User login
Dispatch from HM19: COPD updates
Session presenter
Cathy Grossman MD, FCCP, CHSE
Session title
COPD Updates 2019
Session summary
Chronic obstructive pulmonary disease (COPD) is the third most common cause of death in the United States and accounts for close to 730,000 admissions and 120,000 deaths per year.1 That correlates to one death every 4 minutes. By 2020, the adjusted cost of COPD in the United States was projected to be approximately $50 billion.2
Every COPD exacerbation is associated with economic, social, and mortality burdens. The probability of survival decreases to 20% by the end of 5 years in patients with frequent readmissions, compared with patients with no acute exacerbations of COPD.3 The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recently released its 2019 report and gave fresh guidance on medication changes to consider in patients who have had a COPD exacerbation.
At HM19, Cathy Grossman, MD, assistant professor of medicine in the division of pulmonary and critical care medicine at Virginia Commonwealth University, Richmond, discussed the updates. She explained that most of the patients who are treated by hospitalists are GOLD group C or group D, and stressed the importance of involving the pulmonology team in the care of these patients.
Dr. Grossman explained that GOLD 2019 recommended using eosinophil counts to predict the effect of inhaled corticosteroids (ICS), added to regular maintenance bronchodilator treatment, in preventing future exacerbations. These effects are observed to be incrementally increasing at higher eosinophil counts. For patients who are taking a long-acting beta2-agonist or muscarinic antagonist (LABA or LAMA), and have a high eosinophil count (at least 300 cells/mcL, or at least 100 cells/mcL plus a history of several exacerbations), one could consider adding an ICS.4 For patients who don’t fulfill these criteria, one could try a LABA plus a LAMA. However, one has to be cautious as some of these patients get intravenous dexamethasone by EMS and admission labs may not show eosinophils.
A caveat to using ICS is that, in some of these of the patients, ICS may lead to bacterial overgrowth and therefore more pneumonias, and that may be contributing to frequent admissions of these patients. In such patients, discontinuation might be a viable option. The guidelines recommend starting GOLD group C and D patients with LAMA or LAMA/LABA combination inhalers, and ICS if they have high eosinophil counts. If patients are already on triple therapy, one could add roflumilast5 or a macrolide.
The effectiveness of noninvasive positive-pressure ventilation (NIV) in COPD patients with prolonged hypercapnia after ventilatory support for acute respiratory failure remains unclear, although there is some data to support the use of home NIV in patients with COPD and obstructive sleep apnea, both with and without hypercapnia. Dr. Grossman mentioned that there are still many unanswered questions, like identifying the right patient, right time, and right settings, and more studies are underway.
Dr. Grossman concluded that bread-and-butter topics like smoking cessation counseling, inhaler instruction, and referral to pulmonary rehab are still the most important tools to decrease COPD exacerbations.
Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, of hospital medicine at Baystate Medical Center in Springfield, Mass.
References
1. Guarascio AJ et al. The clinical and economic burden of chronic obstructive pulmonary disease in the USA. Clinicoecon Outcomes Res. 2013 Jun 17;5:235-45.
2. Morbidity & Mortality: 2012 Chart Book on Cardiovascular, Lung, and Blood Disease. National Institutes of Health and National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/files/docs/research/2012_ChartBook_508.pdf.
3. Soler-Cataluña JJ et al. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease; Thorax. 2005;60:925-31.
4. Cheng SL. Blood eosinophils and inhaled corticosteroids in patients with COPD: Systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis. 2018 Sept 6;13:2775-84.
5. FJ Martinez et al. Effect of roflumilast on exacerbations in patients with severe chronic obstructive pulmonary disease uncontrolled by combination therapy (REACT): A multicenter, randomized, controlled trial. Lancet. 2015;385(9971):857-66.
Session presenter
Cathy Grossman MD, FCCP, CHSE
Session title
COPD Updates 2019
Session summary
Chronic obstructive pulmonary disease (COPD) is the third most common cause of death in the United States and accounts for close to 730,000 admissions and 120,000 deaths per year.1 That correlates to one death every 4 minutes. By 2020, the adjusted cost of COPD in the United States was projected to be approximately $50 billion.2
Every COPD exacerbation is associated with economic, social, and mortality burdens. The probability of survival decreases to 20% by the end of 5 years in patients with frequent readmissions, compared with patients with no acute exacerbations of COPD.3 The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recently released its 2019 report and gave fresh guidance on medication changes to consider in patients who have had a COPD exacerbation.
At HM19, Cathy Grossman, MD, assistant professor of medicine in the division of pulmonary and critical care medicine at Virginia Commonwealth University, Richmond, discussed the updates. She explained that most of the patients who are treated by hospitalists are GOLD group C or group D, and stressed the importance of involving the pulmonology team in the care of these patients.
Dr. Grossman explained that GOLD 2019 recommended using eosinophil counts to predict the effect of inhaled corticosteroids (ICS), added to regular maintenance bronchodilator treatment, in preventing future exacerbations. These effects are observed to be incrementally increasing at higher eosinophil counts. For patients who are taking a long-acting beta2-agonist or muscarinic antagonist (LABA or LAMA), and have a high eosinophil count (at least 300 cells/mcL, or at least 100 cells/mcL plus a history of several exacerbations), one could consider adding an ICS.4 For patients who don’t fulfill these criteria, one could try a LABA plus a LAMA. However, one has to be cautious as some of these patients get intravenous dexamethasone by EMS and admission labs may not show eosinophils.
A caveat to using ICS is that, in some of these of the patients, ICS may lead to bacterial overgrowth and therefore more pneumonias, and that may be contributing to frequent admissions of these patients. In such patients, discontinuation might be a viable option. The guidelines recommend starting GOLD group C and D patients with LAMA or LAMA/LABA combination inhalers, and ICS if they have high eosinophil counts. If patients are already on triple therapy, one could add roflumilast5 or a macrolide.
The effectiveness of noninvasive positive-pressure ventilation (NIV) in COPD patients with prolonged hypercapnia after ventilatory support for acute respiratory failure remains unclear, although there is some data to support the use of home NIV in patients with COPD and obstructive sleep apnea, both with and without hypercapnia. Dr. Grossman mentioned that there are still many unanswered questions, like identifying the right patient, right time, and right settings, and more studies are underway.
Dr. Grossman concluded that bread-and-butter topics like smoking cessation counseling, inhaler instruction, and referral to pulmonary rehab are still the most important tools to decrease COPD exacerbations.
Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, of hospital medicine at Baystate Medical Center in Springfield, Mass.
References
1. Guarascio AJ et al. The clinical and economic burden of chronic obstructive pulmonary disease in the USA. Clinicoecon Outcomes Res. 2013 Jun 17;5:235-45.
2. Morbidity & Mortality: 2012 Chart Book on Cardiovascular, Lung, and Blood Disease. National Institutes of Health and National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/files/docs/research/2012_ChartBook_508.pdf.
3. Soler-Cataluña JJ et al. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease; Thorax. 2005;60:925-31.
4. Cheng SL. Blood eosinophils and inhaled corticosteroids in patients with COPD: Systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis. 2018 Sept 6;13:2775-84.
5. FJ Martinez et al. Effect of roflumilast on exacerbations in patients with severe chronic obstructive pulmonary disease uncontrolled by combination therapy (REACT): A multicenter, randomized, controlled trial. Lancet. 2015;385(9971):857-66.
Session presenter
Cathy Grossman MD, FCCP, CHSE
Session title
COPD Updates 2019
Session summary
Chronic obstructive pulmonary disease (COPD) is the third most common cause of death in the United States and accounts for close to 730,000 admissions and 120,000 deaths per year.1 That correlates to one death every 4 minutes. By 2020, the adjusted cost of COPD in the United States was projected to be approximately $50 billion.2
Every COPD exacerbation is associated with economic, social, and mortality burdens. The probability of survival decreases to 20% by the end of 5 years in patients with frequent readmissions, compared with patients with no acute exacerbations of COPD.3 The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recently released its 2019 report and gave fresh guidance on medication changes to consider in patients who have had a COPD exacerbation.
At HM19, Cathy Grossman, MD, assistant professor of medicine in the division of pulmonary and critical care medicine at Virginia Commonwealth University, Richmond, discussed the updates. She explained that most of the patients who are treated by hospitalists are GOLD group C or group D, and stressed the importance of involving the pulmonology team in the care of these patients.
Dr. Grossman explained that GOLD 2019 recommended using eosinophil counts to predict the effect of inhaled corticosteroids (ICS), added to regular maintenance bronchodilator treatment, in preventing future exacerbations. These effects are observed to be incrementally increasing at higher eosinophil counts. For patients who are taking a long-acting beta2-agonist or muscarinic antagonist (LABA or LAMA), and have a high eosinophil count (at least 300 cells/mcL, or at least 100 cells/mcL plus a history of several exacerbations), one could consider adding an ICS.4 For patients who don’t fulfill these criteria, one could try a LABA plus a LAMA. However, one has to be cautious as some of these patients get intravenous dexamethasone by EMS and admission labs may not show eosinophils.
A caveat to using ICS is that, in some of these of the patients, ICS may lead to bacterial overgrowth and therefore more pneumonias, and that may be contributing to frequent admissions of these patients. In such patients, discontinuation might be a viable option. The guidelines recommend starting GOLD group C and D patients with LAMA or LAMA/LABA combination inhalers, and ICS if they have high eosinophil counts. If patients are already on triple therapy, one could add roflumilast5 or a macrolide.
The effectiveness of noninvasive positive-pressure ventilation (NIV) in COPD patients with prolonged hypercapnia after ventilatory support for acute respiratory failure remains unclear, although there is some data to support the use of home NIV in patients with COPD and obstructive sleep apnea, both with and without hypercapnia. Dr. Grossman mentioned that there are still many unanswered questions, like identifying the right patient, right time, and right settings, and more studies are underway.
Dr. Grossman concluded that bread-and-butter topics like smoking cessation counseling, inhaler instruction, and referral to pulmonary rehab are still the most important tools to decrease COPD exacerbations.
Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, of hospital medicine at Baystate Medical Center in Springfield, Mass.
References
1. Guarascio AJ et al. The clinical and economic burden of chronic obstructive pulmonary disease in the USA. Clinicoecon Outcomes Res. 2013 Jun 17;5:235-45.
2. Morbidity & Mortality: 2012 Chart Book on Cardiovascular, Lung, and Blood Disease. National Institutes of Health and National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/files/docs/research/2012_ChartBook_508.pdf.
3. Soler-Cataluña JJ et al. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease; Thorax. 2005;60:925-31.
4. Cheng SL. Blood eosinophils and inhaled corticosteroids in patients with COPD: Systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis. 2018 Sept 6;13:2775-84.
