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You are one of the best representatives of the hospital medicine movement. You can share your enthusiasm for the specialty and for improving the care of hospitalized patients by telling others about SHM.

And, as an added bonus, you can earn credit toward SHM membership dues.

Through the end of the year, all active SHM members can earn 2016-2017 dues credits and special recognition for recruiting new physician, physician assistant, nurse practitioner, pharmacist, or affiliate members.

Active members will be eligible for:

• A $35 credit toward 2016-2017 dues when recruiting one new member;
• A $50 credit toward 2016-2017 dues when recruiting 2-4 new members;
• A $75 credit toward 2016-2017 dues when recruiting 5-9 new members; or
• A $125 credit toward 2016-2017 dues when recruiting 10+ new members.

For every member recruited, individuals will receive one entry into a grand prize drawing to receive complimentary registration to HM16 in San Diego.

Click here for more details.

You are one of the best representatives of the hospital medicine movement. You can share your enthusiasm for the specialty and for improving the care of hospitalized patients by telling others about SHM.

And, as an added bonus, you can earn credit toward SHM membership dues.

Through the end of the year, all active SHM members can earn 2016-2017 dues credits and special recognition for recruiting new physician, physician assistant, nurse practitioner, pharmacist, or affiliate members.

Active members will be eligible for:

• A $35 credit toward 2016-2017 dues when recruiting one new member;
• A $50 credit toward 2016-2017 dues when recruiting 2-4 new members;
• A $75 credit toward 2016-2017 dues when recruiting 5-9 new members; or
• A $125 credit toward 2016-2017 dues when recruiting 10+ new members.

For every member recruited, individuals will receive one entry into a grand prize drawing to receive complimentary registration to HM16 in San Diego.

Click here for more details.

You are one of the best representatives of the hospital medicine movement. You can share your enthusiasm for the specialty and for improving the care of hospitalized patients by telling others about SHM.

And, as an added bonus, you can earn credit toward SHM membership dues.

Through the end of the year, all active SHM members can earn 2016-2017 dues credits and special recognition for recruiting new physician, physician assistant, nurse practitioner, pharmacist, or affiliate members.

Active members will be eligible for:

• A $35 credit toward 2016-2017 dues when recruiting one new member;
• A $50 credit toward 2016-2017 dues when recruiting 2-4 new members;
• A $75 credit toward 2016-2017 dues when recruiting 5-9 new members; or
• A $125 credit toward 2016-2017 dues when recruiting 10+ new members.

For every member recruited, individuals will receive one entry into a grand prize drawing to receive complimentary registration to HM16 in San Diego.

Click here for more details.

Are you ready to shape the future of the hospital medicine movement? Now is the time to step up by nominating yourself or someone else for SHM’s many leadership and recognition opportunities. But act quickly. The deadline for many of them is October 16. You can help lead the movement and earn recognition through:

• Nominating yourself or a colleague for one of SHM’s Awards of Excellence, which will be presented at HM16 in San Diego;
• Joining a committee that matches your professional interests or personal passions;
• Applying for SHM’s board of directors; or
• Nominating a colleague for the Master in Hospital Medicine designation, SHM’s most prestigious honor.

For more information, click on the “membership” section of the SHM website.

Are you ready to shape the future of the hospital medicine movement? Now is the time to step up by nominating yourself or someone else for SHM’s many leadership and recognition opportunities. But act quickly. The deadline for many of them is October 16. You can help lead the movement and earn recognition through:

• Nominating yourself or a colleague for one of SHM’s Awards of Excellence, which will be presented at HM16 in San Diego;
• Joining a committee that matches your professional interests or personal passions;
• Applying for SHM’s board of directors; or
• Nominating a colleague for the Master in Hospital Medicine designation, SHM’s most prestigious honor.

For more information, click on the “membership” section of the SHM website.

Are you ready to shape the future of the hospital medicine movement? Now is the time to step up by nominating yourself or someone else for SHM’s many leadership and recognition opportunities. But act quickly. The deadline for many of them is October 16. You can help lead the movement and earn recognition through:

• Nominating yourself or a colleague for one of SHM’s Awards of Excellence, which will be presented at HM16 in San Diego;
• Joining a committee that matches your professional interests or personal passions;
• Applying for SHM’s board of directors; or
• Nominating a colleague for the Master in Hospital Medicine designation, SHM’s most prestigious honor.

For more information, click on the “membership” section of the SHM website.

Studying for the Focused Practice in Hospital Medicine Maintenance of Certification Exam? SHM’s new online test prep tool is now available!

SPARK is the only test prep resource designed specifically for hospitalists and the American Board of Internal Medicine Focused Practice in Hospital Medicine MOC exam. Unlike other test prep tools, this focuses on topics unique to the everyday practice of hospital medicine, including:

• Palliative care, medical ethics, and decision-making;
• Peri-operative care and consultative co-management; and
• Quality, safety, and clinical reasoning.

SPARK gives hospitalists the peace of mind that comes with knowing they are ready for the MOC exam; it features 175 vignette-style, single best answer, multiple-choice questions, complete with answers, discussion, reasoning, references, and quizzing capabilities. This new resource provides targeted study areas to supplement other educational material.

Studying for the Focused Practice in Hospital Medicine Maintenance of Certification Exam? SHM’s new online test prep tool is now available!

SPARK is the only test prep resource designed specifically for hospitalists and the American Board of Internal Medicine Focused Practice in Hospital Medicine MOC exam. Unlike other test prep tools, this focuses on topics unique to the everyday practice of hospital medicine, including:

• Palliative care, medical ethics, and decision-making;
• Peri-operative care and consultative co-management; and
• Quality, safety, and clinical reasoning.

