercise tolerance undergoing vascular surgery with risk factors if the results may impact care.”

“Ischemic Stroke Diagnosis and Management”: All patients who suffer a transient ischemic attack or ischemic stroke should get the following, summarized Galen Henderson, MD, Brigham and Women’s Hospital:

• Brain and neurovascular imaging;
• Blood glucose and serum electrolytes;
• Complete blood count with platelets;
• Prothrombin time/partial thromboplastin/international normalized ratio;
• A 12-lead EKG and Holter monitoring;
• Transthoracic echocardiogram/ transesophageal echcardiogram; and
• Supplemental oxygen fever reduction and lipids.

“Common Endocrine Problems for the Hospitalist”: “Regardless of a prior history of diabetes, keep glucose at 80-110 mg/dl for better outcomes,” advised Jordan Geller, MD, of the Endocrinology Department at Cedars-Sinai Medical Center in Los Angeles.

“New Practices in ACLS”: Jason Persoff, MD, of the Mayo Clinic in Jacksonville, Fla., reviewed new studies showing that the best course for basic life support is to begin chest compressions immediately, pushing hard and pumping fast. Focus on this, not bag-valve-mask or intubation, to save more lives.

Attendees at Hospital Medicine 2008 were the first to hear the results of the latest SHM survey of hospitalists, learning that hospitalist pay is up, roughly one-third of hospitalist leaders don’t know their groups’ expenses or fee revenues, and that financial support has grown substantially.

The society’s biannual survey of U.S. hospital medicine groups went to 1,700 of an estimated 2,200 groups in 2007. SHM Senior Vice President Joseph Miller and Burke Kealey, MD, chair of SHM’s Benchmarks Committee (which designed the survey) presented the findings from the “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement.”

“Our purpose is to provide a snapshot of hospital medicine at a moment in time for hospitalists and hospital medicine groups,” Miller said. “I think this is the best SHM survey ever conducted.”

Survey Basics

The survey drew a 24% response rate, gleaning information from 440 hospital medicine groups representing 3,242 individual hospitalists, as well as summary data from a separate survey sent to the nation’s largest hospital medicine groups. “We think it adds to the richness of the data,” explained Miller.

All data were collected between September and December 2007 and reflects information for the previous 12 months. Miller was careful to note that RVU values changed midway through that period.

Hospital medicine still is a young specialty, but, Miller said, “I think we’re seeing a growing experience base.” The median age of hospitalists is 37, with 3.7 years of mean experience. For leaders, the median age is 41, with 6.7 years of experience.

The State of HMGs

Today’s hospital medicine groups are growing, and so is the financial support they receive from hospitals.

“There has been significant growth in the number of [full-time employees] in hospital medicine groups,” Miller said. Since the previous survey two years ago, there is a 31% mean growth in groups. “We’re seeing fewer new groups, with more growth coming from the established groups” More groups are using nurse practitioners and/or physician assistants, up from 29% to 38%.

As for the leadership of the hospital medicine groups, the survey revealed some serious knowledge gaps. “Thirty-five to 37% of leaders did not know the finances of their groups,” Miller pointed out. This percentage—up somewhat from two years ago—could not answer survey questions on their group’s expenses or fee revenue.

The numbers of those who know where their money comes from show that hospitals (or partner institutions) are supplying more financial support now. A whopping 91% of responding programs receive money, with the total mean amount exceeding $97,000 per full-time physician. “This has increased substantially since the last survey,” Miller said.

Productivity and Pay

To ensure clarity of data, the survey breaks down compensation and productivity information for hospitalists into four separate groups: those who treat adult patients; those who treat pediatric patients; those who treat both; and nurse practitioners and physician assistants. In the session, Dr. Kealey covered only the first group.

He pointed out the strong correlation between the number of hours worked and higher productivity, and between higher productivity and higher compensation.

“Encounters have remained relatively flat,” he said. (They are down just 4% from the previous survey.) “But total compensation has increased by 13%.” In other words, hospitalists are working about the same amount they were two years ago, but are making more money—on average, $193,000.

Of the survey respondents, 25.3% are paid by straight salary; 6.1% are paid based on productivity, and the remainder earn a mix of salary and bonus.

Productivity figures show hospitalist experience pays off: Experienced hospitalists have more encounters in the same number of hours than their less-experienced counterparts. They also have higher compensation.

Another disturbing trend among hospitalist leaders is that they put in about as many clinical hours as nonleaders. “This indicates that they may not have enough time to lead,” Dr. Kealey said.

The survey included information on 106 respondents who are nocturnists. These night workers have significantly fewer encounters, and work slightly fewer hours for slightly less money. Dr. Kealey noted that “when you cover nights, your productivity drops. This is good to know if you’re thinking about adding night coverage in your practice.”

The complete survey results should be available sometime in May, and information will be posted on the SHM Web site at www.hospitalmedicine.org.

Attendees at Hospital Medicine 2008 were the first to hear the results of the latest SHM survey of hospitalists, learning that hospitalist pay is up, roughly one-third of hospitalist leaders don’t know their groups’ expenses or fee revenues, and that financial support has grown substantially.

The society’s biannual survey of U.S. hospital medicine groups went to 1,700 of an estimated 2,200 groups in 2007. SHM Senior Vice President Joseph Miller and Burke Kealey, MD, chair of SHM’s Benchmarks Committee (which designed the survey) presented the findings from the “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement.”

“Our purpose is to provide a snapshot of hospital medicine at a moment in time for hospitalists and hospital medicine groups,” Miller said. “I think this is the best SHM survey ever conducted.”

Survey Basics

The survey drew a 24% response rate, gleaning information from 440 hospital medicine groups representing 3,242 individual hospitalists, as well as summary data from a separate survey sent to the nation’s largest hospital medicine groups. “We think it adds to the richness of the data,” explained Miller.

All data were collected between September and December 2007 and reflects information for the previous 12 months. Miller was careful to note that RVU values changed midway through that period.

Hospital medicine still is a young specialty, but, Miller said, “I think we’re seeing a growing experience base.” The median age of hospitalists is 37, with 3.7 years of mean experience. For leaders, the median age is 41, with 6.7 years of experience.

The State of HMGs

Today’s hospital medicine groups are growing, and so is the financial support they receive from hospitals.

“There has been significant growth in the number of [full-time employees] in hospital medicine groups,” Miller said. Since the previous survey two years ago, there is a 31% mean growth in groups. “We’re seeing fewer new groups, with more growth coming from the established groups” More groups are using nurse practitioners and/or physician assistants, up from 29% to 38%.

As for the leadership of the hospital medicine groups, the survey revealed some serious knowledge gaps. “Thirty-five to 37% of leaders did not know the finances of their groups,” Miller pointed out. This percentage—up somewhat from two years ago—could not answer survey questions on their group’s expenses or fee revenue.

The numbers of those who know where their money comes from show that hospitals (or partner institutions) are supplying more financial support now. A whopping 91% of responding programs receive money, with the total mean amount exceeding $97,000 per full-time physician. “This has increased substantially since the last survey,” Miller said.

Productivity and Pay

To ensure clarity of data, the survey breaks down compensation and productivity information for hospitalists into four separate groups: those who treat adult patients; those who treat pediatric patients; those who treat both; and nurse practitioners and physician assistants. In the session, Dr. Kealey covered only the first group.

He pointed out the strong correlation between the number of hours worked and higher productivity, and between higher productivity and higher compensation.

“Encounters have remained relatively flat,” he said. (They are down just 4% from the previous survey.) “But total compensation has increased by 13%.” In other words, hospitalists are working about the same amount they were two years ago, but are making more money—on average, $193,000.

Of the survey respondents, 25.3% are paid by straight salary; 6.1% are paid based on productivity, and the remainder earn a mix of salary and bonus.