5. FJ Martinez et al. Effect of roflumilast on exacerbations in patients with severe chronic obstructive pulmonary disease uncontrolled by combination therapy (REACT): A multicenter, randomized, controlled trial. Lancet. 2015;385(9971):857-66.
HM19: Sepsis care update
Presenter
Patricia Kritek MD, EdM
Session Title
Sepsis update: From screening to refractory shock
Background
Each year 1.7 million adults in America develop sepsis, and 270,000 Americans die from sepsis annually. Sepsis costs U.S. health care over $27 billion dollars each year. Because of the wide range of etiologies and variation in presentation and intensity, it is a challenge to establish homogeneous evidence based guidelines.1
The definition of sepsis based on the “SIRS” criterion was developed initially in 1992, later revised as Sepsis-2 in 2001. The latest Sepsis-3 definition – “life-threatening organ dysfunction due to a dysregulated host response to infection” – was developed in 2016 by the Third International Consensus Definitions for Sepsis and Septic Shock. This newest definition has renounced the SIRS criterion and adopted the Sequential Organ Failure Assessment (SOFA) score. Treatment guidelines in sepsis were developed by the Surviving Sepsis Campaign starting with the Barcelona Declaration in 2002 and revised multiple times, with the development of 3-hour and 6-hour care bundles in 2012. The latest revision, in 2018, consolidated to a 1-hour bundle.2
Sepsis is a continuum of every severe infection, and with the combined efforts of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, evidence-based guidelines have been developed over the past 2 decades, with the latest iteration in 2018. The Centers for Medicare & Medicaid Services still uses Sepsis-2 for diagnosis, and the 3-hr/6-hr bundle compliance (2016) for expected care.3
Session summary
Dr. Kritek, of the division of pulmonary, critical care, and sleep medicine at the University of Washington, Seattle, presented to a room of over 1,000 enthusiastic hospitalists. She was able to capture everyone’s attention with a great presentation. As sepsis is one of the most common and serious conditions we encounter, most hospitalists are fairly well versed in evidence-based practices, and Dr. Kritek was able to keep us engaged, describing in detail the evolving definition, pathophysiology, and screening procedures for sepsis. She also spoke about important studies and the latest evidence that will positively impact each hospitalist’s practice in treating sepsis.
Dr. Kritek explained clearly how the Surviving Sepsis Campaign developed a vital and nontraditional guideline that “recommends health systems have a performance improvement program for sepsis including screening for high-risk patients.” In a 1-hour session, Dr. Kritek did a commendable job untangling this bewildering health care challenge, and aligned each component to explain how to best use available resources and address sepsis in individual hospitals.
She talked about the statistics and historical aspects involved in the definition of sepsis, and the Surviving Sepsis Campaign. With three good case scenarios, Dr. Kritek explained how it was difficult to accurately diagnose sepsis using the Sepsis-2/SIRS criterion, and how the SIRS criterion led to several false positives. This created a need for the new Sepsis-3 definition, which used delta SOFA score of 2 indicating “organ failure.”
Key takeaways: Screening
- Sepsis-3 with delta SOFA score of at least 2 and Quick SOFA (qSOFA) of at least 2 was best at predicting in-hospital death, ICU admission, and long ICU stay in ED.
- qSOFA was not helpful in the admitted ICU population. An increase of at least 2 points in SOFA score within 24 hours of admission to the ICU was the best predictor of in-hospital mortality and long ICU stays.
- SIRS has high sensitivity and low specificity. The Early Warning Score has accuracy similar to qSOFA.
- Understanding that there is no perfect answer regarding screening, but having a process is vital for each organization. This approach led to the Surviving Sepsis Campaign guideline: “Recommend health systems have a performance improvement program for sepsis including screening for high-risk patients.”
Key takeaways: Treatment
- Meta-analysis showed that specifically targeted, early goal–directed treatment (specifically, central venous pressure 8-12 mm Hg, central venous oxygen saturation greater than 70%, packed red blood cell inotropes used) did not show any improvement in 90-day mortality, and actually generated worse outcomes, including cirrhosis, as well as higher costs of care.
- Antibiotics: Though part of the 3-hour bundle, antibiotics are recommended to be administered within 1 hour.
- Intravenous fluids: Patients with sepsis-induced hypoperfusion need 30 mL/kg crystalloids. Normal saline and lactated ringer are preferred. Lactated ringer has the advantage over normal saline, with a reduced incidence of major adverse kidney events.
- Importance of bundle compliance: N.Y. study showed use of protocols cut mortality from 30.2% to 25.4%.
Refractory septic shock
- Adding hydrocortisone and fludrocortisone improved mortality at 28 days, helped patients get off vasopressors sooner, and ultimately resulted in less organ failure. But no difference in 90-day mortality.
- A study of vitamin C use in septic patients needs further studies to validate, as it only included 47 patients.
- Early renal replacement therapy showed no difference in mortality or length of stay.
Dr. Kritek’s presentation made a positive impact by helping to explain the reasoning behind the established and evolving best practices and guidelines for care of patients with sepsis and septic shock. Her approach will help hospitalists provide cost-effective care, by understanding which expensive interventions and practices do not make a difference in patient care.
Dr. Odeti is hospitalist medical director at Johnston Memorial Hospital in Abingdon, Va. JMH is part of Ballad Health, a health system operating 21 hospitals in northeast Tennessee and southwest Virginia.
References
1. https://www.sepsis.org/wp-content/uploads/2017/05/Sepsis-Fact-Sheet-2018.pdf.
2. http://www.survivingsepsis.org/News/Pages/SCCM-and-ACEP-Release-Joint-Statement-About-the-Surviving-Sepsis-Campaign-Hour-1-Bundle.aspx
3. Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-17 (1Q17) through 12-31-17 (4Q17).
Presenter
Patricia Kritek MD, EdM
Session Title
Sepsis update: From screening to refractory shock
Background
Each year 1.7 million adults in America develop sepsis, and 270,000 Americans die from sepsis annually. Sepsis costs U.S. health care over $27 billion dollars each year. Because of the wide range of etiologies and variation in presentation and intensity, it is a challenge to establish homogeneous evidence based guidelines.1
The definition of sepsis based on the “SIRS” criterion was developed initially in 1992, later revised as Sepsis-2 in 2001. The latest Sepsis-3 definition – “life-threatening organ dysfunction due to a dysregulated host response to infection” – was developed in 2016 by the Third International Consensus Definitions for Sepsis and Septic Shock. This newest definition has renounced the SIRS criterion and adopted the Sequential Organ Failure Assessment (SOFA) score. Treatment guidelines in sepsis were developed by the Surviving Sepsis Campaign starting with the Barcelona Declaration in 2002 and revised multiple times, with the development of 3-hour and 6-hour care bundles in 2012. The latest revision, in 2018, consolidated to a 1-hour bundle.2
Sepsis is a continuum of every severe infection, and with the combined efforts of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, evidence-based guidelines have been developed over the past 2 decades, with the latest iteration in 2018. The Centers for Medicare & Medicaid Services still uses Sepsis-2 for diagnosis, and the 3-hr/6-hr bundle compliance (2016) for expected care.3
Session summary
Dr. Kritek, of the division of pulmonary, critical care, and sleep medicine at the University of Washington, Seattle, presented to a room of over 1,000 enthusiastic hospitalists. She was able to capture everyone’s attention with a great presentation. As sepsis is one of the most common and serious conditions we encounter, most hospitalists are fairly well versed in evidence-based practices, and Dr. Kritek was able to keep us engaged, describing in detail the evolving definition, pathophysiology, and screening procedures for sepsis. She also spoke about important studies and the latest evidence that will positively impact each hospitalist’s practice in treating sepsis.
Dr. Kritek explained clearly how the Surviving Sepsis Campaign developed a vital and nontraditional guideline that “recommends health systems have a performance improvement program for sepsis including screening for high-risk patients.” In a 1-hour session, Dr. Kritek did a commendable job untangling this bewildering health care challenge, and aligned each component to explain how to best use available resources and address sepsis in individual hospitals.
She talked about the statistics and historical aspects involved in the definition of sepsis, and the Surviving Sepsis Campaign. With three good case scenarios, Dr. Kritek explained how it was difficult to accurately diagnose sepsis using the Sepsis-2/SIRS criterion, and how the SIRS criterion led to several false positives. This created a need for the new Sepsis-3 definition, which used delta SOFA score of 2 indicating “organ failure.”
Key takeaways: Screening
- Sepsis-3 with delta SOFA score of at least 2 and Quick SOFA (qSOFA) of at least 2 was best at predicting in-hospital death, ICU admission, and long ICU stay in ED.
- qSOFA was not helpful in the admitted ICU population. An increase of at least 2 points in SOFA score within 24 hours of admission to the ICU was the best predictor of in-hospital mortality and long ICU stays.
- SIRS has high sensitivity and low specificity. The Early Warning Score has accuracy similar to qSOFA.
- Understanding that there is no perfect answer regarding screening, but having a process is vital for each organization. This approach led to the Surviving Sepsis Campaign guideline: “Recommend health systems have a performance improvement program for sepsis including screening for high-risk patients.”
Key takeaways: Treatment
- Meta-analysis showed that specifically targeted, early goal–directed treatment (specifically, central venous pressure 8-12 mm Hg, central venous oxygen saturation greater than 70%, packed red blood cell inotropes used) did not show any improvement in 90-day mortality, and actually generated worse outcomes, including cirrhosis, as well as higher costs of care.
- Antibiotics: Though part of the 3-hour bundle, antibiotics are recommended to be administered within 1 hour.
- Intravenous fluids: Patients with sepsis-induced hypoperfusion need 30 mL/kg crystalloids. Normal saline and lactated ringer are preferred. Lactated ringer has the advantage over normal saline, with a reduced incidence of major adverse kidney events.
- Importance of bundle compliance: N.Y. study showed use of protocols cut mortality from 30.2% to 25.4%.
Refractory septic shock
- Adding hydrocortisone and fludrocortisone improved mortality at 28 days, helped patients get off vasopressors sooner, and ultimately resulted in less organ failure. But no difference in 90-day mortality.
- A study of vitamin C use in septic patients needs further studies to validate, as it only included 47 patients.
- Early renal replacement therapy showed no difference in mortality or length of stay.
Dr. Kritek’s presentation made a positive impact by helping to explain the reasoning behind the established and evolving best practices and guidelines for care of patients with sepsis and septic shock. Her approach will help hospitalists provide cost-effective care, by understanding which expensive interventions and practices do not make a difference in patient care.
Dr. Odeti is hospitalist medical director at Johnston Memorial Hospital in Abingdon, Va. JMH is part of Ballad Health, a health system operating 21 hospitals in northeast Tennessee and southwest Virginia.
References
1. https://www.sepsis.org/wp-content/uploads/2017/05/Sepsis-Fact-Sheet-2018.pdf.