SPARK gives hospitalists the peace of mind that comes with knowing they are ready for the MOC exam; it features 175 vignette-style, single best answer, multiple-choice questions, complete with answers, discussion, reasoning, references, and quizzing capabilities. This new resource provides targeted study areas to supplement other educational material.

Studying for the Focused Practice in Hospital Medicine Maintenance of Certification Exam? SHM’s new online test prep tool is now available!

SPARK is the only test prep resource designed specifically for hospitalists and the American Board of Internal Medicine Focused Practice in Hospital Medicine MOC exam. Unlike other test prep tools, this focuses on topics unique to the everyday practice of hospital medicine, including:

• Palliative care, medical ethics, and decision-making;
• Peri-operative care and consultative co-management; and
• Quality, safety, and clinical reasoning.

SPARK gives hospitalists the peace of mind that comes with knowing they are ready for the MOC exam; it features 175 vignette-style, single best answer, multiple-choice questions, complete with answers, discussion, reasoning, references, and quizzing capabilities. This new resource provides targeted study areas to supplement other educational material.

Get started today on your application for SHM’s other designations, Fellow in Hospital Medicine (FHM) and Senior Fellow in Hospital Medicine (SFHM). Don’t wait until the last minute; the application can take some time to assemble.

Click here to apply.

Get started today on your application for SHM’s other designations, Fellow in Hospital Medicine (FHM) and Senior Fellow in Hospital Medicine (SFHM). Don’t wait until the last minute; the application can take some time to assemble.

Click here to apply.

Get started today on your application for SHM’s other designations, Fellow in Hospital Medicine (FHM) and Senior Fellow in Hospital Medicine (SFHM). Don’t wait until the last minute; the application can take some time to assemble.

Click here to apply.

Approximately 1.7 million patients are hospitalized for acute coronary syndrome (ACS), and 600,000 die of an acute myocardial infarction. Although ACS is a major cause of morbidity and mortality, a broad range of clinical strategies can affect outcomes if implemented effectively. In addition, quality improvement (QI) strategies implemented around ACS can improve performance on quality measures.

The ACS PI-CME is a self-directed, web-based activity designed to help you evaluate your practice. Participation is free. Upon completion of the activity, participants will receive 20 CME credits.

The educational interventions will be pragmatic and address the challenges faced by clinicians responsible for managing patient care. They include:

• Etiology and diagnosis of ACS: educating the team on the pathophysiology of atherosclerotic plaque;
• Inpatient treatment of ACS; and
• Transitions of care for ACS patients.

Act today, because spaces are limited for this program. For more information, visit the QI section of SHM’s website.

---

Brendon Shank is SHM’s associate vice president of communications.ences (CHS) 13-105 10833 Le Conte Ave., Los Angeles, Calif.

Approximately 1.7 million patients are hospitalized for acute coronary syndrome (ACS), and 600,000 die of an acute myocardial infarction. Although ACS is a major cause of morbidity and mortality, a broad range of clinical strategies can affect outcomes if implemented effectively. In addition, quality improvement (QI) strategies implemented around ACS can improve performance on quality measures.

The ACS PI-CME is a self-directed, web-based activity designed to help you evaluate your practice. Participation is free. Upon completion of the activity, participants will receive 20 CME credits.

The educational interventions will be pragmatic and address the challenges faced by clinicians responsible for managing patient care. They include:

• Etiology and diagnosis of ACS: educating the team on the pathophysiology of atherosclerotic plaque;
• Inpatient treatment of ACS; and
• Transitions of care for ACS patients.

Act today, because spaces are limited for this program. For more information, visit the QI section of SHM’s website.

---

Brendon Shank is SHM’s associate vice president of communications.ences (CHS) 13-105 10833 Le Conte Ave., Los Angeles, Calif.

Approximately 1.7 million patients are hospitalized for acute coronary syndrome (ACS), and 600,000 die of an acute myocardial infarction. Although ACS is a major cause of morbidity and mortality, a broad range of clinical strategies can affect outcomes if implemented effectively. In addition, quality improvement (QI) strategies implemented around ACS can improve performance on quality measures.

The ACS PI-CME is a self-directed, web-based activity designed to help you evaluate your practice. Participation is free. Upon completion of the activity, participants will receive 20 CME credits.

The educational interventions will be pragmatic and address the challenges faced by clinicians responsible for managing patient care. They include:

• Etiology and diagnosis of ACS: educating the team on the pathophysiology of atherosclerotic plaque;
• Inpatient treatment of ACS; and
• Transitions of care for ACS patients.

Act today, because spaces are limited for this program. For more information, visit the QI section of SHM’s website.

---

Brendon Shank is SHM’s associate vice president of communications.ences (CHS) 13-105 10833 Le Conte Ave., Los Angeles, Calif.

The Society of Hospital Medicine (SHM) hosts a series of special events for students and residents on campuses throughout the country. Learn more about these networking receptions featuring nationally recognized hospitalists speaking on careers in hospital medicine.

Jefferson University Hospital

Oct. 21, 5-6:30 p.m.

Bluemle Life Sciences Building, Room 101

233 South 10th Street, Philadelphia, Pa.

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University of California at Los Angeles

October 22, noon to 1:15 p.m.