Productivity figures show hospitalist experience pays off: Experienced hospitalists have more encounters in the same number of hours than their less-experienced counterparts. They also have higher compensation.

Another disturbing trend among hospitalist leaders is that they put in about as many clinical hours as nonleaders. “This indicates that they may not have enough time to lead,” Dr. Kealey said.

The survey included information on 106 respondents who are nocturnists. These night workers have significantly fewer encounters, and work slightly fewer hours for slightly less money. Dr. Kealey noted that “when you cover nights, your productivity drops. This is good to know if you’re thinking about adding night coverage in your practice.”

The complete survey results should be available sometime in May, and information will be posted on the SHM Web site at www.hospitalmedicine.org.

Attendees at Hospital Medicine 2008 were the first to hear the results of the latest SHM survey of hospitalists, learning that hospitalist pay is up, roughly one-third of hospitalist leaders don’t know their groups’ expenses or fee revenues, and that financial support has grown substantially.

The society’s biannual survey of U.S. hospital medicine groups went to 1,700 of an estimated 2,200 groups in 2007. SHM Senior Vice President Joseph Miller and Burke Kealey, MD, chair of SHM’s Benchmarks Committee (which designed the survey) presented the findings from the “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement.”

“Our purpose is to provide a snapshot of hospital medicine at a moment in time for hospitalists and hospital medicine groups,” Miller said. “I think this is the best SHM survey ever conducted.”

Survey Basics

The survey drew a 24% response rate, gleaning information from 440 hospital medicine groups representing 3,242 individual hospitalists, as well as summary data from a separate survey sent to the nation’s largest hospital medicine groups. “We think it adds to the richness of the data,” explained Miller.

All data were collected between September and December 2007 and reflects information for the previous 12 months. Miller was careful to note that RVU values changed midway through that period.

Hospital medicine still is a young specialty, but, Miller said, “I think we’re seeing a growing experience base.” The median age of hospitalists is 37, with 3.7 years of mean experience. For leaders, the median age is 41, with 6.7 years of experience.

The State of HMGs

Today’s hospital medicine groups are growing, and so is the financial support they receive from hospitals.

“There has been significant growth in the number of [full-time employees] in hospital medicine groups,” Miller said. Since the previous survey two years ago, there is a 31% mean growth in groups. “We’re seeing fewer new groups, with more growth coming from the established groups” More groups are using nurse practitioners and/or physician assistants, up from 29% to 38%.

As for the leadership of the hospital medicine groups, the survey revealed some serious knowledge gaps. “Thirty-five to 37% of leaders did not know the finances of their groups,” Miller pointed out. This percentage—up somewhat from two years ago—could not answer survey questions on their group’s expenses or fee revenue.

The numbers of those who know where their money comes from show that hospitals (or partner institutions) are supplying more financial support now. A whopping 91% of responding programs receive money, with the total mean amount exceeding $97,000 per full-time physician. “This has increased substantially since the last survey,” Miller said.

Productivity and Pay

To ensure clarity of data, the survey breaks down compensation and productivity information for hospitalists into four separate groups: those who treat adult patients; those who treat pediatric patients; those who treat both; and nurse practitioners and physician assistants. In the session, Dr. Kealey covered only the first group.

He pointed out the strong correlation between the number of hours worked and higher productivity, and between higher productivity and higher compensation.

“Encounters have remained relatively flat,” he said. (They are down just 4% from the previous survey.) “But total compensation has increased by 13%.” In other words, hospitalists are working about the same amount they were two years ago, but are making more money—on average, $193,000.

Of the survey respondents, 25.3% are paid by straight salary; 6.1% are paid based on productivity, and the remainder earn a mix of salary and bonus.

Productivity figures show hospitalist experience pays off: Experienced hospitalists have more encounters in the same number of hours than their less-experienced counterparts. They also have higher compensation.

Another disturbing trend among hospitalist leaders is that they put in about as many clinical hours as nonleaders. “This indicates that they may not have enough time to lead,” Dr. Kealey said.

The survey included information on 106 respondents who are nocturnists. These night workers have significantly fewer encounters, and work slightly fewer hours for slightly less money. Dr. Kealey noted that “when you cover nights, your productivity drops. This is good to know if you’re thinking about adding night coverage in your practice.”

The complete survey results should be available sometime in May, and information will be posted on the SHM Web site at www.hospitalmedicine.org.

Three healthcare visionaries inspired attendees of SHM’s Annual Meeting with unique views of the future of U.S. healthcare and the role hospitalists can play in shaping a new model of efficient, high-quality care.

Meeting attendees were galvanized April 4 by Donald M. Berwick, MD, MPP, president and CEO of the Institute for Healthcare Improvement (IHI) and architect of the “100,000 Lives” and “5 Million Lives” campaigns. In his opening-day address “Improving Healthcare Quality and Value: Hospitalists and the Quality Revolution,” Dr. Berwick pointed out that physicians react to care problems by working harder and harder—but that the real solution must come from big-picture changes. Like his 12-year-old Subaru Outback, Dr. Berwick emphasized: “You have a top speed, and you can’t go beyond that. The system has to depend on interdependency, not on [individual] heroism.”

After setting the stage with data highlighting healthcare’s disparities and underperformance, Dr. Berwick unveiled the Triple Aim, a proposal that would fundamentally change U.S. healthcare. The Triple Aim goes beyond standard quality improvement and the concept of universal healthcare to target three areas: population health (preventive measures), experience of care (safety, efficiency, patient-centered care), and per-capita cost.

“We need to create a system that provides better care to all populations and controls the inflation of costs,” Dr. Berwick stressed. He said giant steps are needed to pursue the Triple Aim, including continued transparency, public health interventions, coordination of care, universal access, a financial management system, and an organization or consortium to act as integrator.

“There’s no question in my mind that hospitalists can participate,” said Dr. Berwick. “Can you help with Triple Aim? I’m not sure. You have to decide [your role]. Do you want to be contributors?”

From audience reaction, the answer seemed to be a resounding “yes.”

“His comments about the systemwide process versus a single doctor really rang true,” said attendee Arpi Bekmezian, MD, a pediatric hospitalist at University of California, Los Angeles. “Changing the system is the key to improving quality in a hospital because it’s such a large, crazy, intense institution.”

“Pimp My Ride” Care

On April 5, author, consultant, and healthcare futurist Ian Morrison, PhD, provided a thought-provoking look at healthcare flaws in “Hospitalists and the Future of Healthcare: The Quest for Value for All Americans.” Dr. Morrison terms our system “Pimp My Ride” healthcare. “We’re adding unbelievable amounts of technology on a frame that’s tired, old, and ineffective,” he asserted.

Dr. Morrison warned that Americans have worse health than their counterparts in other industrialized countries, and this trend is going to get worse.

“We have coming at us over the next two decades a triple tsunami of chronic care needs that will overwhelm our current health system,” he warned: obesity and its related conditions, cancer as a chronic condition, and depression. He pointed out that hospitalists must see a lot of hypertensive, obese, non-compliant, and diabetic patients. “When you see [these] patients, you’re seeing the failure of primary care,” he said.

The bottom line, according to Dr. Morrison, is progress will take great effort—and hospitalists can lead the charge: “Systems of healthcare need to be continually improved to deliver greater value. This will require clinical skills, process skills, the use of cutting-edge information technology and clinical technology. You’re right at the heart of that. We need new models of safer, more reliable, higher quality, more cost-effective care, and I think your profession can make a central contribution to that.”

Wachter’s “Mega-trends”

As is traditional at SHM meetings, Bob Wachter wrapped up the meeting with his insights on the present and future of hospital medicine. Dr. Wachter, who coined the term “hospitalist,” presented “Whipsawed: Can Hospitalists Survive in the Face of Co-Management, Non-Teaching Services, Transparency and the Reality of Perpetual Change.”