2. http://www.survivingsepsis.org/News/Pages/SCCM-and-ACEP-Release-Joint-Statement-About-the-Surviving-Sepsis-Campaign-Hour-1-Bundle.aspx
3. Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-17 (1Q17) through 12-31-17 (4Q17).
Presenter
Patricia Kritek MD, EdM
Session Title
Sepsis update: From screening to refractory shock
Background
Each year 1.7 million adults in America develop sepsis, and 270,000 Americans die from sepsis annually. Sepsis costs U.S. health care over $27 billion dollars each year. Because of the wide range of etiologies and variation in presentation and intensity, it is a challenge to establish homogeneous evidence based guidelines.1
The definition of sepsis based on the “SIRS” criterion was developed initially in 1992, later revised as Sepsis-2 in 2001. The latest Sepsis-3 definition – “life-threatening organ dysfunction due to a dysregulated host response to infection” – was developed in 2016 by the Third International Consensus Definitions for Sepsis and Septic Shock. This newest definition has renounced the SIRS criterion and adopted the Sequential Organ Failure Assessment (SOFA) score. Treatment guidelines in sepsis were developed by the Surviving Sepsis Campaign starting with the Barcelona Declaration in 2002 and revised multiple times, with the development of 3-hour and 6-hour care bundles in 2012. The latest revision, in 2018, consolidated to a 1-hour bundle.2
Sepsis is a continuum of every severe infection, and with the combined efforts of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, evidence-based guidelines have been developed over the past 2 decades, with the latest iteration in 2018. The Centers for Medicare & Medicaid Services still uses Sepsis-2 for diagnosis, and the 3-hr/6-hr bundle compliance (2016) for expected care.3
Session summary
Dr. Kritek, of the division of pulmonary, critical care, and sleep medicine at the University of Washington, Seattle, presented to a room of over 1,000 enthusiastic hospitalists. She was able to capture everyone’s attention with a great presentation. As sepsis is one of the most common and serious conditions we encounter, most hospitalists are fairly well versed in evidence-based practices, and Dr. Kritek was able to keep us engaged, describing in detail the evolving definition, pathophysiology, and screening procedures for sepsis. She also spoke about important studies and the latest evidence that will positively impact each hospitalist’s practice in treating sepsis.
Dr. Kritek explained clearly how the Surviving Sepsis Campaign developed a vital and nontraditional guideline that “recommends health systems have a performance improvement program for sepsis including screening for high-risk patients.” In a 1-hour session, Dr. Kritek did a commendable job untangling this bewildering health care challenge, and aligned each component to explain how to best use available resources and address sepsis in individual hospitals.
She talked about the statistics and historical aspects involved in the definition of sepsis, and the Surviving Sepsis Campaign. With three good case scenarios, Dr. Kritek explained how it was difficult to accurately diagnose sepsis using the Sepsis-2/SIRS criterion, and how the SIRS criterion led to several false positives. This created a need for the new Sepsis-3 definition, which used delta SOFA score of 2 indicating “organ failure.”
Key takeaways: Screening
- Sepsis-3 with delta SOFA score of at least 2 and Quick SOFA (qSOFA) of at least 2 was best at predicting in-hospital death, ICU admission, and long ICU stay in ED.
- qSOFA was not helpful in the admitted ICU population. An increase of at least 2 points in SOFA score within 24 hours of admission to the ICU was the best predictor of in-hospital mortality and long ICU stays.
- SIRS has high sensitivity and low specificity. The Early Warning Score has accuracy similar to qSOFA.
- Understanding that there is no perfect answer regarding screening, but having a process is vital for each organization. This approach led to the Surviving Sepsis Campaign guideline: “Recommend health systems have a performance improvement program for sepsis including screening for high-risk patients.”
Key takeaways: Treatment
- Meta-analysis showed that specifically targeted, early goal–directed treatment (specifically, central venous pressure 8-12 mm Hg, central venous oxygen saturation greater than 70%, packed red blood cell inotropes used) did not show any improvement in 90-day mortality, and actually generated worse outcomes, including cirrhosis, as well as higher costs of care.
- Antibiotics: Though part of the 3-hour bundle, antibiotics are recommended to be administered within 1 hour.
- Intravenous fluids: Patients with sepsis-induced hypoperfusion need 30 mL/kg crystalloids. Normal saline and lactated ringer are preferred. Lactated ringer has the advantage over normal saline, with a reduced incidence of major adverse kidney events.
- Importance of bundle compliance: N.Y. study showed use of protocols cut mortality from 30.2% to 25.4%.
Refractory septic shock
- Adding hydrocortisone and fludrocortisone improved mortality at 28 days, helped patients get off vasopressors sooner, and ultimately resulted in less organ failure. But no difference in 90-day mortality.
- A study of vitamin C use in septic patients needs further studies to validate, as it only included 47 patients.
- Early renal replacement therapy showed no difference in mortality or length of stay.
Dr. Kritek’s presentation made a positive impact by helping to explain the reasoning behind the established and evolving best practices and guidelines for care of patients with sepsis and septic shock. Her approach will help hospitalists provide cost-effective care, by understanding which expensive interventions and practices do not make a difference in patient care.
Dr. Odeti is hospitalist medical director at Johnston Memorial Hospital in Abingdon, Va. JMH is part of Ballad Health, a health system operating 21 hospitals in northeast Tennessee and southwest Virginia.
References
1. https://www.sepsis.org/wp-content/uploads/2017/05/Sepsis-Fact-Sheet-2018.pdf.
2. http://www.survivingsepsis.org/News/Pages/SCCM-and-ACEP-Release-Joint-Statement-About-the-Surviving-Sepsis-Campaign-Hour-1-Bundle.aspx
3. Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-17 (1Q17) through 12-31-17 (4Q17).
HM19: One chapter’s experience
The Society of Hospital Medicine is an organization vested in improving the quality of inpatient medicine by empowering its members with education and providing venues for professional development including networking, advocacy, and leadership advancement. Every year, SHM holds a national conference which is a focused meeting point for over 5,000 hospitalists.
SHM hosts more than 50 local chapters nationwide to increase networking, education, and collaboration within the hospital medicine community. The Wiregrass chapter of SHM is based in the southeast corner of Alabama, covering the counties of lower Alabama and the panhandle of Florida. This year we were recognized as a platinum status chapter, which is the highest status, based on our work and participation to improve the quality of inpatient medicine.
As part of winning the platinum ribbon, we were awarded three complimentary registration scholarships to the SHM Annual Conference in 2019. The chapter leadership met and selected three individuals who have been involved with the chapter actively but have never had an opportunity to experience SHM’s Annual Conference. We selected a first-year resident, Dr. Avani Parrekh; a hospital medicine nurse practitioner, Madison Rivenbark; and a fourth-year medical student who is about to start his internal medicine residency, William Bancroft.
After the meeting we interviewed them to better understand their experience. Below are their thoughts.
Avani Parekh, MD
First year, Internal Medicine Residency
Southeast Health Medical Center
Dothan, Ala.
I am so thankful for the opportunity that was given to me by the Wiregrass chapter by sponsoring my attendance at the 2019 SHM Annual Conference in Washington. This was my first SHM conference, and it was truly a rewarding experience.
I thoroughly enjoyed attending the lectures. They were very informative and engaging. Every presenter was so passionate and inspiring. Coming from an “all-female class” of PGY-1 at my program, I especially enjoyed the “Fe(male) in medicine” talk, as well as Quick Talks on women in medicine. The “Updates in Hospital Medicine” session on various topics such as heart failure, pneumonia, and sepsis was outstanding. I was excited to apply the knowledge I gained from this event into my patient care.
Overall, it was a well-organized and up-to-date event. I am looking forward to attending more SHM conferences in the future.
Madison Rivenbark, NP
Department of Hospital Medicine
Southeast Health Medical Center
Dothan, Ala.
I was extremely fortunate to be selected to receive a scholarship that covered the conference fee for the 2019 SHM Annual Conference. This was my first SHM conference, and it was quite the learning experience. I enjoyed each educational session that I attended. I felt like I was able to bring something home with me that I can incorporate into my practice to better care for the patients that I see each day.
As mentioned above, I learned from each session, but my personal favorite was the “Updates in Hospital Medicine” session. I was very impressed by the enthusiasm of the two speakers. The information provided was presented so that it engaged each attendee.
Not only did I learn a wealth of valuable information that will help me in my career, I gained affirmation concerning my future educational endeavors. I was inspired to pursue a higher level of learning regarding my career. I witnessed this awesome organization that is filled with encouraging and motivating people, and I realized I wanted to be more involved on a local level, and maybe one day, on a larger level. In addition, this conference inspired me to continue to be a lifetime learner and to always crave more knowledge. I am blessed to be a part of hospital medicine. I look forward to the future of this specialty.
William Bancroft, MS IV
Alabama College of Osteopathic Medicine
Dothan, Ala.
I was honored to have been chosen by the Wiregrass chapter as the medical student representative for the SHM Annual Conference. I have been serving in the local chapter during both my 3rd and 4th years in different roles, from helping as a student liaison for our medical students to executive planning coordinator for events. It was a surprise when I got asked by the chapter to be their student representative, but one that I was very excited to accept.
This was my first medical conference. I had heard about what different conferences were like from many of my attendings, so I had some expectations, but this experience was so much better. I enjoyed meeting and networking with people. I also found myself eagerly waiting to get to the next lecture because I was getting an opportunity to hear about different case studies, new research outcomes, and new standards of care.
It was a real treat to learn about all the new changes to treatment, but even more encouraging to know that most of it was just reinforcing everything my attendings have been teaching us as medical students. I enjoyed my time at the SHM Annual Conference so much that I emailed all my new coresidents and encouraged them to join the Society.
Dr. Skandhan is a hospitalist at Southeast Health Medical Center in Dothan, Ala., as well as president and founder of the Wiregrass chapter of SHM.
The Society of Hospital Medicine is an organization vested in improving the quality of inpatient medicine by empowering its members with education and providing venues for professional development including networking, advocacy, and leadership advancement. Every year, SHM holds a national conference which is a focused meeting point for over 5,000 hospitalists.
SHM hosts more than 50 local chapters nationwide to increase networking, education, and collaboration within the hospital medicine community. The Wiregrass chapter of SHM is based in the southeast corner of Alabama, covering the counties of lower Alabama and the panhandle of Florida. This year we were recognized as a platinum status chapter, which is the highest status, based on our work and participation to improve the quality of inpatient medicine.
As part of winning the platinum ribbon, we were awarded three complimentary registration scholarships to the SHM Annual Conference in 2019. The chapter leadership met and selected three individuals who have been involved with the chapter actively but have never had an opportunity to experience SHM’s Annual Conference. We selected a first-year resident, Dr. Avani Parrekh; a hospital medicine nurse practitioner, Madison Rivenbark; and a fourth-year medical student who is about to start his internal medicine residency, William Bancroft.