David Geffen School of Medicine at UCLA Center for Health Sciences (CHS) 13-105

10833 Le Conte Ave., Los Angeles, Calif.

The Society of Hospital Medicine (SHM) hosts a series of special events for students and residents on campuses throughout the country. Learn more about these networking receptions featuring nationally recognized hospitalists speaking on careers in hospital medicine.

Jefferson University Hospital

Oct. 21, 5-6:30 p.m.

Bluemle Life Sciences Building, Room 101

233 South 10th Street, Philadelphia, Pa.

---

University of California at Los Angeles

October 22, noon to 1:15 p.m.

David Geffen School of Medicine at UCLA Center for Health Sciences (CHS) 13-105

10833 Le Conte Ave., Los Angeles, Calif.

The Society of Hospital Medicine (SHM) hosts a series of special events for students and residents on campuses throughout the country. Learn more about these networking receptions featuring nationally recognized hospitalists speaking on careers in hospital medicine.

Jefferson University Hospital

Oct. 21, 5-6:30 p.m.

Bluemle Life Sciences Building, Room 101

233 South 10th Street, Philadelphia, Pa.

---

University of California at Los Angeles

October 22, noon to 1:15 p.m.

David Geffen School of Medicine at UCLA Center for Health Sciences (CHS) 13-105

10833 Le Conte Ave., Los Angeles, Calif.

According to the Centers for Medicare and Medicaid Services, an accountable care organization (ACO) is defined as a “group of doctors, hospitals, and other healthcare providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.” The goal of an ACO is “to ensure that patients, especially chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.”

In many ways, the Department of Veterans Affairs (VA) is similar to an ACO. While some of the veterans have Medicare, not all of them do. Across the nation, the VA has the infrastructure to deliver high quality care to our patients. Large medical centers that are affiliated with medical schools and academic teaching hospitals teach medical students and resident physicians to provide excellent care to our patients. To meet the needs of our patients in smaller cities or rural areas, community-based outpatient clinics (CBOCs) deliver quality care to patients.

Our electronic medical record, called the Computerized Personal Record System (CPRS), links veterans nationally. A patient can be seen at the CBOC in Mansfield, Ohio, the Palo Alto VA medical center in California, and the Washington, D.C., VA medical center, and not have to worry about the physicians not having access to his medical information. This prevents physicians from ordering unnecessary radiographic studies, and it can decrease the chance of medication errors and polypharmacy.

The use of electronic consults, also known as eConsults, allows for faster access to specialists. After the PCP orders the patient’s chart, the specialist will review the information, provide recommendations to the PCP, and determine how quickly the patient needs to be seen by the specialist. This is important for our rural population, who will then have to make fewer trips to medical centers.

The Specialty Care Access Network-Extension of Community Healthcare Outcomes (SCAN-ECHO) project is another tool designed to assist our rural population. The program targets those who have diabetes, heart failure, and/or chronic pain. Patients travel to their CBOC and interact via the internet with the VA specialist located at a larger medical center, thereby reducing the number of long trips they must make to the medical center and the long waits they would normally have to endure to be seen by specialists.

Telehealth is another way the VA is coordinating high quality care for our veterans. In the comfort of their own homes, veterans upload weight, vitals, and blood glucose levels to assist physicians in monitoring and treating chronic medical conditions.

The VA also delivers highly quality care through its pharmacies. Electronic ordering of outpatient medications for patients is extremely easy; these medications can either be mailed home or made available for same day pick-up. Certain medications are restricted and require approval by specialists; however, when patients fulfill criteria for a nonformulary medication, it is easily accessible. In addition, the approval process is evidence-based, limiting the effect of pharmaceutical companies on patient care.

As a result of using the formulary process for medications, patients share in the savings through lower co-pays. Pharmacists participate in both antibiotic stewardship, as with inpatient vancomycin dosing, and in managing inpatient anticoagulation, which is often more reliable and less expensive than using physicians.

Through these and other programs, the VA ensures that patients receive the services they need in a thoughtful, evidence-based, and timely way.

---

Dr. Nemeth is a hospitalist at Louis Stokes VA Medical Center in Cleveland, Ohio, and assistant professor of medicine at Case Western Reserve University School of Medicine. He is a member of SHM’s Veterans Affairs Task Force.

According to the Centers for Medicare and Medicaid Services, an accountable care organization (ACO) is defined as a “group of doctors, hospitals, and other healthcare providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.” The goal of an ACO is “to ensure that patients, especially chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.”

In many ways, the Department of Veterans Affairs (VA) is similar to an ACO. While some of the veterans have Medicare, not all of them do. Across the nation, the VA has the infrastructure to deliver high quality care to our patients. Large medical centers that are affiliated with medical schools and academic teaching hospitals teach medical students and resident physicians to provide excellent care to our patients. To meet the needs of our patients in smaller cities or rural areas, community-based outpatient clinics (CBOCs) deliver quality care to patients.

Our electronic medical record, called the Computerized Personal Record System (CPRS), links veterans nationally. A patient can be seen at the CBOC in Mansfield, Ohio, the Palo Alto VA medical center in California, and the Washington, D.C., VA medical center, and not have to worry about the physicians not having access to his medical information. This prevents physicians from ordering unnecessary radiographic studies, and it can decrease the chance of medication errors and polypharmacy.

The use of electronic consults, also known as eConsults, allows for faster access to specialists. After the PCP orders the patient’s chart, the specialist will review the information, provide recommendations to the PCP, and determine how quickly the patient needs to be seen by the specialist. This is important for our rural population, who will then have to make fewer trips to medical centers.