Dr. Wachter sees six “mega-trends” affecting hospital medicine:

1. Quality and value issues: “Even if payer pay-for-performance stalls out, local programs will grow,” he predicted. “When transparency increases, your CMO will start asking for accountability from the hospital medicine program. There will likely be a bonus scheme attached to this.”

2. Patient safety: “The emergence of state reporting systems is huge,” Wachter said. “I’m not sure if that’s good or not.” One key shift is the National Quality Forum’s list of 28 “never events,” or errors that are clearly identifiable, preventable, and serious for patients. “You’ll start to see more pressure from state bureaucrats on this.”

3. Information technology: The downside of enhanced technology, Wachter believes, is that “IT leads to dislocation of medicine. The physician relationships that are formed while we’re on the floor are gone.” Doctors can now complete their notes at home or in their office.

4. Co-management: There is massive growth in opportunities for co-managing patients. Dr. Wachter sees this as inevitable: “Don’t bother trying to not own it. It’s going to happen.”

5. ACGME regulations for teaching institutions: “We’ve seen the end of using residents as a cheap labor pools,” Dr. Wachter said. “Now academic hospitals have to figure out how to be like community hospitals.”

6. Work force issues: Tremendous growth requires comprehensive changes to how business is done. “Thriving now takes a new set of skills: leadership, change management, team building, and the skill to say ‘No’ or ‘Yes, if you can …’ ” said Dr. Wachter. Sharing those skills with your clinical hospitalists is imperative, he stressed: “Now, leadership and innovation must be everyone’s job. Your practice must become a bureaucracy.”

There is good news, Dr. Wachter stressed: “We’re in the driver’s seat. We can demand” what we need to survive and thrive.

Three healthcare visionaries inspired attendees of SHM’s Annual Meeting with unique views of the future of U.S. healthcare and the role hospitalists can play in shaping a new model of efficient, high-quality care.

Meeting attendees were galvanized April 4 by Donald M. Berwick, MD, MPP, president and CEO of the Institute for Healthcare Improvement (IHI) and architect of the “100,000 Lives” and “5 Million Lives” campaigns. In his opening-day address “Improving Healthcare Quality and Value: Hospitalists and the Quality Revolution,” Dr. Berwick pointed out that physicians react to care problems by working harder and harder—but that the real solution must come from big-picture changes. Like his 12-year-old Subaru Outback, Dr. Berwick emphasized: “You have a top speed, and you can’t go beyond that. The system has to depend on interdependency, not on [individual] heroism.”

After setting the stage with data highlighting healthcare’s disparities and underperformance, Dr. Berwick unveiled the Triple Aim, a proposal that would fundamentally change U.S. healthcare. The Triple Aim goes beyond standard quality improvement and the concept of universal healthcare to target three areas: population health (preventive measures), experience of care (safety, efficiency, patient-centered care), and per-capita cost.

“We need to create a system that provides better care to all populations and controls the inflation of costs,” Dr. Berwick stressed. He said giant steps are needed to pursue the Triple Aim, including continued transparency, public health interventions, coordination of care, universal access, a financial management system, and an organization or consortium to act as integrator.

“There’s no question in my mind that hospitalists can participate,” said Dr. Berwick. “Can you help with Triple Aim? I’m not sure. You have to decide [your role]. Do you want to be contributors?”

From audience reaction, the answer seemed to be a resounding “yes.”

“His comments about the systemwide process versus a single doctor really rang true,” said attendee Arpi Bekmezian, MD, a pediatric hospitalist at University of California, Los Angeles. “Changing the system is the key to improving quality in a hospital because it’s such a large, crazy, intense institution.”

“Pimp My Ride” Care

On April 5, author, consultant, and healthcare futurist Ian Morrison, PhD, provided a thought-provoking look at healthcare flaws in “Hospitalists and the Future of Healthcare: The Quest for Value for All Americans.” Dr. Morrison terms our system “Pimp My Ride” healthcare. “We’re adding unbelievable amounts of technology on a frame that’s tired, old, and ineffective,” he asserted.

Dr. Morrison warned that Americans have worse health than their counterparts in other industrialized countries, and this trend is going to get worse.

“We have coming at us over the next two decades a triple tsunami of chronic care needs that will overwhelm our current health system,” he warned: obesity and its related conditions, cancer as a chronic condition, and depression. He pointed out that hospitalists must see a lot of hypertensive, obese, non-compliant, and diabetic patients. “When you see [these] patients, you’re seeing the failure of primary care,” he said.

The bottom line, according to Dr. Morrison, is progress will take great effort—and hospitalists can lead the charge: “Systems of healthcare need to be continually improved to deliver greater value. This will require clinical skills, process skills, the use of cutting-edge information technology and clinical technology. You’re right at the heart of that. We need new models of safer, more reliable, higher quality, more cost-effective care, and I think your profession can make a central contribution to that.”

Wachter’s “Mega-trends”

As is traditional at SHM meetings, Bob Wachter wrapped up the meeting with his insights on the present and future of hospital medicine. Dr. Wachter, who coined the term “hospitalist,” presented “Whipsawed: Can Hospitalists Survive in the Face of Co-Management, Non-Teaching Services, Transparency and the Reality of Perpetual Change.”

Dr. Wachter sees six “mega-trends” affecting hospital medicine:

1. Quality and value issues: “Even if payer pay-for-performance stalls out, local programs will grow,” he predicted. “When transparency increases, your CMO will start asking for accountability from the hospital medicine program. There will likely be a bonus scheme attached to this.”

2. Patient safety: “The emergence of state reporting systems is huge,” Wachter said. “I’m not sure if that’s good or not.” One key shift is the National Quality Forum’s list of 28 “never events,” or errors that are clearly identifiable, preventable, and serious for patients. “You’ll start to see more pressure from state bureaucrats on this.”

3. Information technology: The downside of enhanced technology, Wachter believes, is that “IT leads to dislocation of medicine. The physician relationships that are formed while we’re on the floor are gone.” Doctors can now complete their notes at home or in their office.

4. Co-management: There is massive growth in opportunities for co-managing patients. Dr. Wachter sees this as inevitable: “Don’t bother trying to not own it. It’s going to happen.”

5. ACGME regulations for teaching institutions: “We’ve seen the end of using residents as a cheap labor pools,” Dr. Wachter said. “Now academic hospitals have to figure out how to be like community hospitals.”

6. Work force issues: Tremendous growth requires comprehensive changes to how business is done. “Thriving now takes a new set of skills: leadership, change management, team building, and the skill to say ‘No’ or ‘Yes, if you can …’ ” said Dr. Wachter. Sharing those skills with your clinical hospitalists is imperative, he stressed: “Now, leadership and innovation must be everyone’s job. Your practice must become a bureaucracy.”

There is good news, Dr. Wachter stressed: “We’re in the driver’s seat. We can demand” what we need to survive and thrive.

Three healthcare visionaries inspired attendees of SHM’s Annual Meeting with unique views of the future of U.S. healthcare and the role hospitalists can play in shaping a new model of efficient, high-quality care.

Meeting attendees were galvanized April 4 by Donald M. Berwick, MD, MPP, president and CEO of the Institute for Healthcare Improvement (IHI) and architect of the “100,000 Lives” and “5 Million Lives” campaigns. In his opening-day address “Improving Healthcare Quality and Value: Hospitalists and the Quality Revolution,” Dr. Berwick pointed out that physicians react to care problems by working harder and harder—but that the real solution must come from big-picture changes. Like his 12-year-old Subaru Outback, Dr. Berwick emphasized: “You have a top speed, and you can’t go beyond that. The system has to depend on interdependency, not on [individual] heroism.”

After setting the stage with data highlighting healthcare’s disparities and underperformance, Dr. Berwick unveiled the Triple Aim, a proposal that would fundamentally change U.S. healthcare. The Triple Aim goes beyond standard quality improvement and the concept of universal healthcare to target three areas: population health (preventive measures), experience of care (safety, efficiency, patient-centered care), and per-capita cost.