After the meeting we interviewed them to better understand their experience. Below are their thoughts.
Avani Parekh, MD
First year, Internal Medicine Residency
Southeast Health Medical Center
Dothan, Ala.
I am so thankful for the opportunity that was given to me by the Wiregrass chapter by sponsoring my attendance at the 2019 SHM Annual Conference in Washington. This was my first SHM conference, and it was truly a rewarding experience.
I thoroughly enjoyed attending the lectures. They were very informative and engaging. Every presenter was so passionate and inspiring. Coming from an “all-female class” of PGY-1 at my program, I especially enjoyed the “Fe(male) in medicine” talk, as well as Quick Talks on women in medicine. The “Updates in Hospital Medicine” session on various topics such as heart failure, pneumonia, and sepsis was outstanding. I was excited to apply the knowledge I gained from this event into my patient care.
Overall, it was a well-organized and up-to-date event. I am looking forward to attending more SHM conferences in the future.
Madison Rivenbark, NP
Department of Hospital Medicine
Southeast Health Medical Center
Dothan, Ala.
I was extremely fortunate to be selected to receive a scholarship that covered the conference fee for the 2019 SHM Annual Conference. This was my first SHM conference, and it was quite the learning experience. I enjoyed each educational session that I attended. I felt like I was able to bring something home with me that I can incorporate into my practice to better care for the patients that I see each day.
As mentioned above, I learned from each session, but my personal favorite was the “Updates in Hospital Medicine” session. I was very impressed by the enthusiasm of the two speakers. The information provided was presented so that it engaged each attendee.
Not only did I learn a wealth of valuable information that will help me in my career, I gained affirmation concerning my future educational endeavors. I was inspired to pursue a higher level of learning regarding my career. I witnessed this awesome organization that is filled with encouraging and motivating people, and I realized I wanted to be more involved on a local level, and maybe one day, on a larger level. In addition, this conference inspired me to continue to be a lifetime learner and to always crave more knowledge. I am blessed to be a part of hospital medicine. I look forward to the future of this specialty.
William Bancroft, MS IV
Alabama College of Osteopathic Medicine
Dothan, Ala.
I was honored to have been chosen by the Wiregrass chapter as the medical student representative for the SHM Annual Conference. I have been serving in the local chapter during both my 3rd and 4th years in different roles, from helping as a student liaison for our medical students to executive planning coordinator for events. It was a surprise when I got asked by the chapter to be their student representative, but one that I was very excited to accept.
This was my first medical conference. I had heard about what different conferences were like from many of my attendings, so I had some expectations, but this experience was so much better. I enjoyed meeting and networking with people. I also found myself eagerly waiting to get to the next lecture because I was getting an opportunity to hear about different case studies, new research outcomes, and new standards of care.
It was a real treat to learn about all the new changes to treatment, but even more encouraging to know that most of it was just reinforcing everything my attendings have been teaching us as medical students. I enjoyed my time at the SHM Annual Conference so much that I emailed all my new coresidents and encouraged them to join the Society.
Dr. Skandhan is a hospitalist at Southeast Health Medical Center in Dothan, Ala., as well as president and founder of the Wiregrass chapter of SHM.
The Society of Hospital Medicine is an organization vested in improving the quality of inpatient medicine by empowering its members with education and providing venues for professional development including networking, advocacy, and leadership advancement. Every year, SHM holds a national conference which is a focused meeting point for over 5,000 hospitalists.
SHM hosts more than 50 local chapters nationwide to increase networking, education, and collaboration within the hospital medicine community. The Wiregrass chapter of SHM is based in the southeast corner of Alabama, covering the counties of lower Alabama and the panhandle of Florida. This year we were recognized as a platinum status chapter, which is the highest status, based on our work and participation to improve the quality of inpatient medicine.
As part of winning the platinum ribbon, we were awarded three complimentary registration scholarships to the SHM Annual Conference in 2019. The chapter leadership met and selected three individuals who have been involved with the chapter actively but have never had an opportunity to experience SHM’s Annual Conference. We selected a first-year resident, Dr. Avani Parrekh; a hospital medicine nurse practitioner, Madison Rivenbark; and a fourth-year medical student who is about to start his internal medicine residency, William Bancroft.
After the meeting we interviewed them to better understand their experience. Below are their thoughts.
Avani Parekh, MD
First year, Internal Medicine Residency
Southeast Health Medical Center
Dothan, Ala.
I am so thankful for the opportunity that was given to me by the Wiregrass chapter by sponsoring my attendance at the 2019 SHM Annual Conference in Washington. This was my first SHM conference, and it was truly a rewarding experience.
I thoroughly enjoyed attending the lectures. They were very informative and engaging. Every presenter was so passionate and inspiring. Coming from an “all-female class” of PGY-1 at my program, I especially enjoyed the “Fe(male) in medicine” talk, as well as Quick Talks on women in medicine. The “Updates in Hospital Medicine” session on various topics such as heart failure, pneumonia, and sepsis was outstanding. I was excited to apply the knowledge I gained from this event into my patient care.
Overall, it was a well-organized and up-to-date event. I am looking forward to attending more SHM conferences in the future.
Madison Rivenbark, NP
Department of Hospital Medicine
Southeast Health Medical Center
Dothan, Ala.
I was extremely fortunate to be selected to receive a scholarship that covered the conference fee for the 2019 SHM Annual Conference. This was my first SHM conference, and it was quite the learning experience. I enjoyed each educational session that I attended. I felt like I was able to bring something home with me that I can incorporate into my practice to better care for the patients that I see each day.
As mentioned above, I learned from each session, but my personal favorite was the “Updates in Hospital Medicine” session. I was very impressed by the enthusiasm of the two speakers. The information provided was presented so that it engaged each attendee.
Not only did I learn a wealth of valuable information that will help me in my career, I gained affirmation concerning my future educational endeavors. I was inspired to pursue a higher level of learning regarding my career. I witnessed this awesome organization that is filled with encouraging and motivating people, and I realized I wanted to be more involved on a local level, and maybe one day, on a larger level. In addition, this conference inspired me to continue to be a lifetime learner and to always crave more knowledge. I am blessed to be a part of hospital medicine. I look forward to the future of this specialty.
William Bancroft, MS IV
Alabama College of Osteopathic Medicine
Dothan, Ala.
I was honored to have been chosen by the Wiregrass chapter as the medical student representative for the SHM Annual Conference. I have been serving in the local chapter during both my 3rd and 4th years in different roles, from helping as a student liaison for our medical students to executive planning coordinator for events. It was a surprise when I got asked by the chapter to be their student representative, but one that I was very excited to accept.
This was my first medical conference. I had heard about what different conferences were like from many of my attendings, so I had some expectations, but this experience was so much better. I enjoyed meeting and networking with people. I also found myself eagerly waiting to get to the next lecture because I was getting an opportunity to hear about different case studies, new research outcomes, and new standards of care.
It was a real treat to learn about all the new changes to treatment, but even more encouraging to know that most of it was just reinforcing everything my attendings have been teaching us as medical students. I enjoyed my time at the SHM Annual Conference so much that I emailed all my new coresidents and encouraged them to join the Society.
Dr. Skandhan is a hospitalist at Southeast Health Medical Center in Dothan, Ala., as well as president and founder of the Wiregrass chapter of SHM.
The impact of HM19 on my practice
As an academic nurse practitioner hospitalist with faculty and leadership roles, I found that HM19 had many important and helpful topics that apply directly to my practice.
The “Onboarding Best Practices” session provided specific examples and tips for clinical ramp up, enculturation, and orienting staff to an academic career. As a result of this talk, I began the process of establishing a formal enculturation activity for new hires that includes a panel of senior advanced practice provider (APP) hospitalists to give career path advice.
The “Adaptive Leadership for Hospitalists” workshop provided the opportunity to practice emotional intelligence and effective communication in managing routine and difficult leadership interactions. The “Practice Models/Models of Care for Optimal Integration of NPs and PAs” presentation provided insight into variable team structures at other institutions that could be considered for improved efficiency in my group. The “Academic NP/PA” session provided ideas for how to apply for faculty positions in academic institutions. It also gave APPs who have faculty appointment specific illustrations of using current educational, quality improvement, and research projects to promote. I particularly found the “What Mentorship Has Meant to Me” talk significant. It gave practical essential advice on making sure there is chemistry and trust when seeking a mentor and staying engaged to be a successful mentee.
APPs, whether practicing in academic, private, or community settings, should attend the SHM Annual Conference. SHM is very inclusive and proud of APPs as colleagues and leaders. There are topics that directly apply to the needs of APP hospitalists – including career advancement – and that create excitement for APP practice in hospital medicine.
The Annual Conference also provides the very unique opportunity to meet and establish relationships with APP and physician colleagues and leaders nationwide. These relationships lend to career advancing opportunities for collaboration in clinical excellence, education, quality improvement, research, and leadership.
Dr. Apodaca is assistant professor and nurse practitioner hospitalist at the University of New Mexico. She is one of the first APPNP/PAs to receive faculty appointment at UNM. She serves as codirector of the UNM APP Hospital Medicine Fellowship and director of the APP Hospital Medicine Team. She is also the president of the New Mexico Chapter of SHM and is the first APP at her institution to achieve designation as a Fellow in Hospital Medicine.
As an academic nurse practitioner hospitalist with faculty and leadership roles, I found that HM19 had many important and helpful topics that apply directly to my practice.
The “Onboarding Best Practices” session provided specific examples and tips for clinical ramp up, enculturation, and orienting staff to an academic career. As a result of this talk, I began the process of establishing a formal enculturation activity for new hires that includes a panel of senior advanced practice provider (APP) hospitalists to give career path advice.
The “Adaptive Leadership for Hospitalists” workshop provided the opportunity to practice emotional intelligence and effective communication in managing routine and difficult leadership interactions. The “Practice Models/Models of Care for Optimal Integration of NPs and PAs” presentation provided insight into variable team structures at other institutions that could be considered for improved efficiency in my group. The “Academic NP/PA” session provided ideas for how to apply for faculty positions in academic institutions. It also gave APPs who have faculty appointment specific illustrations of using current educational, quality improvement, and research projects to promote. I particularly found the “What Mentorship Has Meant to Me” talk significant. It gave practical essential advice on making sure there is chemistry and trust when seeking a mentor and staying engaged to be a successful mentee.
APPs, whether practicing in academic, private, or community settings, should attend the SHM Annual Conference. SHM is very inclusive and proud of APPs as colleagues and leaders. There are topics that directly apply to the needs of APP hospitalists – including career advancement – and that create excitement for APP practice in hospital medicine.