The Specialty Care Access Network-Extension of Community Healthcare Outcomes (SCAN-ECHO) project is another tool designed to assist our rural population. The program targets those who have diabetes, heart failure, and/or chronic pain. Patients travel to their CBOC and interact via the internet with the VA specialist located at a larger medical center, thereby reducing the number of long trips they must make to the medical center and the long waits they would normally have to endure to be seen by specialists.

Telehealth is another way the VA is coordinating high quality care for our veterans. In the comfort of their own homes, veterans upload weight, vitals, and blood glucose levels to assist physicians in monitoring and treating chronic medical conditions.

The VA also delivers highly quality care through its pharmacies. Electronic ordering of outpatient medications for patients is extremely easy; these medications can either be mailed home or made available for same day pick-up. Certain medications are restricted and require approval by specialists; however, when patients fulfill criteria for a nonformulary medication, it is easily accessible. In addition, the approval process is evidence-based, limiting the effect of pharmaceutical companies on patient care.

As a result of using the formulary process for medications, patients share in the savings through lower co-pays. Pharmacists participate in both antibiotic stewardship, as with inpatient vancomycin dosing, and in managing inpatient anticoagulation, which is often more reliable and less expensive than using physicians.

Through these and other programs, the VA ensures that patients receive the services they need in a thoughtful, evidence-based, and timely way.

---

Dr. Nemeth is a hospitalist at Louis Stokes VA Medical Center in Cleveland, Ohio, and assistant professor of medicine at Case Western Reserve University School of Medicine. He is a member of SHM’s Veterans Affairs Task Force.

According to the Centers for Medicare and Medicaid Services, an accountable care organization (ACO) is defined as a “group of doctors, hospitals, and other healthcare providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.” The goal of an ACO is “to ensure that patients, especially chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.”

In many ways, the Department of Veterans Affairs (VA) is similar to an ACO. While some of the veterans have Medicare, not all of them do. Across the nation, the VA has the infrastructure to deliver high quality care to our patients. Large medical centers that are affiliated with medical schools and academic teaching hospitals teach medical students and resident physicians to provide excellent care to our patients. To meet the needs of our patients in smaller cities or rural areas, community-based outpatient clinics (CBOCs) deliver quality care to patients.

Our electronic medical record, called the Computerized Personal Record System (CPRS), links veterans nationally. A patient can be seen at the CBOC in Mansfield, Ohio, the Palo Alto VA medical center in California, and the Washington, D.C., VA medical center, and not have to worry about the physicians not having access to his medical information. This prevents physicians from ordering unnecessary radiographic studies, and it can decrease the chance of medication errors and polypharmacy.

The use of electronic consults, also known as eConsults, allows for faster access to specialists. After the PCP orders the patient’s chart, the specialist will review the information, provide recommendations to the PCP, and determine how quickly the patient needs to be seen by the specialist. This is important for our rural population, who will then have to make fewer trips to medical centers.

The Specialty Care Access Network-Extension of Community Healthcare Outcomes (SCAN-ECHO) project is another tool designed to assist our rural population. The program targets those who have diabetes, heart failure, and/or chronic pain. Patients travel to their CBOC and interact via the internet with the VA specialist located at a larger medical center, thereby reducing the number of long trips they must make to the medical center and the long waits they would normally have to endure to be seen by specialists.

Telehealth is another way the VA is coordinating high quality care for our veterans. In the comfort of their own homes, veterans upload weight, vitals, and blood glucose levels to assist physicians in monitoring and treating chronic medical conditions.

The VA also delivers highly quality care through its pharmacies. Electronic ordering of outpatient medications for patients is extremely easy; these medications can either be mailed home or made available for same day pick-up. Certain medications are restricted and require approval by specialists; however, when patients fulfill criteria for a nonformulary medication, it is easily accessible. In addition, the approval process is evidence-based, limiting the effect of pharmaceutical companies on patient care.

As a result of using the formulary process for medications, patients share in the savings through lower co-pays. Pharmacists participate in both antibiotic stewardship, as with inpatient vancomycin dosing, and in managing inpatient anticoagulation, which is often more reliable and less expensive than using physicians.

Through these and other programs, the VA ensures that patients receive the services they need in a thoughtful, evidence-based, and timely way.

---

Dr. Nemeth is a hospitalist at Louis Stokes VA Medical Center in Cleveland, Ohio, and assistant professor of medicine at Case Western Reserve University School of Medicine. He is a member of SHM’s Veterans Affairs Task Force.

Left ventricular assist devices (LVADs) are rapidly becoming commonplace treatment for end-stage heart failure, either as a bridge to transplant or as destination therapy alone.^1,2 More and more patients are surviving with LVAD therapy and going on to live longer, fuller lives. As a result, unfortunately, more LVAD patients are being admitted and readmitted to the hospital for common non-cardiac illnesses.

For five years, Bon Secours St. Mary’s Hospital in Richmond, Va., has been one of the few community hospitals with an advanced heart failure and LVAD program. Historically, when LVAD patients presented for admission with noncardiac complaints, they were deemed too complex for general care and admitted by their cardiothoracic surgeon or cardiologist. Over a year ago, the hospitalist group at St. Mary’s met with leadership of our advance heart failure program to try to improve and streamline care for these patients. This conversation spawned our LVAD medical management program.

At the outset, more than 80% of our hospitalists had hands-on experience with LVAD management. Although there was a good base of understanding of cardiac functioning and the physiology of mechanical assistance, the nuances of such subspecialized care created a great deal of anxiety. To create a knowledge base to build up, we developed a training curriculum that included online didactics and hands-on training with an LVAD. All hospitalists at St. Mary’s underwent three hours of training online through the Thoratec provider portal for the HeartMate II left ventricular assist device, and, subsequently, an in-person education session by heart failure coordinators. All new hospitalists complete the same training within six months of their hire date.