“We need to create a system that provides better care to all populations and controls the inflation of costs,” Dr. Berwick stressed. He said giant steps are needed to pursue the Triple Aim, including continued transparency, public health interventions, coordination of care, universal access, a financial management system, and an organization or consortium to act as integrator.

“There’s no question in my mind that hospitalists can participate,” said Dr. Berwick. “Can you help with Triple Aim? I’m not sure. You have to decide [your role]. Do you want to be contributors?”

From audience reaction, the answer seemed to be a resounding “yes.”

“His comments about the systemwide process versus a single doctor really rang true,” said attendee Arpi Bekmezian, MD, a pediatric hospitalist at University of California, Los Angeles. “Changing the system is the key to improving quality in a hospital because it’s such a large, crazy, intense institution.”

“Pimp My Ride” Care

On April 5, author, consultant, and healthcare futurist Ian Morrison, PhD, provided a thought-provoking look at healthcare flaws in “Hospitalists and the Future of Healthcare: The Quest for Value for All Americans.” Dr. Morrison terms our system “Pimp My Ride” healthcare. “We’re adding unbelievable amounts of technology on a frame that’s tired, old, and ineffective,” he asserted.

Dr. Morrison warned that Americans have worse health than their counterparts in other industrialized countries, and this trend is going to get worse.

“We have coming at us over the next two decades a triple tsunami of chronic care needs that will overwhelm our current health system,” he warned: obesity and its related conditions, cancer as a chronic condition, and depression. He pointed out that hospitalists must see a lot of hypertensive, obese, non-compliant, and diabetic patients. “When you see [these] patients, you’re seeing the failure of primary care,” he said.

The bottom line, according to Dr. Morrison, is progress will take great effort—and hospitalists can lead the charge: “Systems of healthcare need to be continually improved to deliver greater value. This will require clinical skills, process skills, the use of cutting-edge information technology and clinical technology. You’re right at the heart of that. We need new models of safer, more reliable, higher quality, more cost-effective care, and I think your profession can make a central contribution to that.”

Wachter’s “Mega-trends”

As is traditional at SHM meetings, Bob Wachter wrapped up the meeting with his insights on the present and future of hospital medicine. Dr. Wachter, who coined the term “hospitalist,” presented “Whipsawed: Can Hospitalists Survive in the Face of Co-Management, Non-Teaching Services, Transparency and the Reality of Perpetual Change.”

Dr. Wachter sees six “mega-trends” affecting hospital medicine:

1. Quality and value issues: “Even if payer pay-for-performance stalls out, local programs will grow,” he predicted. “When transparency increases, your CMO will start asking for accountability from the hospital medicine program. There will likely be a bonus scheme attached to this.”

2. Patient safety: “The emergence of state reporting systems is huge,” Wachter said. “I’m not sure if that’s good or not.” One key shift is the National Quality Forum’s list of 28 “never events,” or errors that are clearly identifiable, preventable, and serious for patients. “You’ll start to see more pressure from state bureaucrats on this.”

3. Information technology: The downside of enhanced technology, Wachter believes, is that “IT leads to dislocation of medicine. The physician relationships that are formed while we’re on the floor are gone.” Doctors can now complete their notes at home or in their office.

4. Co-management: There is massive growth in opportunities for co-managing patients. Dr. Wachter sees this as inevitable: “Don’t bother trying to not own it. It’s going to happen.”

5. ACGME regulations for teaching institutions: “We’ve seen the end of using residents as a cheap labor pools,” Dr. Wachter said. “Now academic hospitals have to figure out how to be like community hospitals.”

6. Work force issues: Tremendous growth requires comprehensive changes to how business is done. “Thriving now takes a new set of skills: leadership, change management, team building, and the skill to say ‘No’ or ‘Yes, if you can …’ ” said Dr. Wachter. Sharing those skills with your clinical hospitalists is imperative, he stressed: “Now, leadership and innovation must be everyone’s job. Your practice must become a bureaucracy.”

There is good news, Dr. Wachter stressed: “We’re in the driver’s seat. We can demand” what we need to survive and thrive.

Dr. Li

Hospitalists across the nation stand ready for a possible shortage of Baxter Healthcare Corporation-produced heparin, a blood thinner linked to 785 reported serious injuries and 19 deaths.

The initial January recall of multidose vials of the anticoagulant—used for surgery, dialysis and for the bedridden—broadened in February after magnetic resonance imaging tests uncovered that as much as 20% of the product’s active ingredient was a heparin mimic blended in with the actual product. The most serious injuries and death occurred in patients who received high doses of heparin during short periods of time.

The contaminant, an altered form of chondroitin sulfate, was identified in March.

Heparin is made from pig intestines. The raw product bought by the Waunaukee, Wis.-based Scientific Protein Laboratories was produced in small, unregulated family workshops in China and processed in plants in Wisconsin and China, according to heparin traders and producers in China. Baxter sells the finished product.

Pharmacist Gerard Barber of the University of Colorado Hospital sent an e-mail to staff there warning of the “erratic supply chain” caused by the heparin recall involving Baxter-produced heparin products.

“Ultimately there may be a true short supply of heparin, particularly when used subcutaneously for prophylaxis of DVTs—but we have managed to maintain an adequate supply of heparin product thus far,” he wrote in a March 7 e-mail.

Barber says the Department of Pharmacy has been aware of the situation since early February and took the added precaution of sequestering the product.

“Currently, we have managed to secure enough heparin product to avoid therapeutic interchanges to other heparin volumes (e.g., 5,000 units per 0.5 mL to 5,000 units per 1 mL) thus far,” he wrote.

Barber was still trying to procure “the same concentrations of heparin we’ve long used” in April.

“For as much heparin as all the [doctors] use, with the widened recall we’re particularly keeping an eye on other sizes (1,000 units/mL, 30 mL) for areas very, very dependent on the drug such as dialysis and perfusion for cardiothoracic surgery,” Barber says. “In areas like these it would be very difficult if at all possible to use alternative agents as we could if needed for DVTs and switching to low-molecular weight products.”

Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston, says it will be incumbent upon other manufacturers to “ramp up” production of the drug.

“Certainly, if hospitalists were unable to use unfractionated heparin, providers can reach for low molecular weight heparin [LMWH] products,” he says.

William D. Atchley Jr., MD, medical director of the Division of Hospital Medicine for the Sentara Medical Group in Norfolk, Va., agrees with Dr. Li that use of LMWH could be a viable alternative.

“The impact in our system has been directed by the clinical pharmacists,” he says when asked how his group is handling the recalls. “We have received no notification regarding heparin that we presently use.”

Baxter International Inc., announced Feb. 28 it would voluntarily recall all remaining lots and doses of its heparin sodium injection multidose and single-dose vials, as well as its HEP-LOCK heparin flush products, according to a press release posted on the U.S. Food and Drug Administration’s Web site.

On Jan. 17, the company initially recalled nine lots of heparin sodium injection multidose vials as a precautionary measure due to a “higher than usual number of reports of adverse patient reactions,” the release noted.

Nearly all adverse reactions were seen in patients receiving high doses of heparin during short periods of time. Reactions patients reported included difficulty breathing, nausea, vomiting, excessive sweating, and rapidly falling blood pressure, which in some cases led to life-threatening shock. Such reactions were not seen in patients receiving lower doses of the drug or those who received higher doses over longer periods. TH

Molly R. Okeon is a journalist based in California.

Dr. Li

Hospitalists across the nation stand ready for a possible shortage of Baxter Healthcare Corporation-produced heparin, a blood thinner linked to 785 reported serious injuries and 19 deaths.

The initial January recall of multidose vials of the anticoagulant—used for surgery, dialysis and for the bedridden—broadened in February after magnetic resonance imaging tests uncovered that as much as 20% of the product’s active ingredient was a heparin mimic blended in with the actual product. The most serious injuries and death occurred in patients who received high doses of heparin during short periods of time.