The Annual Conference also provides the very unique opportunity to meet and establish relationships with APP and physician colleagues and leaders nationwide. These relationships lend to career advancing opportunities for collaboration in clinical excellence, education, quality improvement, research, and leadership.
Dr. Apodaca is assistant professor and nurse practitioner hospitalist at the University of New Mexico. She is one of the first APPNP/PAs to receive faculty appointment at UNM. She serves as codirector of the UNM APP Hospital Medicine Fellowship and director of the APP Hospital Medicine Team. She is also the president of the New Mexico Chapter of SHM and is the first APP at her institution to achieve designation as a Fellow in Hospital Medicine.
As an academic nurse practitioner hospitalist with faculty and leadership roles, I found that HM19 had many important and helpful topics that apply directly to my practice.
The “Onboarding Best Practices” session provided specific examples and tips for clinical ramp up, enculturation, and orienting staff to an academic career. As a result of this talk, I began the process of establishing a formal enculturation activity for new hires that includes a panel of senior advanced practice provider (APP) hospitalists to give career path advice.
The “Adaptive Leadership for Hospitalists” workshop provided the opportunity to practice emotional intelligence and effective communication in managing routine and difficult leadership interactions. The “Practice Models/Models of Care for Optimal Integration of NPs and PAs” presentation provided insight into variable team structures at other institutions that could be considered for improved efficiency in my group. The “Academic NP/PA” session provided ideas for how to apply for faculty positions in academic institutions. It also gave APPs who have faculty appointment specific illustrations of using current educational, quality improvement, and research projects to promote. I particularly found the “What Mentorship Has Meant to Me” talk significant. It gave practical essential advice on making sure there is chemistry and trust when seeking a mentor and staying engaged to be a successful mentee.
APPs, whether practicing in academic, private, or community settings, should attend the SHM Annual Conference. SHM is very inclusive and proud of APPs as colleagues and leaders. There are topics that directly apply to the needs of APP hospitalists – including career advancement – and that create excitement for APP practice in hospital medicine.
The Annual Conference also provides the very unique opportunity to meet and establish relationships with APP and physician colleagues and leaders nationwide. These relationships lend to career advancing opportunities for collaboration in clinical excellence, education, quality improvement, research, and leadership.
Dr. Apodaca is assistant professor and nurse practitioner hospitalist at the University of New Mexico. She is one of the first APPNP/PAs to receive faculty appointment at UNM. She serves as codirector of the UNM APP Hospital Medicine Fellowship and director of the APP Hospital Medicine Team. She is also the president of the New Mexico Chapter of SHM and is the first APP at her institution to achieve designation as a Fellow in Hospital Medicine.
HM19: Things we do for no reason
The pediatric version
Presenters
Amit K. Pahwa, MD, FAAP; Nicola Orlov, MD, MPH, FAAP
Workshop title
Things we do for no reason (pediatrics)
Session summary
As he began by stating the Institute of Medicine definition of high-value care (HVC), Amit K. Pahwa, MD, of Johns Hopkins Medicine, Baltimore, described HVC as the best care for the patient, with the optimal result for the circumstances, at the right price. But few pediatric residency programs provide education regarding HVC, with only 11% providing a formal HVC curriculum, as found by a survey of pediatric program directors and chief residents in a study published in 2017.
Dr. Pahwa then provided examples of cases in which HVC could be optimized, including reducing rebound bilirubin levels in neonatal hyperbilirubinemia, giving nasogastric feeds instead of IV hydration in bronchiolitis, reducing unnecessary vital sign checks, and providing apple juice supplemented with liquids of choice instead of more expensive oral electrolyte solutions.
Nicola Orlov, MD, of the University of Chicago presented another illustrative case which highlighted the need to reduce vital sign frequency when appropriate. This was linked to her work at Comer Children’s Hospital on reducing nighttime sleep disruptions in hospitalized children, as part of the SIESTA (Sleep for Inpatients: Empowering Staff to Act) study. This led to a significant reduction in nurse/physician interruptions during the study period.
Key takeaways for HM
- High-value care (HVC) is a key focus of systems improvement in the field of pediatric hospital medicine.
- Educational efforts for all levels of learners is inadequate currently, and needs to be augmented.
- Quality improvement projects to promote HVC can lead not only to reduced costs, but improved quality and patient experience.
Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital in Springfield, Mass., and is the pediatric editor of The Hospitalist.
The pediatric version
The pediatric version
Presenters
Amit K. Pahwa, MD, FAAP; Nicola Orlov, MD, MPH, FAAP
Workshop title
Things we do for no reason (pediatrics)
Session summary
As he began by stating the Institute of Medicine definition of high-value care (HVC), Amit K. Pahwa, MD, of Johns Hopkins Medicine, Baltimore, described HVC as the best care for the patient, with the optimal result for the circumstances, at the right price. But few pediatric residency programs provide education regarding HVC, with only 11% providing a formal HVC curriculum, as found by a survey of pediatric program directors and chief residents in a study published in 2017.
Dr. Pahwa then provided examples of cases in which HVC could be optimized, including reducing rebound bilirubin levels in neonatal hyperbilirubinemia, giving nasogastric feeds instead of IV hydration in bronchiolitis, reducing unnecessary vital sign checks, and providing apple juice supplemented with liquids of choice instead of more expensive oral electrolyte solutions.
Nicola Orlov, MD, of the University of Chicago presented another illustrative case which highlighted the need to reduce vital sign frequency when appropriate. This was linked to her work at Comer Children’s Hospital on reducing nighttime sleep disruptions in hospitalized children, as part of the SIESTA (Sleep for Inpatients: Empowering Staff to Act) study. This led to a significant reduction in nurse/physician interruptions during the study period.
Key takeaways for HM
- High-value care (HVC) is a key focus of systems improvement in the field of pediatric hospital medicine.
- Educational efforts for all levels of learners is inadequate currently, and needs to be augmented.
- Quality improvement projects to promote HVC can lead not only to reduced costs, but improved quality and patient experience.
Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital in Springfield, Mass., and is the pediatric editor of The Hospitalist.
Presenters
Amit K. Pahwa, MD, FAAP; Nicola Orlov, MD, MPH, FAAP
Workshop title
Things we do for no reason (pediatrics)
Session summary
As he began by stating the Institute of Medicine definition of high-value care (HVC), Amit K. Pahwa, MD, of Johns Hopkins Medicine, Baltimore, described HVC as the best care for the patient, with the optimal result for the circumstances, at the right price. But few pediatric residency programs provide education regarding HVC, with only 11% providing a formal HVC curriculum, as found by a survey of pediatric program directors and chief residents in a study published in 2017.
Dr. Pahwa then provided examples of cases in which HVC could be optimized, including reducing rebound bilirubin levels in neonatal hyperbilirubinemia, giving nasogastric feeds instead of IV hydration in bronchiolitis, reducing unnecessary vital sign checks, and providing apple juice supplemented with liquids of choice instead of more expensive oral electrolyte solutions.
Nicola Orlov, MD, of the University of Chicago presented another illustrative case which highlighted the need to reduce vital sign frequency when appropriate. This was linked to her work at Comer Children’s Hospital on reducing nighttime sleep disruptions in hospitalized children, as part of the SIESTA (Sleep for Inpatients: Empowering Staff to Act) study. This led to a significant reduction in nurse/physician interruptions during the study period.
Key takeaways for HM
- High-value care (HVC) is a key focus of systems improvement in the field of pediatric hospital medicine.
- Educational efforts for all levels of learners is inadequate currently, and needs to be augmented.
- Quality improvement projects to promote HVC can lead not only to reduced costs, but improved quality and patient experience.
Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital in Springfield, Mass., and is the pediatric editor of The Hospitalist.
HM19: Pediatric sepsis
Improving recognition and treatment
Presenters
Elise van der Jagt, MD, MPH
Workshop title
What you need to know about pediatric sepsis
Session summary
Dr. Elise van der Jagt of the University of Rochester (N.Y.) Medical Center, introduced the topic of pediatric sepsis and its epidemiology with the story of 12-year-old Rory Staunton, who died in 2012 of sepsis. In pediatrics, sepsis is the 10th leading cause of death, with severe sepsis having a mortality rate of 4%-10%. As a response to Rory Staunton’s death from sepsis, New York Governor Andrew Cuomo mandated all hospitals to implement ways to improve recognition and treatment of septic shock, especially in children.
The definition and management of sepsis in pediatrics is complex, and forms a spectrum of disease from sepsis to severe sepsis, and septic shock. Dr. van der Jagt advised not to use the adult sepsis definition in children. Sepsis, stated Dr. van der Jagt, is systemic inflammatory response syndrome in association with suspected or proven infection. Severe sepsis is sepsis with cardiovascular dysfunction, respiratory dysfunction, or dysfunction of two other systems. Septic shock is sepsis with cardiovascular dysfunction that persists despite 40 mL/kg of fluid bolus in 1 hour.
Early recognition and management of sepsis decreases mortality. Early recognition can be improved by initiating a recognition bundle. Multiple trigger tools are available such as pSOFA (Pediatric Sequential Organ Failure Assessment). Any trigger tool, however, must be combined with physician evaluation. This clinician assessment should be initiated within 15 minutes for any patient who screens positive with a trigger tool.
Resuscitation bundles also decrease mortality. A good goal is establishing intravenous or intraosseous access within 5 minutes, fluid administration within 30 minutes, and antibiotics and inotrope administration (if needed) in 60 minutes. Resuscitation bundles could include a sepsis clock, rapid response team, check list, protocol, and order set. Additional studies are needed to determine which of the components of a sepsis bundle is most important. Studies show that mortality increases with delays in initiating fluids and less fluids given. However, giving too much fluid also increases morbidity. It is imperative, stated Dr. van der Jagt, to reassess after fluid boluses. Use of lactate measurement can be problematic in pediatrics, as normal lactate can be seen with florid sepsis.
Stabilization bundles are more common in the ICU setting. They include an arterial line, central venous pressure, cardiopulmonary monitor, urinary catheter, and pulse oximeter. A performance bundle is important to assess adherence to the other bundles. This could include providing debriefing, data review, feedback, and formal quality improvement projects. Assigning a sepsis champion in each area helps to overcome barriers and continue performance bundles.
Key takeaways for HM
- Patients with severe sepsis/septic shock should be rapidly identified with the 2014/2017 American College of Critical Care Medicine consensus criteria.
- Efficient, time-based care should be provided during the first hour after recognizing pediatric severe sepsis/septic shock.
- Overcoming systems barriers to rapid sepsis recognition and treatment requires sepsis champions in each area, continuous data collection and feedback, persistence, and patience.
Dr. Eboh is a pediatric hospitalist at Covenant Children’s Hospital in Lubbock, Texas, and assistant professor of pediatrics at Texas Tech University Health Sciences Center. Dr. Wright is a pediatric hospitalist at Texas Tech University Health Sciences Center.