As we moved forward with the program, we set clear expectations. Our hospitalists are not expected to manage the LVAD directly; however, knowledge of the device parameters (i.e., rotor speed, power, and pulse index) is necessary for diagnosis and management of patients. The heart failure team is consulted on every LVAD patient who is admitted to the hospital for device management and LVAD-related complications.

A hospitalist attending admitted the first LVAD patient more than a year ago. Patients admitted under the hospitalist service are at least six months post-LVAD implantation. In review, we believe that six months was a conservative starting point. Our hospitalists' confidence and comfort with this population has grown over the year and allowed us to consider taking on these patients much sooner after implantation.

Since initiating the program, we have admitted 15 unique patients for 33 separate encounters. The hospitalist team has provided care for illnesses commonly experienced by LVAD patients, such as GI bleeding and drive-line site infection, as well as general medicine complaints (concussion, septic arthritis, lung cancer, and pneumonia).^3,4

Our team manages more than 90% of the St. Mary's non-surgical adult patients, and in reality, the role we play for these patients is much the same as for other complex medical and surgical patients. We provide first point of contact, diagnosis and treatment, coordination of subspecialty care, and safe discharge.

The program of hospitalist care for LVAD patients at St. Mary’s has passed its first birthday. It’s an innovation that we’re very proud of. Since the outset of our care for these patients, we have been collecting data about patient outcomes, length of stay, and resource utilization. Moving forward, we plan to begin identifying places where we can improve the general medical care for this specialized group of patients. TH

---

Dr. Thistlethwaite is an adult hospitalist at Bon Secours St. Mary’s Hospital in Richmond, Va. Dr. Mbanu is chief of the adult hospitalist department at St. Mary’s Hospital and medical director of clinical integration at Bon Secours Health System, Inc.

 

Editor's note: this article was updated Feb. 3, 2016.

References

1. Lampropulos JF, Kim N, Wang Y, et al. Trends in left ventricular assist device use and outcomes among Medicare beneficiaries, 2004–2011. Open Heart. 2014;1(1):e000109. doi:10.1136/openhrt-2014-000109.
2. Jorde UP, Kushwaha SS, Tatooles AJ, et al. Results of the destination therapy post-food and drug administration approval study with a continuous flow left ventricular assist device: a prospective study using the INTERMACS registry (Interagency Registry for Mechanically Assisted Circulatory Support). J Am Coll Cardiol. 2014;63(17):1751-1757.
3. Stern DR, Kazam J, Edwards P, et al. Increased incidence of gastrointestinal bleeding following implantation of the HeartMate II LVAD. J Card Surg. 2010;25(3):352-356.
4. Fischer SA, Trenholme GM, Costanzo MR, Piccione W. Infectious complications in left ventricular assist device recipients. Clin Infect Dis. 1997;24(1):18-23.

Left ventricular assist devices (LVADs) are rapidly becoming commonplace treatment for end-stage heart failure, either as a bridge to transplant or as destination therapy alone.^1,2 More and more patients are surviving with LVAD therapy and going on to live longer, fuller lives. As a result, unfortunately, more LVAD patients are being admitted and readmitted to the hospital for common non-cardiac illnesses.

For five years, Bon Secours St. Mary’s Hospital in Richmond, Va., has been one of the few community hospitals with an advanced heart failure and LVAD program. Historically, when LVAD patients presented for admission with noncardiac complaints, they were deemed too complex for general care and admitted by their cardiothoracic surgeon or cardiologist. Over a year ago, the hospitalist group at St. Mary’s met with leadership of our advance heart failure program to try to improve and streamline care for these patients. This conversation spawned our LVAD medical management program.

At the outset, more than 80% of our hospitalists had hands-on experience with LVAD management. Although there was a good base of understanding of cardiac functioning and the physiology of mechanical assistance, the nuances of such subspecialized care created a great deal of anxiety. To create a knowledge base to build up, we developed a training curriculum that included online didactics and hands-on training with an LVAD. All hospitalists at St. Mary’s underwent three hours of training online through the Thoratec provider portal for the HeartMate II left ventricular assist device, and, subsequently, an in-person education session by heart failure coordinators. All new hospitalists complete the same training within six months of their hire date.

As we moved forward with the program, we set clear expectations. Our hospitalists are not expected to manage the LVAD directly; however, knowledge of the device parameters (i.e., rotor speed, power, and pulse index) is necessary for diagnosis and management of patients. The heart failure team is consulted on every LVAD patient who is admitted to the hospital for device management and LVAD-related complications.

A hospitalist attending admitted the first LVAD patient more than a year ago. Patients admitted under the hospitalist service are at least six months post-LVAD implantation. In review, we believe that six months was a conservative starting point. Our hospitalists' confidence and comfort with this population has grown over the year and allowed us to consider taking on these patients much sooner after implantation.

Since initiating the program, we have admitted 15 unique patients for 33 separate encounters. The hospitalist team has provided care for illnesses commonly experienced by LVAD patients, such as GI bleeding and drive-line site infection, as well as general medicine complaints (concussion, septic arthritis, lung cancer, and pneumonia).^3,4

Our team manages more than 90% of the St. Mary's non-surgical adult patients, and in reality, the role we play for these patients is much the same as for other complex medical and surgical patients. We provide first point of contact, diagnosis and treatment, coordination of subspecialty care, and safe discharge.