The contaminant, an altered form of chondroitin sulfate, was identified in March.

Heparin is made from pig intestines. The raw product bought by the Waunaukee, Wis.-based Scientific Protein Laboratories was produced in small, unregulated family workshops in China and processed in plants in Wisconsin and China, according to heparin traders and producers in China. Baxter sells the finished product.

Pharmacist Gerard Barber of the University of Colorado Hospital sent an e-mail to staff there warning of the “erratic supply chain” caused by the heparin recall involving Baxter-produced heparin products.

“Ultimately there may be a true short supply of heparin, particularly when used subcutaneously for prophylaxis of DVTs—but we have managed to maintain an adequate supply of heparin product thus far,” he wrote in a March 7 e-mail.

Barber says the Department of Pharmacy has been aware of the situation since early February and took the added precaution of sequestering the product.

“Currently, we have managed to secure enough heparin product to avoid therapeutic interchanges to other heparin volumes (e.g., 5,000 units per 0.5 mL to 5,000 units per 1 mL) thus far,” he wrote.

Barber was still trying to procure “the same concentrations of heparin we’ve long used” in April.

“For as much heparin as all the [doctors] use, with the widened recall we’re particularly keeping an eye on other sizes (1,000 units/mL, 30 mL) for areas very, very dependent on the drug such as dialysis and perfusion for cardiothoracic surgery,” Barber says. “In areas like these it would be very difficult if at all possible to use alternative agents as we could if needed for DVTs and switching to low-molecular weight products.”

Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston, says it will be incumbent upon other manufacturers to “ramp up” production of the drug.

“Certainly, if hospitalists were unable to use unfractionated heparin, providers can reach for low molecular weight heparin [LMWH] products,” he says.

William D. Atchley Jr., MD, medical director of the Division of Hospital Medicine for the Sentara Medical Group in Norfolk, Va., agrees with Dr. Li that use of LMWH could be a viable alternative.

“The impact in our system has been directed by the clinical pharmacists,” he says when asked how his group is handling the recalls. “We have received no notification regarding heparin that we presently use.”

Baxter International Inc., announced Feb. 28 it would voluntarily recall all remaining lots and doses of its heparin sodium injection multidose and single-dose vials, as well as its HEP-LOCK heparin flush products, according to a press release posted on the U.S. Food and Drug Administration’s Web site.

On Jan. 17, the company initially recalled nine lots of heparin sodium injection multidose vials as a precautionary measure due to a “higher than usual number of reports of adverse patient reactions,” the release noted.

Nearly all adverse reactions were seen in patients receiving high doses of heparin during short periods of time. Reactions patients reported included difficulty breathing, nausea, vomiting, excessive sweating, and rapidly falling blood pressure, which in some cases led to life-threatening shock. Such reactions were not seen in patients receiving lower doses of the drug or those who received higher doses over longer periods. TH

Molly R. Okeon is a journalist based in California.

Dr. Li

Hospitalists across the nation stand ready for a possible shortage of Baxter Healthcare Corporation-produced heparin, a blood thinner linked to 785 reported serious injuries and 19 deaths.

The initial January recall of multidose vials of the anticoagulant—used for surgery, dialysis and for the bedridden—broadened in February after magnetic resonance imaging tests uncovered that as much as 20% of the product’s active ingredient was a heparin mimic blended in with the actual product. The most serious injuries and death occurred in patients who received high doses of heparin during short periods of time.

The contaminant, an altered form of chondroitin sulfate, was identified in March.

Heparin is made from pig intestines. The raw product bought by the Waunaukee, Wis.-based Scientific Protein Laboratories was produced in small, unregulated family workshops in China and processed in plants in Wisconsin and China, according to heparin traders and producers in China. Baxter sells the finished product.

Pharmacist Gerard Barber of the University of Colorado Hospital sent an e-mail to staff there warning of the “erratic supply chain” caused by the heparin recall involving Baxter-produced heparin products.

“Ultimately there may be a true short supply of heparin, particularly when used subcutaneously for prophylaxis of DVTs—but we have managed to maintain an adequate supply of heparin product thus far,” he wrote in a March 7 e-mail.

Barber says the Department of Pharmacy has been aware of the situation since early February and took the added precaution of sequestering the product.

“Currently, we have managed to secure enough heparin product to avoid therapeutic interchanges to other heparin volumes (e.g., 5,000 units per 0.5 mL to 5,000 units per 1 mL) thus far,” he wrote.

Barber was still trying to procure “the same concentrations of heparin we’ve long used” in April.

“For as much heparin as all the [doctors] use, with the widened recall we’re particularly keeping an eye on other sizes (1,000 units/mL, 30 mL) for areas very, very dependent on the drug such as dialysis and perfusion for cardiothoracic surgery,” Barber says. “In areas like these it would be very difficult if at all possible to use alternative agents as we could if needed for DVTs and switching to low-molecular weight products.”

Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston, says it will be incumbent upon other manufacturers to “ramp up” production of the drug.

“Certainly, if hospitalists were unable to use unfractionated heparin, providers can reach for low molecular weight heparin [LMWH] products,” he says.

William D. Atchley Jr., MD, medical director of the Division of Hospital Medicine for the Sentara Medical Group in Norfolk, Va., agrees with Dr. Li that use of LMWH could be a viable alternative.

“The impact in our system has been directed by the clinical pharmacists,” he says when asked how his group is handling the recalls. “We have received no notification regarding heparin that we presently use.”

Baxter International Inc., announced Feb. 28 it would voluntarily recall all remaining lots and doses of its heparin sodium injection multidose and single-dose vials, as well as its HEP-LOCK heparin flush products, according to a press release posted on the U.S. Food and Drug Administration’s Web site.

On Jan. 17, the company initially recalled nine lots of heparin sodium injection multidose vials as a precautionary measure due to a “higher than usual number of reports of adverse patient reactions,” the release noted.

Nearly all adverse reactions were seen in patients receiving high doses of heparin during short periods of time. Reactions patients reported included difficulty breathing, nausea, vomiting, excessive sweating, and rapidly falling blood pressure, which in some cases led to life-threatening shock. Such reactions were not seen in patients receiving lower doses of the drug or those who received higher doses over longer periods. TH

Molly R. Okeon is a journalist based in California.

In a few months, Medicare will begin denying reimbursement for certain conditions if they’re acquired in the hospital. Hospitalist groups are working against the clock to refine their screening methods to better document when those conditions exist on admission.

Hospitalist groups are also implementing more vigilant checks on admitted patients to make sure those complications—such as bed sores and line infections—are less likely to develop.

The new rules for the In-patient Prospective Payment System (IPPS) name eight conditions, from injuries during a fall to an object left in a surgical patient, that Medicare no longer will pay for. More conditions will be added the following year. The changes also establish 745 new Medicare severity-adjusted diagnosis-related groups (MSDRGs), replacing the current 538.

The changes, ordered by the Centers for Medicare and Medicaid Services (CMS), won’t restrict payment until Oct. 1; coding changes went into effect in October 2007. Coding not only affects payment but also allows for public reporting of hospital performance.

What They’re Doing

“Hospitalists are in an extraordinarily crucial position to help their facilities prepare and manage the new MSDRGs and pay-for-performance models that are being rolled out,” says James S. Kennedy, MD. He is a director with FTI Healthcare in Atlanta and author of the book Severity DRGs and Reimbursement: An MS-DRG Primer, published by the American Health Information Management Association.

Hospitalists “have a tremendous amount of in-patient hospital volume and they can better standardize their approaches,” clearing the way for other medical workers, he says.

He suggests designating one hospitalist per group to develop a working knowledge of ICD-9-CM codes and DRGs and serve as a physician adviser to the coding department.