Improving recognition and treatment
Improving recognition and treatment
Presenters
Elise van der Jagt, MD, MPH
Workshop title
What you need to know about pediatric sepsis
Session summary
Dr. Elise van der Jagt of the University of Rochester (N.Y.) Medical Center, introduced the topic of pediatric sepsis and its epidemiology with the story of 12-year-old Rory Staunton, who died in 2012 of sepsis. In pediatrics, sepsis is the 10th leading cause of death, with severe sepsis having a mortality rate of 4%-10%. As a response to Rory Staunton’s death from sepsis, New York Governor Andrew Cuomo mandated all hospitals to implement ways to improve recognition and treatment of septic shock, especially in children.
The definition and management of sepsis in pediatrics is complex, and forms a spectrum of disease from sepsis to severe sepsis, and septic shock. Dr. van der Jagt advised not to use the adult sepsis definition in children. Sepsis, stated Dr. van der Jagt, is systemic inflammatory response syndrome in association with suspected or proven infection. Severe sepsis is sepsis with cardiovascular dysfunction, respiratory dysfunction, or dysfunction of two other systems. Septic shock is sepsis with cardiovascular dysfunction that persists despite 40 mL/kg of fluid bolus in 1 hour.
Early recognition and management of sepsis decreases mortality. Early recognition can be improved by initiating a recognition bundle. Multiple trigger tools are available such as pSOFA (Pediatric Sequential Organ Failure Assessment). Any trigger tool, however, must be combined with physician evaluation. This clinician assessment should be initiated within 15 minutes for any patient who screens positive with a trigger tool.
Resuscitation bundles also decrease mortality. A good goal is establishing intravenous or intraosseous access within 5 minutes, fluid administration within 30 minutes, and antibiotics and inotrope administration (if needed) in 60 minutes. Resuscitation bundles could include a sepsis clock, rapid response team, check list, protocol, and order set. Additional studies are needed to determine which of the components of a sepsis bundle is most important. Studies show that mortality increases with delays in initiating fluids and less fluids given. However, giving too much fluid also increases morbidity. It is imperative, stated Dr. van der Jagt, to reassess after fluid boluses. Use of lactate measurement can be problematic in pediatrics, as normal lactate can be seen with florid sepsis.
Stabilization bundles are more common in the ICU setting. They include an arterial line, central venous pressure, cardiopulmonary monitor, urinary catheter, and pulse oximeter. A performance bundle is important to assess adherence to the other bundles. This could include providing debriefing, data review, feedback, and formal quality improvement projects. Assigning a sepsis champion in each area helps to overcome barriers and continue performance bundles.
Key takeaways for HM
- Patients with severe sepsis/septic shock should be rapidly identified with the 2014/2017 American College of Critical Care Medicine consensus criteria.
- Efficient, time-based care should be provided during the first hour after recognizing pediatric severe sepsis/septic shock.
- Overcoming systems barriers to rapid sepsis recognition and treatment requires sepsis champions in each area, continuous data collection and feedback, persistence, and patience.
Dr. Eboh is a pediatric hospitalist at Covenant Children’s Hospital in Lubbock, Texas, and assistant professor of pediatrics at Texas Tech University Health Sciences Center. Dr. Wright is a pediatric hospitalist at Texas Tech University Health Sciences Center.
Presenters
Elise van der Jagt, MD, MPH
Workshop title
What you need to know about pediatric sepsis
Session summary
Dr. Elise van der Jagt of the University of Rochester (N.Y.) Medical Center, introduced the topic of pediatric sepsis and its epidemiology with the story of 12-year-old Rory Staunton, who died in 2012 of sepsis. In pediatrics, sepsis is the 10th leading cause of death, with severe sepsis having a mortality rate of 4%-10%. As a response to Rory Staunton’s death from sepsis, New York Governor Andrew Cuomo mandated all hospitals to implement ways to improve recognition and treatment of septic shock, especially in children.
The definition and management of sepsis in pediatrics is complex, and forms a spectrum of disease from sepsis to severe sepsis, and septic shock. Dr. van der Jagt advised not to use the adult sepsis definition in children. Sepsis, stated Dr. van der Jagt, is systemic inflammatory response syndrome in association with suspected or proven infection. Severe sepsis is sepsis with cardiovascular dysfunction, respiratory dysfunction, or dysfunction of two other systems. Septic shock is sepsis with cardiovascular dysfunction that persists despite 40 mL/kg of fluid bolus in 1 hour.
Early recognition and management of sepsis decreases mortality. Early recognition can be improved by initiating a recognition bundle. Multiple trigger tools are available such as pSOFA (Pediatric Sequential Organ Failure Assessment). Any trigger tool, however, must be combined with physician evaluation. This clinician assessment should be initiated within 15 minutes for any patient who screens positive with a trigger tool.
Resuscitation bundles also decrease mortality. A good goal is establishing intravenous or intraosseous access within 5 minutes, fluid administration within 30 minutes, and antibiotics and inotrope administration (if needed) in 60 minutes. Resuscitation bundles could include a sepsis clock, rapid response team, check list, protocol, and order set. Additional studies are needed to determine which of the components of a sepsis bundle is most important. Studies show that mortality increases with delays in initiating fluids and less fluids given. However, giving too much fluid also increases morbidity. It is imperative, stated Dr. van der Jagt, to reassess after fluid boluses. Use of lactate measurement can be problematic in pediatrics, as normal lactate can be seen with florid sepsis.
Stabilization bundles are more common in the ICU setting. They include an arterial line, central venous pressure, cardiopulmonary monitor, urinary catheter, and pulse oximeter. A performance bundle is important to assess adherence to the other bundles. This could include providing debriefing, data review, feedback, and formal quality improvement projects. Assigning a sepsis champion in each area helps to overcome barriers and continue performance bundles.
Key takeaways for HM
- Patients with severe sepsis/septic shock should be rapidly identified with the 2014/2017 American College of Critical Care Medicine consensus criteria.
- Efficient, time-based care should be provided during the first hour after recognizing pediatric severe sepsis/septic shock.
- Overcoming systems barriers to rapid sepsis recognition and treatment requires sepsis champions in each area, continuous data collection and feedback, persistence, and patience.
Dr. Eboh is a pediatric hospitalist at Covenant Children’s Hospital in Lubbock, Texas, and assistant professor of pediatrics at Texas Tech University Health Sciences Center. Dr. Wright is a pediatric hospitalist at Texas Tech University Health Sciences Center.
HM19: Interprofessional rounds
Better process, outcomes
Session presenters
Surekha Bhamidipati, MD, FACP; Preetham Talari, MD, FACP, SFHM; Mark V. Williams, MD, FACP, MHM
Session title
Interprofessional rounds: What’s the right way?
Session summary
Interprofessional or multidisciplinary rounds involve all members of the care delivery team, including physicians, nurses, case managers, social workers, pharmacists, nurse facilitators, and of course, patients. The primary goal for these rounds is patient-centered care, and to improve communication among the health care team members, as well as with patients and their families.
At HM19, Dr. Preetham Talari and Dr. Mark Williams of the University of Kentucky, and Dr. Surekha Bhamidipati of Christiana Care Health System in Newark, Del., discussed their system-based efforts to try to implement interprofessional rounds, and the role of these rounds in improving patient outcome measures.
The presenters noted that the purpose of these rounds is effective communication and efficient patient care. As shown by multiple studies, there is significant impact in team member satisfaction, decrease in length of stay,1 reduction in adverse events2 and improvement in patient experience.3 They emphasized the importance of implementing these rounds at the bedside, so that patients and families can be engaged in the patient’s care, thereby improving closed communication among the team and the patient. These rounds always offer an opportunity for the patient to ask questions of multiple health care team members as they are gathered together at the same time.
The University of Kentucky named these rounds the “Interprofessional Teamwork Innovation Model (ITIM),” to promote communication and patient-centered coordinated care. Their model showed a significant reduction in readmission rates, and no increase in costs despite adding pharmacy and case managers to the rounds.
Dr. Bhamidipati described how Christiana Care Health System designed multidisciplinary rounds based on the application of Team STEPPS 2.0, a teamwork system developed by the Department of Defense and the Agency for Healthcare Research and Quality to improve the institutional collaboration and communication relating to patient safety.
The Christiana Care model is based on a few principles of team structure, communication, leadership, situation monitoring, and mutual support. The interprofessional team was trained and observed, and a short video recording was made. This video was used as an educational tool in coaching the rest of the team. Dr. Bhamidipati described the importance of interprofessional leaders as coaches to train other team members, and highlighted the engagement of unit leaders in successfully implementing these rounds. The Christiana Care team used its informational technology system to collect real-time data, which was then used for team review.
In summary, the presenters from both the University of Kentucky and Christiana Care highlighted the importance of interprofessional rounds, as well as the need for continued measurement of process and outcome metrics.
Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, Hospital Medicine, at Baystate Medical Center, Springfield, Mass.
References
1. Yoo JW et al. Effects of an internal medicine floor interdisciplinary team on hospital and clinical outcomes of seniors with acute medical illness. Geriatr Gerontol Int. 2013 Oct;13(4):942-8. doi: 10.1111/ggi.12035. Epub 2013 Feb 26.
2. O’Leary KJ et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011 Apr 11;171(7):678-84. doi: 10.1001/archinternmed.2011.128.
3. Ratelle JT et al. Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Qual Saf. 2019;28:317-326.
Better process, outcomes
Better process, outcomes
Session presenters
Surekha Bhamidipati, MD, FACP; Preetham Talari, MD, FACP, SFHM; Mark V. Williams, MD, FACP, MHM
Session title
Interprofessional rounds: What’s the right way?
Session summary
Interprofessional or multidisciplinary rounds involve all members of the care delivery team, including physicians, nurses, case managers, social workers, pharmacists, nurse facilitators, and of course, patients. The primary goal for these rounds is patient-centered care, and to improve communication among the health care team members, as well as with patients and their families.
At HM19, Dr. Preetham Talari and Dr. Mark Williams of the University of Kentucky, and Dr. Surekha Bhamidipati of Christiana Care Health System in Newark, Del., discussed their system-based efforts to try to implement interprofessional rounds, and the role of these rounds in improving patient outcome measures.
The presenters noted that the purpose of these rounds is effective communication and efficient patient care. As shown by multiple studies, there is significant impact in team member satisfaction, decrease in length of stay,1 reduction in adverse events2 and improvement in patient experience.3 They emphasized the importance of implementing these rounds at the bedside, so that patients and families can be engaged in the patient’s care, thereby improving closed communication among the team and the patient. These rounds always offer an opportunity for the patient to ask questions of multiple health care team members as they are gathered together at the same time.