The program of hospitalist care for LVAD patients at St. Mary’s has passed its first birthday. It’s an innovation that we’re very proud of. Since the outset of our care for these patients, we have been collecting data about patient outcomes, length of stay, and resource utilization. Moving forward, we plan to begin identifying places where we can improve the general medical care for this specialized group of patients. TH

---

Dr. Thistlethwaite is an adult hospitalist at Bon Secours St. Mary’s Hospital in Richmond, Va. Dr. Mbanu is chief of the adult hospitalist department at St. Mary’s Hospital and medical director of clinical integration at Bon Secours Health System, Inc.

 

Editor's note: this article was updated Feb. 3, 2016.

References

1. Lampropulos JF, Kim N, Wang Y, et al. Trends in left ventricular assist device use and outcomes among Medicare beneficiaries, 2004–2011. Open Heart. 2014;1(1):e000109. doi:10.1136/openhrt-2014-000109.
2. Jorde UP, Kushwaha SS, Tatooles AJ, et al. Results of the destination therapy post-food and drug administration approval study with a continuous flow left ventricular assist device: a prospective study using the INTERMACS registry (Interagency Registry for Mechanically Assisted Circulatory Support). J Am Coll Cardiol. 2014;63(17):1751-1757.
3. Stern DR, Kazam J, Edwards P, et al. Increased incidence of gastrointestinal bleeding following implantation of the HeartMate II LVAD. J Card Surg. 2010;25(3):352-356.
4. Fischer SA, Trenholme GM, Costanzo MR, Piccione W. Infectious complications in left ventricular assist device recipients. Clin Infect Dis. 1997;24(1):18-23.

Left ventricular assist devices (LVADs) are rapidly becoming commonplace treatment for end-stage heart failure, either as a bridge to transplant or as destination therapy alone.^1,2 More and more patients are surviving with LVAD therapy and going on to live longer, fuller lives. As a result, unfortunately, more LVAD patients are being admitted and readmitted to the hospital for common non-cardiac illnesses.

For five years, Bon Secours St. Mary’s Hospital in Richmond, Va., has been one of the few community hospitals with an advanced heart failure and LVAD program. Historically, when LVAD patients presented for admission with noncardiac complaints, they were deemed too complex for general care and admitted by their cardiothoracic surgeon or cardiologist. Over a year ago, the hospitalist group at St. Mary’s met with leadership of our advance heart failure program to try to improve and streamline care for these patients. This conversation spawned our LVAD medical management program.

At the outset, more than 80% of our hospitalists had hands-on experience with LVAD management. Although there was a good base of understanding of cardiac functioning and the physiology of mechanical assistance, the nuances of such subspecialized care created a great deal of anxiety. To create a knowledge base to build up, we developed a training curriculum that included online didactics and hands-on training with an LVAD. All hospitalists at St. Mary’s underwent three hours of training online through the Thoratec provider portal for the HeartMate II left ventricular assist device, and, subsequently, an in-person education session by heart failure coordinators. All new hospitalists complete the same training within six months of their hire date.

As we moved forward with the program, we set clear expectations. Our hospitalists are not expected to manage the LVAD directly; however, knowledge of the device parameters (i.e., rotor speed, power, and pulse index) is necessary for diagnosis and management of patients. The heart failure team is consulted on every LVAD patient who is admitted to the hospital for device management and LVAD-related complications.

A hospitalist attending admitted the first LVAD patient more than a year ago. Patients admitted under the hospitalist service are at least six months post-LVAD implantation. In review, we believe that six months was a conservative starting point. Our hospitalists' confidence and comfort with this population has grown over the year and allowed us to consider taking on these patients much sooner after implantation.

Since initiating the program, we have admitted 15 unique patients for 33 separate encounters. The hospitalist team has provided care for illnesses commonly experienced by LVAD patients, such as GI bleeding and drive-line site infection, as well as general medicine complaints (concussion, septic arthritis, lung cancer, and pneumonia).^3,4

Our team manages more than 90% of the St. Mary's non-surgical adult patients, and in reality, the role we play for these patients is much the same as for other complex medical and surgical patients. We provide first point of contact, diagnosis and treatment, coordination of subspecialty care, and safe discharge.

The program of hospitalist care for LVAD patients at St. Mary’s has passed its first birthday. It’s an innovation that we’re very proud of. Since the outset of our care for these patients, we have been collecting data about patient outcomes, length of stay, and resource utilization. Moving forward, we plan to begin identifying places where we can improve the general medical care for this specialized group of patients. TH

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Dr. Thistlethwaite is an adult hospitalist at Bon Secours St. Mary’s Hospital in Richmond, Va. Dr. Mbanu is chief of the adult hospitalist department at St. Mary’s Hospital and medical director of clinical integration at Bon Secours Health System, Inc.

 

Editor's note: this article was updated Feb. 3, 2016.

References

1. Lampropulos JF, Kim N, Wang Y, et al. Trends in left ventricular assist device use and outcomes among Medicare beneficiaries, 2004–2011. Open Heart. 2014;1(1):e000109. doi:10.1136/openhrt-2014-000109.
2. Jorde UP, Kushwaha SS, Tatooles AJ, et al. Results of the destination therapy post-food and drug administration approval study with a continuous flow left ventricular assist device: a prospective study using the INTERMACS registry (Interagency Registry for Mechanically Assisted Circulatory Support). J Am Coll Cardiol. 2014;63(17):1751-1757.
3. Stern DR, Kazam J, Edwards P, et al. Increased incidence of gastrointestinal bleeding following implantation of the HeartMate II LVAD. J Card Surg. 2010;25(3):352-356.
4. Fischer SA, Trenholme GM, Costanzo MR, Piccione W. Infectious complications in left ventricular assist device recipients. Clin Infect Dis. 1997;24(1):18-23.