“It has to be clear to the coder whether or not every condition that was documented by a physician was present on admission or not,” Dr. Kennedy points out.

It makes sense that CMS would order these changes in reimbursement, says Patrick Torcson, MD, chairman of SHM’s Performance and Standards Committee, and medical director for the hospitalist program St. Tammany Parish Hospital in Covington, La.

“With preventable conditions acquired in the hospital, there’s this perverse incentive that hospitals can get more money when complications occur,” Dr. Torcson says.

How are hospitalist groups preparing for these changes? At St. Tammany, there’s a new emphasis on educating hospitalists on documentation to note those present-on-admission indicators (POAIs). Dictation templates now include reminders to note that data. Also, multidisciplinary rounding that’s been effective in the intensive-care unit is being extended to general medical floors.

“There might be the tendency to just order more tests at the time of hospital admission,” Dr. Torcson points out. “Our group is going to avoid going down the track of ordering a urinalysis on every patient admitted, for example, just to rule out a urinary tract infection. We’re going to emphasize clinical judgment on a case-by-case basis.”

For hospital groups with high-risk populations, more testing may be exactly what’s needed. Randy Ferrance, DC, MD, a hospitalist at Riverside Tappahannock Hospital in Virginia, says the average age of his patients is about 70.

“We are doing a lot more screening and urinalysis than we used to do,” Dr. Ferrance says. “Nearly everyone is getting urinalysis, if they have any risk factors at all.”

The group of about four full-time hospitalists also relies more on nurses to note in patients’ charts any skin abnormalities so they can be prevented from developing into sores. The nurses are also “developing criteria for who we consider to be a high risk for decubitus ulcers,” Dr. Ferrance says. “We’re lowering the threshold for what we consider to be high risk.”

The group just revised its history-and-physical template to include more prompts, reminding the admitting physician to check for these POAIs.

Reminders like that coupled with the right technology can make it easier for hospitalists to capture all this information, says Brian Harte, MD, acting chairman of the Department of Hospital Medicine at the Cleveland Clinic, and a member of SHM’s Hospital Quality and Patient Safety Committee.

“What we will be doing is looking at ways to include this primarily into our electronic documentation,” Dr. Harte says. “[We’re] finding a way to cue people so that the default is to think about them, to answer ‘yes’ or ‘no’ to these conditions.”

He recommends giving physicians and nurses plenty of opportunities to note conditions—and not just by adding “pop-up” reminders in electronic records, which, he points out, can start looking like a Web site without ad blockers.

About two years ago, Beth Israel Deaconess Medical Center in Boston was trying to determine how central lines were becoming infected. It was discovered the facility didn’t have a system to record who had placed the lines.

“We wanted a smaller group of providers doing a higher volume of lines, with the belief that if we trained these people and helped them understand, we could minimize the variation of putting in the lines, and we could change the outcome,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess.

The hospital now has a nurse dedicated to checking the lines every day. It also designates skin-care nurses who regularly check for pressure ulcers.

Understanding the motivations behind the changes in IPPS will go a long way toward helping hospitalists adapt to them and provide better care, asserts Dr. Li, a member of the SHM Board of Directors.

“Of course we never want to leave something by accident inside a patient,” Dr. Li says. But less dramatic complications, like bedsores, can start to seem routine. “I think what happens over time is people get dulled to it,” he says. “They begin to believe it’s OK to have pressure ulcers, and it’s never OK.”

Difficulties

For all the good intentions behind CMS’s changes, it might be problematic for hospitalists to screen for the conditions CMS selected, says Heidi Wald, MD, MSPH, assistant professor of medicine at the University of Colorado, Denver, School of Medicine. Dr. Wald co-wrote a commentary called “Nonpayment for Harms Resulting from Medical Care” in the December 2007 Journal of the American Medical Association (JAMA).

A diagnosis can be coded as present on admission, not present on admission, unable to determine because the documentation was lacking, or unable to clinically say, Dr. Wald notes. She wants more information from CMS’s pilot studies, and says it remains to be seen how efficient the changes will be in practice.

For an example of how things can get complicated, Dr. Wald suggests a hypothetical situation: A patient comes to the emergency department with chest pain, is admitted to the hospital, receives a catheter, develops a fever, and is found in a subsequent urinalysis to have a urinary tract infection (UTI).

“Did the ED doc screen for a UTI on admission?” Dr. Wald asks. “Probably not. It would be ‘clinically unable to determine,’ from the way I’m reading it, because they didn’t have testing on admission. So in this case, it would behoove you not to screen.”

Dr. Wald praises CMS for giving hospitals a financial reason to focus on complications. She’s happy to see an increase in awareness of nosocomial infections.

“This is the right thing for hospitals to be doing, to find out ways to improve practice and to decrease infectious complications,” she notes. “I think the financial incentive is a way to push the cultural change along.”

Temple University in Philadelphia, which has about 25 hospitalists in its group, hopes to roll out formal changes in its policies in late spring or early summer, says William Ford, MD, program medical director of Cogent Healthcare and chief of the section of hospital medicine at Temple.

His hospitalists’ monthly meeting will include a regular, five-minute presentation on a topic in emergency medicine that pertains to the CMS changes, Dr. Ford says. It also will be part of their monthly journal meetings.

The goal is to make three of the conditions—UTIs, blood infections, and ulcers—part of physicians’ daily assessment, keeping it uppermost in their minds to continually evaluate the need for treatments such as Foley catheters or central lines.

Sometimes “three days go by and the doctor doesn’t think, because he or she is treating other parts of their illness, ‘Do they still need that Foley catheter, do they still need that IV?’ ” Dr. Ford notes. “If the patient does not need those two modalities, discontinue them … because those are two big causes for infection.”

Early Reaction

While the changes are incentive to be more attentive to detail, Dr. Ferrance wonders whether there could be a down side.

“I’ll be honest and admit I didn’t catch every single Stage 1 decubitus ulcer on every patient I admitted,” he says. “Now I’m much more vigilant.” Still, he adds: “It increases the paperwork burden, and it adds to the nonpatient part of our day. I have to wonder if the increased burden of paperwork pays off in that much benefit to the patient.”

And pressure is building. Insurers Aetna Inc. and WellPoint Inc. are following Medicare’s example, moving to end payment for some of the most serious hospital errors. Other major insurers are investigating changing their policies.

The public also cares quite a bit about the issue, Dr. Wald notes. When a New York Times blog mentioned Dr. Wald’s JAMA article, readers left scores of comments. Some were stunned to hear hospitals can be paid extra when complications occur.

Professional societies and organizations can help medical centers adjust to these changes by providing guidance and leadership, suggests Dr. Li. Hospitals will benefit by educating all providers about the system changes and the reasons behind them, he says.

“This is about a lot more than the doctor and the patient,” he argues. “This is about changing the culture and institution.” TH

Liz Tascio is a medical journalist based in New York.

In a few months, Medicare will begin denying reimbursement for certain conditions if they’re acquired in the hospital. Hospitalist groups are working against the clock to refine their screening methods to better document when those conditions exist on admission.

Hospitalist groups are also implementing more vigilant checks on admitted patients to make sure those complications—such as bed sores and line infections—are less likely to develop.

The new rules for the In-patient Prospective Payment System (IPPS) name eight conditions, from injuries during a fall to an object left in a surgical patient, that Medicare no longer will pay for. More conditions will be added the following year. The changes also establish 745 new Medicare severity-adjusted diagnosis-related groups (MSDRGs), replacing the current 538.

The changes, ordered by the Centers for Medicare and Medicaid Services (CMS), won’t restrict payment until Oct. 1; coding changes went into effect in October 2007. Coding not only affects payment but also allows for public reporting of hospital performance.