The University of Kentucky named these rounds the “Interprofessional Teamwork Innovation Model (ITIM),” to promote communication and patient-centered coordinated care. Their model showed a significant reduction in readmission rates, and no increase in costs despite adding pharmacy and case managers to the rounds.
Dr. Bhamidipati described how Christiana Care Health System designed multidisciplinary rounds based on the application of Team STEPPS 2.0, a teamwork system developed by the Department of Defense and the Agency for Healthcare Research and Quality to improve the institutional collaboration and communication relating to patient safety.
The Christiana Care model is based on a few principles of team structure, communication, leadership, situation monitoring, and mutual support. The interprofessional team was trained and observed, and a short video recording was made. This video was used as an educational tool in coaching the rest of the team. Dr. Bhamidipati described the importance of interprofessional leaders as coaches to train other team members, and highlighted the engagement of unit leaders in successfully implementing these rounds. The Christiana Care team used its informational technology system to collect real-time data, which was then used for team review.
In summary, the presenters from both the University of Kentucky and Christiana Care highlighted the importance of interprofessional rounds, as well as the need for continued measurement of process and outcome metrics.
Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, Hospital Medicine, at Baystate Medical Center, Springfield, Mass.
References
1. Yoo JW et al. Effects of an internal medicine floor interdisciplinary team on hospital and clinical outcomes of seniors with acute medical illness. Geriatr Gerontol Int. 2013 Oct;13(4):942-8. doi: 10.1111/ggi.12035. Epub 2013 Feb 26.
2. O’Leary KJ et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011 Apr 11;171(7):678-84. doi: 10.1001/archinternmed.2011.128.
3. Ratelle JT et al. Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Qual Saf. 2019;28:317-326.
Session presenters
Surekha Bhamidipati, MD, FACP; Preetham Talari, MD, FACP, SFHM; Mark V. Williams, MD, FACP, MHM
Session title
Interprofessional rounds: What’s the right way?
Session summary
Interprofessional or multidisciplinary rounds involve all members of the care delivery team, including physicians, nurses, case managers, social workers, pharmacists, nurse facilitators, and of course, patients. The primary goal for these rounds is patient-centered care, and to improve communication among the health care team members, as well as with patients and their families.
At HM19, Dr. Preetham Talari and Dr. Mark Williams of the University of Kentucky, and Dr. Surekha Bhamidipati of Christiana Care Health System in Newark, Del., discussed their system-based efforts to try to implement interprofessional rounds, and the role of these rounds in improving patient outcome measures.
The presenters noted that the purpose of these rounds is effective communication and efficient patient care. As shown by multiple studies, there is significant impact in team member satisfaction, decrease in length of stay,1 reduction in adverse events2 and improvement in patient experience.3 They emphasized the importance of implementing these rounds at the bedside, so that patients and families can be engaged in the patient’s care, thereby improving closed communication among the team and the patient. These rounds always offer an opportunity for the patient to ask questions of multiple health care team members as they are gathered together at the same time.
The University of Kentucky named these rounds the “Interprofessional Teamwork Innovation Model (ITIM),” to promote communication and patient-centered coordinated care. Their model showed a significant reduction in readmission rates, and no increase in costs despite adding pharmacy and case managers to the rounds.
Dr. Bhamidipati described how Christiana Care Health System designed multidisciplinary rounds based on the application of Team STEPPS 2.0, a teamwork system developed by the Department of Defense and the Agency for Healthcare Research and Quality to improve the institutional collaboration and communication relating to patient safety.
The Christiana Care model is based on a few principles of team structure, communication, leadership, situation monitoring, and mutual support. The interprofessional team was trained and observed, and a short video recording was made. This video was used as an educational tool in coaching the rest of the team. Dr. Bhamidipati described the importance of interprofessional leaders as coaches to train other team members, and highlighted the engagement of unit leaders in successfully implementing these rounds. The Christiana Care team used its informational technology system to collect real-time data, which was then used for team review.
In summary, the presenters from both the University of Kentucky and Christiana Care highlighted the importance of interprofessional rounds, as well as the need for continued measurement of process and outcome metrics.
Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, Hospital Medicine, at Baystate Medical Center, Springfield, Mass.
References
1. Yoo JW et al. Effects of an internal medicine floor interdisciplinary team on hospital and clinical outcomes of seniors with acute medical illness. Geriatr Gerontol Int. 2013 Oct;13(4):942-8. doi: 10.1111/ggi.12035. Epub 2013 Feb 26.
2. O’Leary KJ et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011 Apr 11;171(7):678-84. doi: 10.1001/archinternmed.2011.128.
3. Ratelle JT et al. Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Qual Saf. 2019;28:317-326.
HM19: Pediatric clinical conundrums
Atypical symptoms and diagnoses
Presenters
Yemisi Jones, MD; Mirna Giordano, MD
Session title
Pediatric Clinical Conundrums
Session summary
Dr. Mirna Giordano of Columbia University Irving Medical Center, New York, and Dr. Yemisi Jones of Cincinnati Children’s Hospital Medical Center, moderated the Pediatric Clinical Conundrums session at HM19. After reviewing multiple submissions, they invited four trainees to present their interesting cases.
Malignancy or infection? Dr. Jeremy Brown, a resident at the University of Louisville, presented a case of a 15-year-old male with right upper quadrant abdominal pain with associated weight loss and intermittent fevers, over the course of several weeks. CT revealed multiple liver lesions, providing concern for possible malignancy, although liver biopsy proved otherwise, with mostly liquefactive tissue and benign liver parenchyma. After a large infectious work-up ensued, the patient was diagnosed with disseminated Bartonella. He was treated with a 10-day course of azithromycin, and his symptoms resolved.
Leg blisters as an uncommon manifestation of a common childhood disease. Dr. Stefan Mammele, a resident at Kapi’olani Medical Center in Honolulu, and the University of Hawaii, presented a case of an 11-year-old boy with a painful and pruritic rash associated with multiple 5- to 10-mm tense bullae located on the patient’s bilateral lower extremities with extension to the trunk. The patient was also found to have hematuria and proteinuria. The bullae drained both serosanguinous and purulent material. Fluid culture grew group A Streptococcus and skin biopsy confirmed IgA vasculitis. Bullae are a rare characteristic of Henoch Schönlein pupura in children, but are more commonly seen as a disease manifestation in adults. The patient was treated with cefazolin, and his lesions improved over the course of several weeks with resolution of his hematuria by 6 months.
Is she crying blood? Dr. Joshua Price, a resident at Baystate Children’s Hospital in Springfield, Mass., described a 12-year-old female who presented with 7 days of left-sided hemolacria with acute vision loss and unilateral eye pain. This patient did not respond to outpatient topical steroids and antibiotics, as prescribed by ophthalmology. For this reason, she underwent further work-up and imaging. MRI of the head and orbits revealed left maxillary sinus disease. She was treated with antibiotics for acute left maxillary sinusitis and her hemolacria resolved within 24 hours. While the differential diagnosis for hemolacria is broad, rarely acute sinusitis has been reported as a cause in medical literature.
Recurrent bronchiolitis or something more? Dr. Moira Black, a resident at Children’s Memorial Hermann in Houston, presented a case of a 7-month-old female with a history of recurrent admissions for increased work of breathing believed to be secondary to viral bronchiolitis. Her first hospitalization occurred at 7 weeks of age and was complicated by spontaneous pneumothorax requiring chest tube placement. She was again hospitalized at 5 months of age with resolution of her increased work of breathing with high-flow nasal cannula. She presented again at 7 months of age with presumed bronchiolitis, however, she decompensated and required intubation on the 5th day of hospitalization. A bronchoscopy was performed and revealed a significantly narrowed left bronchus at the carina and a blind pouch on the right with notable pulsation of the walls. She underwent further imaging and was ultimately diagnosed with a left pulmonary artery sling. Left pulmonary artery slings are a rare, but potentially fatal anomaly that can present with wheezing, stridor, and recurrent respiratory infections. Patient underwent correction by cardiovascular surgery and has since been doing well.
Key takeaways for HM
• Bartonella is a common cause of fever of unknown origin, and should be considered in unusual presentations of febrile illnesses.
• Bullae in IgA vasculitis are rare in children and do not have prognostic value, but streptococcal infection may be a trigger for IgA vasculitis.
• Hemolacria is an atypical presentation of rare and common diagnoses that should prompt further work-up.
• Acute respiratory distress can be caused by underlying cardiac or vascular anomalies and can be mistaken for common viral illnesses.
Dr. Marsicek is a pediatric hospital medicine fellow at Johns Hopkins All Children’s Hospital, St. Petersburg, Fla. Dr. Wysocka is a pediatric resident at Johns Hopkins All Children’s Hospital.
Atypical symptoms and diagnoses
Atypical symptoms and diagnoses
Presenters
Yemisi Jones, MD; Mirna Giordano, MD
Session title
Pediatric Clinical Conundrums
Session summary
Dr. Mirna Giordano of Columbia University Irving Medical Center, New York, and Dr. Yemisi Jones of Cincinnati Children’s Hospital Medical Center, moderated the Pediatric Clinical Conundrums session at HM19. After reviewing multiple submissions, they invited four trainees to present their interesting cases.
Malignancy or infection? Dr. Jeremy Brown, a resident at the University of Louisville, presented a case of a 15-year-old male with right upper quadrant abdominal pain with associated weight loss and intermittent fevers, over the course of several weeks. CT revealed multiple liver lesions, providing concern for possible malignancy, although liver biopsy proved otherwise, with mostly liquefactive tissue and benign liver parenchyma. After a large infectious work-up ensued, the patient was diagnosed with disseminated Bartonella. He was treated with a 10-day course of azithromycin, and his symptoms resolved.
Leg blisters as an uncommon manifestation of a common childhood disease. Dr. Stefan Mammele, a resident at Kapi’olani Medical Center in Honolulu, and the University of Hawaii, presented a case of an 11-year-old boy with a painful and pruritic rash associated with multiple 5- to 10-mm tense bullae located on the patient’s bilateral lower extremities with extension to the trunk. The patient was also found to have hematuria and proteinuria. The bullae drained both serosanguinous and purulent material. Fluid culture grew group A Streptococcus and skin biopsy confirmed IgA vasculitis. Bullae are a rare characteristic of Henoch Schönlein pupura in children, but are more commonly seen as a disease manifestation in adults. The patient was treated with cefazolin, and his lesions improved over the course of several weeks with resolution of his hematuria by 6 months.
Is she crying blood? Dr. Joshua Price, a resident at Baystate Children’s Hospital in Springfield, Mass., described a 12-year-old female who presented with 7 days of left-sided hemolacria with acute vision loss and unilateral eye pain. This patient did not respond to outpatient topical steroids and antibiotics, as prescribed by ophthalmology. For this reason, she underwent further work-up and imaging. MRI of the head and orbits revealed left maxillary sinus disease. She was treated with antibiotics for acute left maxillary sinusitis and her hemolacria resolved within 24 hours. While the differential diagnosis for hemolacria is broad, rarely acute sinusitis has been reported as a cause in medical literature.