Clinical question: In post-operative cardiothoracic surgery patients, is high-flow nasal oxygen therapy inferior to BiPAP for resolution of acute respiratory failure?

Background: Acute respiratory failure is common following cardiothoracic surgery, and noninvasive ventilation often is used to avoid intubation. Noninvasive ventilation is resource-intensive and might be uncomfortable to patients. High-flow nasal oxygen therapy is an alternative modality, which provides large amounts of oxygen with more ease and patient comfort.

Study design: Multi-center, randomized, noninferiority trial.

Setting: Six ICUs in France.

Synopsis: Investigators randomized 830 patients who met criteria (obesity, heart failure, or failure of spontaneous breathing trial) after cardiothoracic surgery. These patients were prophylactically treated with high-flow nasal oxygen or BiPAP. Patients with sleep apnea, nausea/vomiting, agitation/confusion, or hemodynamic instability were excluded. Data collected included arterial blood gas, respiratory rate, and patient-rated dyspnea. The primary outcome was treatment failure as defined by reintubation and mechanical ventilation, a switch to the other study treatment, or study treatment discontinuation.

Complications included pneumothorax, colonic pseudoobstruction, and nosocomial pneumonia. The expected rate of failure for BiPAP was 20%. High-flow nasal oxygen therapy was not inferior to BiPAP, with similar treatment failure rates occurring in both groups (21.9% in BiPAP patients vs. 21% of high-flow nasal oxygen patients); 20% of patients experienced persistent discomfort with either treatment method.

There were no significant differences in complications between the two study groups. Limitations included lack of blinding and potential for bias, leading to treatment failure and crossover.

Bottom line: High-flow nasal oxygen was noninferior to BiPAP in patients with respiratory failure after cardiothoracic surgery.

Citation: Stéphan F, Barrucand B, Petit P, et al. High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial. JAMA. 2015;313(23):2331-2339.

Clinical question: In post-operative cardiothoracic surgery patients, is high-flow nasal oxygen therapy inferior to BiPAP for resolution of acute respiratory failure?

Background: Acute respiratory failure is common following cardiothoracic surgery, and noninvasive ventilation often is used to avoid intubation. Noninvasive ventilation is resource-intensive and might be uncomfortable to patients. High-flow nasal oxygen therapy is an alternative modality, which provides large amounts of oxygen with more ease and patient comfort.

Study design: Multi-center, randomized, noninferiority trial.

Setting: Six ICUs in France.

Synopsis: Investigators randomized 830 patients who met criteria (obesity, heart failure, or failure of spontaneous breathing trial) after cardiothoracic surgery. These patients were prophylactically treated with high-flow nasal oxygen or BiPAP. Patients with sleep apnea, nausea/vomiting, agitation/confusion, or hemodynamic instability were excluded. Data collected included arterial blood gas, respiratory rate, and patient-rated dyspnea. The primary outcome was treatment failure as defined by reintubation and mechanical ventilation, a switch to the other study treatment, or study treatment discontinuation.

Complications included pneumothorax, colonic pseudoobstruction, and nosocomial pneumonia. The expected rate of failure for BiPAP was 20%. High-flow nasal oxygen therapy was not inferior to BiPAP, with similar treatment failure rates occurring in both groups (21.9% in BiPAP patients vs. 21% of high-flow nasal oxygen patients); 20% of patients experienced persistent discomfort with either treatment method.

There were no significant differences in complications between the two study groups. Limitations included lack of blinding and potential for bias, leading to treatment failure and crossover.

Bottom line: High-flow nasal oxygen was noninferior to BiPAP in patients with respiratory failure after cardiothoracic surgery.

Citation: Stéphan F, Barrucand B, Petit P, et al. High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial. JAMA. 2015;313(23):2331-2339.

Clinical question: In post-operative cardiothoracic surgery patients, is high-flow nasal oxygen therapy inferior to BiPAP for resolution of acute respiratory failure?

Background: Acute respiratory failure is common following cardiothoracic surgery, and noninvasive ventilation often is used to avoid intubation. Noninvasive ventilation is resource-intensive and might be uncomfortable to patients. High-flow nasal oxygen therapy is an alternative modality, which provides large amounts of oxygen with more ease and patient comfort.

Study design: Multi-center, randomized, noninferiority trial.

Setting: Six ICUs in France.

Synopsis: Investigators randomized 830 patients who met criteria (obesity, heart failure, or failure of spontaneous breathing trial) after cardiothoracic surgery. These patients were prophylactically treated with high-flow nasal oxygen or BiPAP. Patients with sleep apnea, nausea/vomiting, agitation/confusion, or hemodynamic instability were excluded. Data collected included arterial blood gas, respiratory rate, and patient-rated dyspnea. The primary outcome was treatment failure as defined by reintubation and mechanical ventilation, a switch to the other study treatment, or study treatment discontinuation.

Complications included pneumothorax, colonic pseudoobstruction, and nosocomial pneumonia. The expected rate of failure for BiPAP was 20%. High-flow nasal oxygen therapy was not inferior to BiPAP, with similar treatment failure rates occurring in both groups (21.9% in BiPAP patients vs. 21% of high-flow nasal oxygen patients); 20% of patients experienced persistent discomfort with either treatment method.