What They’re Doing

“Hospitalists are in an extraordinarily crucial position to help their facilities prepare and manage the new MSDRGs and pay-for-performance models that are being rolled out,” says James S. Kennedy, MD. He is a director with FTI Healthcare in Atlanta and author of the book Severity DRGs and Reimbursement: An MS-DRG Primer, published by the American Health Information Management Association.

Hospitalists “have a tremendous amount of in-patient hospital volume and they can better standardize their approaches,” clearing the way for other medical workers, he says.

He suggests designating one hospitalist per group to develop a working knowledge of ICD-9-CM codes and DRGs and serve as a physician adviser to the coding department.

“It has to be clear to the coder whether or not every condition that was documented by a physician was present on admission or not,” Dr. Kennedy points out.

It makes sense that CMS would order these changes in reimbursement, says Patrick Torcson, MD, chairman of SHM’s Performance and Standards Committee, and medical director for the hospitalist program St. Tammany Parish Hospital in Covington, La.

“With preventable conditions acquired in the hospital, there’s this perverse incentive that hospitals can get more money when complications occur,” Dr. Torcson says.

How are hospitalist groups preparing for these changes? At St. Tammany, there’s a new emphasis on educating hospitalists on documentation to note those present-on-admission indicators (POAIs). Dictation templates now include reminders to note that data. Also, multidisciplinary rounding that’s been effective in the intensive-care unit is being extended to general medical floors.

“There might be the tendency to just order more tests at the time of hospital admission,” Dr. Torcson points out. “Our group is going to avoid going down the track of ordering a urinalysis on every patient admitted, for example, just to rule out a urinary tract infection. We’re going to emphasize clinical judgment on a case-by-case basis.”

For hospital groups with high-risk populations, more testing may be exactly what’s needed. Randy Ferrance, DC, MD, a hospitalist at Riverside Tappahannock Hospital in Virginia, says the average age of his patients is about 70.

“We are doing a lot more screening and urinalysis than we used to do,” Dr. Ferrance says. “Nearly everyone is getting urinalysis, if they have any risk factors at all.”

The group of about four full-time hospitalists also relies more on nurses to note in patients’ charts any skin abnormalities so they can be prevented from developing into sores. The nurses are also “developing criteria for who we consider to be a high risk for decubitus ulcers,” Dr. Ferrance says. “We’re lowering the threshold for what we consider to be high risk.”

The group just revised its history-and-physical template to include more prompts, reminding the admitting physician to check for these POAIs.

Reminders like that coupled with the right technology can make it easier for hospitalists to capture all this information, says Brian Harte, MD, acting chairman of the Department of Hospital Medicine at the Cleveland Clinic, and a member of SHM’s Hospital Quality and Patient Safety Committee.

“What we will be doing is looking at ways to include this primarily into our electronic documentation,” Dr. Harte says. “[We’re] finding a way to cue people so that the default is to think about them, to answer ‘yes’ or ‘no’ to these conditions.”

He recommends giving physicians and nurses plenty of opportunities to note conditions—and not just by adding “pop-up” reminders in electronic records, which, he points out, can start looking like a Web site without ad blockers.

About two years ago, Beth Israel Deaconess Medical Center in Boston was trying to determine how central lines were becoming infected. It was discovered the facility didn’t have a system to record who had placed the lines.

“We wanted a smaller group of providers doing a higher volume of lines, with the belief that if we trained these people and helped them understand, we could minimize the variation of putting in the lines, and we could change the outcome,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess.

The hospital now has a nurse dedicated to checking the lines every day. It also designates skin-care nurses who regularly check for pressure ulcers.

Understanding the motivations behind the changes in IPPS will go a long way toward helping hospitalists adapt to them and provide better care, asserts Dr. Li, a member of the SHM Board of Directors.

“Of course we never want to leave something by accident inside a patient,” Dr. Li says. But less dramatic complications, like bedsores, can start to seem routine. “I think what happens over time is people get dulled to it,” he says. “They begin to believe it’s OK to have pressure ulcers, and it’s never OK.”

Difficulties

For all the good intentions behind CMS’s changes, it might be problematic for hospitalists to screen for the conditions CMS selected, says Heidi Wald, MD, MSPH, assistant professor of medicine at the University of Colorado, Denver, School of Medicine. Dr. Wald co-wrote a commentary called “Nonpayment for Harms Resulting from Medical Care” in the December 2007 Journal of the American Medical Association (JAMA).

A diagnosis can be coded as present on admission, not present on admission, unable to determine because the documentation was lacking, or unable to clinically say, Dr. Wald notes. She wants more information from CMS’s pilot studies, and says it remains to be seen how efficient the changes will be in practice.

For an example of how things can get complicated, Dr. Wald suggests a hypothetical situation: A patient comes to the emergency department with chest pain, is admitted to the hospital, receives a catheter, develops a fever, and is found in a subsequent urinalysis to have a urinary tract infection (UTI).

“Did the ED doc screen for a UTI on admission?” Dr. Wald asks. “Probably not. It would be ‘clinically unable to determine,’ from the way I’m reading it, because they didn’t have testing on admission. So in this case, it would behoove you not to screen.”

Dr. Wald praises CMS for giving hospitals a financial reason to focus on complications. She’s happy to see an increase in awareness of nosocomial infections.

“This is the right thing for hospitals to be doing, to find out ways to improve practice and to decrease infectious complications,” she notes. “I think the financial incentive is a way to push the cultural change along.”

Temple University in Philadelphia, which has about 25 hospitalists in its group, hopes to roll out formal changes in its policies in late spring or early summer, says William Ford, MD, program medical director of Cogent Healthcare and chief of the section of hospital medicine at Temple.

His hospitalists’ monthly meeting will include a regular, five-minute presentation on a topic in emergency medicine that pertains to the CMS changes, Dr. Ford says. It also will be part of their monthly journal meetings.

The goal is to make three of the conditions—UTIs, blood infections, and ulcers—part of physicians’ daily assessment, keeping it uppermost in their minds to continually evaluate the need for treatments such as Foley catheters or central lines.

Sometimes “three days go by and the doctor doesn’t think, because he or she is treating other parts of their illness, ‘Do they still need that Foley catheter, do they still need that IV?’ ” Dr. Ford notes. “If the patient does not need those two modalities, discontinue them … because those are two big causes for infection.”

Early Reaction

While the changes are incentive to be more attentive to detail, Dr. Ferrance wonders whether there could be a down side.

“I’ll be honest and admit I didn’t catch every single Stage 1 decubitus ulcer on every patient I admitted,” he says. “Now I’m much more vigilant.” Still, he adds: “It increases the paperwork burden, and it adds to the nonpatient part of our day. I have to wonder if the increased burden of paperwork pays off in that much benefit to the patient.”

And pressure is building. Insurers Aetna Inc. and WellPoint Inc. are following Medicare’s example, moving to end payment for some of the most serious hospital errors. Other major insurers are investigating changing their policies.

The public also cares quite a bit about the issue, Dr. Wald notes. When a New York Times blog mentioned Dr. Wald’s JAMA article, readers left scores of comments. Some were stunned to hear hospitals can be paid extra when complications occur.

Professional societies and organizations can help medical centers adjust to these changes by providing guidance and leadership, suggests Dr. Li. Hospitals will benefit by educating all providers about the system changes and the reasons behind them, he says.

“This is about a lot more than the doctor and the patient,” he argues. “This is about changing the culture and institution.” TH

Liz Tascio is a medical journalist based in New York.

In a few months, Medicare will begin denying reimbursement for certain conditions if they’re acquired in the hospital. Hospitalist groups are working against the clock to refine their screening methods to better document when those conditions exist on admission.

Hospitalist groups are also implementing more vigilant checks on admitted patients to make sure those complications—such as bed sores and line infections—are less likely to develop.

The new rules for the In-patient Prospective Payment System (IPPS) name eight conditions, from injuries during a fall to an object left in a surgical patient, that Medicare no longer will pay for. More conditions will be added the following year. The changes also establish 745 new Medicare severity-adjusted diagnosis-related groups (MSDRGs), replacing the current 538.