There were no significant differences in complications between the two study groups. Limitations included lack of blinding and potential for bias, leading to treatment failure and crossover.

Bottom line: High-flow nasal oxygen was noninferior to BiPAP in patients with respiratory failure after cardiothoracic surgery.

Citation: Stéphan F, Barrucand B, Petit P, et al. High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial. JAMA. 2015;313(23):2331-2339.

Clinical question: Does routine oxygen supplementation in patients with STEMI increase myocardial injury?

Background: Because of physiologic and clinical studies conducted before the era of acute coronary intervention, supplemental oxygen routinely is administered to patients with STEMI, regardless of oxygen saturation; however, recent studies have shown possible adverse effects of oxygen, including increased reperfusion injury and increased adverse outcomes in small clinical trials.

Study design: Multicenter, prospective, randomized, controlled trial (RCT).

Setting: Nine metropolitan hospitals.

Synopsis: This multicenter study included 441 patients with STEMI who were 18 years or older and were randomized by paramedics to receive either 8 L/min of oxygen or no supplemental oxygen. All patients then received protocolized care. The primary endpoint of myocardial infarct size, determined by mean peak of creatine kinase, was significantly increased in the oxygen group compared to the no oxygen group (1948 vs. 1543 U/L; means ratio, 1.27; 95% confidence interval, 1.04-1.52; P=0.01). There were nonsignificant increases of secondary endpoints in the oxygen group, including rate of recurrent myocardial infarction (5.5% vs. 0.9%; P=0.006), frequency of arrhythmia (40.4% vs. 31.4%; P=0.05), and size of infarct on six-month cardiac MRI (n=139; 20.3 vs. 13.1 g; P=0.04).

This study has several limitations: It was powered to detect differences in biomarkers (not clinical endpoints) and the treatment was not blinded to paramedics, patients, or cardiology teams.

Bottom line: Supplemental oxygen administration in patients with STEMI might increase infarct size and lead to poorer clinical outcomes; however, larger clinical trials are warranted.

Citation: Stub D, Smith K, Bernard S, et al. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation. 2015;131(24):2143-2150.

Clinical question: Does routine oxygen supplementation in patients with STEMI increase myocardial injury?

Background: Because of physiologic and clinical studies conducted before the era of acute coronary intervention, supplemental oxygen routinely is administered to patients with STEMI, regardless of oxygen saturation; however, recent studies have shown possible adverse effects of oxygen, including increased reperfusion injury and increased adverse outcomes in small clinical trials.

Study design: Multicenter, prospective, randomized, controlled trial (RCT).

Setting: Nine metropolitan hospitals.

Synopsis: This multicenter study included 441 patients with STEMI who were 18 years or older and were randomized by paramedics to receive either 8 L/min of oxygen or no supplemental oxygen. All patients then received protocolized care. The primary endpoint of myocardial infarct size, determined by mean peak of creatine kinase, was significantly increased in the oxygen group compared to the no oxygen group (1948 vs. 1543 U/L; means ratio, 1.27; 95% confidence interval, 1.04-1.52; P=0.01). There were nonsignificant increases of secondary endpoints in the oxygen group, including rate of recurrent myocardial infarction (5.5% vs. 0.9%; P=0.006), frequency of arrhythmia (40.4% vs. 31.4%; P=0.05), and size of infarct on six-month cardiac MRI (n=139; 20.3 vs. 13.1 g; P=0.04).

This study has several limitations: It was powered to detect differences in biomarkers (not clinical endpoints) and the treatment was not blinded to paramedics, patients, or cardiology teams.

Bottom line: Supplemental oxygen administration in patients with STEMI might increase infarct size and lead to poorer clinical outcomes; however, larger clinical trials are warranted.

Citation: Stub D, Smith K, Bernard S, et al. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation. 2015;131(24):2143-2150.

Clinical question: Does routine oxygen supplementation in patients with STEMI increase myocardial injury?

Background: Because of physiologic and clinical studies conducted before the era of acute coronary intervention, supplemental oxygen routinely is administered to patients with STEMI, regardless of oxygen saturation; however, recent studies have shown possible adverse effects of oxygen, including increased reperfusion injury and increased adverse outcomes in small clinical trials.

Study design: Multicenter, prospective, randomized, controlled trial (RCT).

Setting: Nine metropolitan hospitals.

Synopsis: This multicenter study included 441 patients with STEMI who were 18 years or older and were randomized by paramedics to receive either 8 L/min of oxygen or no supplemental oxygen. All patients then received protocolized care. The primary endpoint of myocardial infarct size, determined by mean peak of creatine kinase, was significantly increased in the oxygen group compared to the no oxygen group (1948 vs. 1543 U/L; means ratio, 1.27; 95% confidence interval, 1.04-1.52; P=0.01). There were nonsignificant increases of secondary endpoints in the oxygen group, including rate of recurrent myocardial infarction (5.5% vs. 0.9%; P=0.006), frequency of arrhythmia (40.4% vs. 31.4%; P=0.05), and size of infarct on six-month cardiac MRI (n=139; 20.3 vs. 13.1 g; P=0.04).

This study has several limitations: It was powered to detect differences in biomarkers (not clinical endpoints) and the treatment was not blinded to paramedics, patients, or cardiology teams.

Bottom line: Supplemental oxygen administration in patients with STEMI might increase infarct size and lead to poorer clinical outcomes; however, larger clinical trials are warranted.

Citation: Stub D, Smith K, Bernard S, et al. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation. 2015;131(24):2143-2150.