The changes, ordered by the Centers for Medicare and Medicaid Services (CMS), won’t restrict payment until Oct. 1; coding changes went into effect in October 2007. Coding not only affects payment but also allows for public reporting of hospital performance.

What They’re Doing

“Hospitalists are in an extraordinarily crucial position to help their facilities prepare and manage the new MSDRGs and pay-for-performance models that are being rolled out,” says James S. Kennedy, MD. He is a director with FTI Healthcare in Atlanta and author of the book Severity DRGs and Reimbursement: An MS-DRG Primer, published by the American Health Information Management Association.

Hospitalists “have a tremendous amount of in-patient hospital volume and they can better standardize their approaches,” clearing the way for other medical workers, he says.

He suggests designating one hospitalist per group to develop a working knowledge of ICD-9-CM codes and DRGs and serve as a physician adviser to the coding department.

“It has to be clear to the coder whether or not every condition that was documented by a physician was present on admission or not,” Dr. Kennedy points out.

It makes sense that CMS would order these changes in reimbursement, says Patrick Torcson, MD, chairman of SHM’s Performance and Standards Committee, and medical director for the hospitalist program St. Tammany Parish Hospital in Covington, La.

“With preventable conditions acquired in the hospital, there’s this perverse incentive that hospitals can get more money when complications occur,” Dr. Torcson says.

How are hospitalist groups preparing for these changes? At St. Tammany, there’s a new emphasis on educating hospitalists on documentation to note those present-on-admission indicators (POAIs). Dictation templates now include reminders to note that data. Also, multidisciplinary rounding that’s been effective in the intensive-care unit is being extended to general medical floors.

“There might be the tendency to just order more tests at the time of hospital admission,” Dr. Torcson points out. “Our group is going to avoid going down the track of ordering a urinalysis on every patient admitted, for example, just to rule out a urinary tract infection. We’re going to emphasize clinical judgment on a case-by-case basis.”

For hospital groups with high-risk populations, more testing may be exactly what’s needed. Randy Ferrance, DC, MD, a hospitalist at Riverside Tappahannock Hospital in Virginia, says the average age of his patients is about 70.

“We are doing a lot more screening and urinalysis than we used to do,” Dr. Ferrance says. “Nearly everyone is getting urinalysis, if they have any risk factors at all.”

The group of about four full-time hospitalists also relies more on nurses to note in patients’ charts any skin abnormalities so they can be prevented from developing into sores. The nurses are also “developing criteria for who we consider to be a high risk for decubitus ulcers,” Dr. Ferrance says. “We’re lowering the threshold for what we consider to be high risk.”

The group just revised its history-and-physical template to include more prompts, reminding the admitting physician to check for these POAIs.

Reminders like that coupled with the right technology can make it easier for hospitalists to capture all this information, says Brian Harte, MD, acting chairman of the Department of Hospital Medicine at the Cleveland Clinic, and a member of SHM’s Hospital Quality and Patient Safety Committee.

“What we will be doing is looking at ways to include this primarily into our electronic documentation,” Dr. Harte says. “[We’re] finding a way to cue people so that the default is to think about them, to answer ‘yes’ or ‘no’ to these conditions.”

He recommends giving physicians and nurses plenty of opportunities to note conditions—and not just by adding “pop-up” reminders in electronic records, which, he points out, can start looking like a Web site without ad blockers.

About two years ago, Beth Israel Deaconess Medical Center in Boston was trying to determine how central lines were becoming infected. It was discovered the facility didn’t have a system to record who had placed the lines.

“We wanted a smaller group of providers doing a higher volume of lines, with the belief that if we trained these people and helped them understand, we could minimize the variation of putting in the lines, and we could change the outcome,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess.

The hospital now has a nurse dedicated to checking the lines every day. It also designates skin-care nurses who regularly check for pressure ulcers.

Understanding the motivations behind the changes in IPPS will go a long way toward helping hospitalists adapt to them and provide better care, asserts Dr. Li, a member of the SHM Board of Directors.

“Of course we never want to leave something by accident inside a patient,” Dr. Li says. But less dramatic complications, like bedsores, can start to seem routine. “I think what happens over time is people get dulled to it,” he says. “They begin to believe it’s OK to have pressure ulcers, and it’s never OK.”

Difficulties

For all the good intentions behind CMS’s changes, it might be problematic for hospitalists to screen for the conditions CMS selected, says Heidi Wald, MD, MSPH, assistant professor of medicine at the University of Colorado, Denver, School of Medicine. Dr. Wald co-wrote a commentary called “Nonpayment for Harms Resulting from Medical Care” in the December 2007 Journal of the American Medical Association (JAMA).

A diagnosis can be coded as present on admission, not present on admission, unable to determine because the documentation was lacking, or unable to clinically say, Dr. Wald notes. She wants more information from CMS’s pilot studies, and says it remains to be seen how efficient the changes will be in practice.

For an example of how things can get complicated, Dr. Wald suggests a hypothetical situation: A patient comes to the emergency department with chest pain, is admitted to the hospital, receives a catheter, develops a fever, and is found in a subsequent urinalysis to have a urinary tract infection (UTI).

“Did the ED doc screen for a UTI on admission?” Dr. Wald asks. “Probably not. It would be ‘clinically unable to determine,’ from the way I’m reading it, because they didn’t have testing on admission. So in this case, it would behoove you not to screen.”

Dr. Wald praises CMS for giving hospitals a financial reason to focus on complications. She’s happy to see an increase in awareness of nosocomial infections.

“This is the right thing for hospitals to be doing, to find out ways to improve practice and to decrease infectious complications,” she notes. “I think the financial incentive is a way to push the cultural change along.”

Temple University in Philadelphia, which has about 25 hospitalists in its group, hopes to roll out formal changes in its policies in late spring or early summer, says William Ford, MD, program medical director of Cogent Healthcare and chief of the section of hospital medicine at Temple.

His hospitalists’ monthly meeting will include a regular, five-minute presentation on a topic in emergency medicine that pertains to the CMS changes, Dr. Ford says. It also will be part of their monthly journal meetings.

The goal is to make three of the conditions—UTIs, blood infections, and ulcers—part of physicians’ daily assessment, keeping it uppermost in their minds to continually evaluate the need for treatments such as Foley catheters or central lines.

Sometimes “three days go by and the doctor doesn’t think, because he or she is treating other parts of their illness, ‘Do they still need that Foley catheter, do they still need that IV?’ ” Dr. Ford notes. “If the patient does not need those two modalities, discontinue them … because those are two big causes for infection.”

Early Reaction

While the changes are incentive to be more attentive to detail, Dr. Ferrance wonders whether there could be a down side.

“I’ll be honest and admit I didn’t catch every single Stage 1 decubitus ulcer on every patient I admitted,” he says. “Now I’m much more vigilant.” Still, he adds: “It increases the paperwork burden, and it adds to the nonpatient part of our day. I have to wonder if the increased burden of paperwork pays off in that much benefit to the patient.”

And pressure is building. Insurers Aetna Inc. and WellPoint Inc. are following Medicare’s example, moving to end payment for some of the most serious hospital errors. Other major insurers are investigating changing their policies.

The public also cares quite a bit about the issue, Dr. Wald notes. When a New York Times blog mentioned Dr. Wald’s JAMA article, readers left scores of comments. Some were stunned to hear hospitals can be paid extra when complications occur.

Professional societies and organizations can help medical centers adjust to these changes by providing guidance and leadership, suggests Dr. Li. Hospitals will benefit by educating all providers about the system changes and the reasons behind them, he says.

“This is about a lot more than the doctor and the patient,” he argues. “This is about changing the culture and institution.” TH

Liz Tascio is a medical journalist based in New York.