Recurrent bronchiolitis or something more? Dr. Moira Black, a resident at Children’s Memorial Hermann in Houston, presented a case of a 7-month-old female with a history of recurrent admissions for increased work of breathing believed to be secondary to viral bronchiolitis. Her first hospitalization occurred at 7 weeks of age and was complicated by spontaneous pneumothorax requiring chest tube placement. She was again hospitalized at 5 months of age with resolution of her increased work of breathing with high-flow nasal cannula. She presented again at 7 months of age with presumed bronchiolitis, however, she decompensated and required intubation on the 5th day of hospitalization. A bronchoscopy was performed and revealed a significantly narrowed left bronchus at the carina and a blind pouch on the right with notable pulsation of the walls. She underwent further imaging and was ultimately diagnosed with a left pulmonary artery sling. Left pulmonary artery slings are a rare, but potentially fatal anomaly that can present with wheezing, stridor, and recurrent respiratory infections. Patient underwent correction by cardiovascular surgery and has since been doing well.
Key takeaways for HM
• Bartonella is a common cause of fever of unknown origin, and should be considered in unusual presentations of febrile illnesses.
• Bullae in IgA vasculitis are rare in children and do not have prognostic value, but streptococcal infection may be a trigger for IgA vasculitis.
• Hemolacria is an atypical presentation of rare and common diagnoses that should prompt further work-up.
• Acute respiratory distress can be caused by underlying cardiac or vascular anomalies and can be mistaken for common viral illnesses.
Dr. Marsicek is a pediatric hospital medicine fellow at Johns Hopkins All Children’s Hospital, St. Petersburg, Fla. Dr. Wysocka is a pediatric resident at Johns Hopkins All Children’s Hospital.
Presenters
Yemisi Jones, MD; Mirna Giordano, MD
Session title
Pediatric Clinical Conundrums
Session summary
Dr. Mirna Giordano of Columbia University Irving Medical Center, New York, and Dr. Yemisi Jones of Cincinnati Children’s Hospital Medical Center, moderated the Pediatric Clinical Conundrums session at HM19. After reviewing multiple submissions, they invited four trainees to present their interesting cases.
Malignancy or infection? Dr. Jeremy Brown, a resident at the University of Louisville, presented a case of a 15-year-old male with right upper quadrant abdominal pain with associated weight loss and intermittent fevers, over the course of several weeks. CT revealed multiple liver lesions, providing concern for possible malignancy, although liver biopsy proved otherwise, with mostly liquefactive tissue and benign liver parenchyma. After a large infectious work-up ensued, the patient was diagnosed with disseminated Bartonella. He was treated with a 10-day course of azithromycin, and his symptoms resolved.
Leg blisters as an uncommon manifestation of a common childhood disease. Dr. Stefan Mammele, a resident at Kapi’olani Medical Center in Honolulu, and the University of Hawaii, presented a case of an 11-year-old boy with a painful and pruritic rash associated with multiple 5- to 10-mm tense bullae located on the patient’s bilateral lower extremities with extension to the trunk. The patient was also found to have hematuria and proteinuria. The bullae drained both serosanguinous and purulent material. Fluid culture grew group A Streptococcus and skin biopsy confirmed IgA vasculitis. Bullae are a rare characteristic of Henoch Schönlein pupura in children, but are more commonly seen as a disease manifestation in adults. The patient was treated with cefazolin, and his lesions improved over the course of several weeks with resolution of his hematuria by 6 months.
Is she crying blood? Dr. Joshua Price, a resident at Baystate Children’s Hospital in Springfield, Mass., described a 12-year-old female who presented with 7 days of left-sided hemolacria with acute vision loss and unilateral eye pain. This patient did not respond to outpatient topical steroids and antibiotics, as prescribed by ophthalmology. For this reason, she underwent further work-up and imaging. MRI of the head and orbits revealed left maxillary sinus disease. She was treated with antibiotics for acute left maxillary sinusitis and her hemolacria resolved within 24 hours. While the differential diagnosis for hemolacria is broad, rarely acute sinusitis has been reported as a cause in medical literature.
Recurrent bronchiolitis or something more? Dr. Moira Black, a resident at Children’s Memorial Hermann in Houston, presented a case of a 7-month-old female with a history of recurrent admissions for increased work of breathing believed to be secondary to viral bronchiolitis. Her first hospitalization occurred at 7 weeks of age and was complicated by spontaneous pneumothorax requiring chest tube placement. She was again hospitalized at 5 months of age with resolution of her increased work of breathing with high-flow nasal cannula. She presented again at 7 months of age with presumed bronchiolitis, however, she decompensated and required intubation on the 5th day of hospitalization. A bronchoscopy was performed and revealed a significantly narrowed left bronchus at the carina and a blind pouch on the right with notable pulsation of the walls. She underwent further imaging and was ultimately diagnosed with a left pulmonary artery sling. Left pulmonary artery slings are a rare, but potentially fatal anomaly that can present with wheezing, stridor, and recurrent respiratory infections. Patient underwent correction by cardiovascular surgery and has since been doing well.
Key takeaways for HM
• Bartonella is a common cause of fever of unknown origin, and should be considered in unusual presentations of febrile illnesses.
• Bullae in IgA vasculitis are rare in children and do not have prognostic value, but streptococcal infection may be a trigger for IgA vasculitis.
• Hemolacria is an atypical presentation of rare and common diagnoses that should prompt further work-up.
• Acute respiratory distress can be caused by underlying cardiac or vascular anomalies and can be mistaken for common viral illnesses.
Dr. Marsicek is a pediatric hospital medicine fellow at Johns Hopkins All Children’s Hospital, St. Petersburg, Fla. Dr. Wysocka is a pediatric resident at Johns Hopkins All Children’s Hospital.
HM19: Practice management tips for pediatric HMGs
Presenter
H. Barrett Fromme, MD, MHPE, FAAP
Session title
Sustainability Isn’t Just For The Forests: Practice management tips for long-term success in your Pediatric Hospital Medicine Group
Session summary
Dr. H. Barrett Fromme of the University of Chicago presented and facilitated a dialogue of sustainability. The audience was guided through a discussion of how efficiency and resources, workload and job demands, work-life integration and social support, and community at work can either lead to burnout or engagement within a Pediatric Hospital Medicine Group.
For each of the four topics, Dr. Fromme presented how individuals and leaders can leverage these areas to counteract burnout and promote engagement, ultimately leading to vitality within the practice group.
She closed her discussion stating that sustainability is a “process that maintains change in a balanced environment of resources, technology, and institutional change [that] are in harmony, and enhances current and future potential to meet human aspirations and needs.”
Key takeaways for HM
- Leaders can advocate with hospital leadership to optimize individual workload and job demands.
- Individuals and leaders can improve care process and clinical work flow to optimize efficiency and resources.
- Individuals and leaders can build high-functioning teams and cultivate communities of practice.
- Individuals and leaders can work together to develop goals to optimize work-life integration.
- Leaders can support values, autonomy, and growth to create an environment where individuals actively value and support their colleagues.
Dr. Kumar is a pediatric hospitalist at Cleveland Clinic Children’s and clinical assistant professor of pediatrics at Cleveland Clinic Lerner College of Medicine at Case Western Reserve University. She serves as the cochair of Pediatric Grand Rounds and is the research director for the Pediatric Hospital Medicine Fellowship at Cleveland Clinic Children’s.
Presenter
H. Barrett Fromme, MD, MHPE, FAAP
Session title
Sustainability Isn’t Just For The Forests: Practice management tips for long-term success in your Pediatric Hospital Medicine Group
Session summary
Dr. H. Barrett Fromme of the University of Chicago presented and facilitated a dialogue of sustainability. The audience was guided through a discussion of how efficiency and resources, workload and job demands, work-life integration and social support, and community at work can either lead to burnout or engagement within a Pediatric Hospital Medicine Group.
For each of the four topics, Dr. Fromme presented how individuals and leaders can leverage these areas to counteract burnout and promote engagement, ultimately leading to vitality within the practice group.
She closed her discussion stating that sustainability is a “process that maintains change in a balanced environment of resources, technology, and institutional change [that] are in harmony, and enhances current and future potential to meet human aspirations and needs.”
Key takeaways for HM
- Leaders can advocate with hospital leadership to optimize individual workload and job demands.
- Individuals and leaders can improve care process and clinical work flow to optimize efficiency and resources.
- Individuals and leaders can build high-functioning teams and cultivate communities of practice.
- Individuals and leaders can work together to develop goals to optimize work-life integration.
- Leaders can support values, autonomy, and growth to create an environment where individuals actively value and support their colleagues.
Dr. Kumar is a pediatric hospitalist at Cleveland Clinic Children’s and clinical assistant professor of pediatrics at Cleveland Clinic Lerner College of Medicine at Case Western Reserve University. She serves as the cochair of Pediatric Grand Rounds and is the research director for the Pediatric Hospital Medicine Fellowship at Cleveland Clinic Children’s.
Presenter
H. Barrett Fromme, MD, MHPE, FAAP
Session title
Sustainability Isn’t Just For The Forests: Practice management tips for long-term success in your Pediatric Hospital Medicine Group
Session summary
Dr. H. Barrett Fromme of the University of Chicago presented and facilitated a dialogue of sustainability. The audience was guided through a discussion of how efficiency and resources, workload and job demands, work-life integration and social support, and community at work can either lead to burnout or engagement within a Pediatric Hospital Medicine Group.
For each of the four topics, Dr. Fromme presented how individuals and leaders can leverage these areas to counteract burnout and promote engagement, ultimately leading to vitality within the practice group.
She closed her discussion stating that sustainability is a “process that maintains change in a balanced environment of resources, technology, and institutional change [that] are in harmony, and enhances current and future potential to meet human aspirations and needs.”
Key takeaways for HM
- Leaders can advocate with hospital leadership to optimize individual workload and job demands.
- Individuals and leaders can improve care process and clinical work flow to optimize efficiency and resources.
- Individuals and leaders can build high-functioning teams and cultivate communities of practice.
- Individuals and leaders can work together to develop goals to optimize work-life integration.
- Leaders can support values, autonomy, and growth to create an environment where individuals actively value and support their colleagues.
Dr. Kumar is a pediatric hospitalist at Cleveland Clinic Children’s and clinical assistant professor of pediatrics at Cleveland Clinic Lerner College of Medicine at Case Western Reserve University. She serves as the cochair of Pediatric Grand Rounds and is the research director for the Pediatric Hospital Medicine Fellowship at Cleveland Clinic Children’s.
Best of RIV highlights practical, innovative projects
Delirium, alcohol detox, and med rec
A project to improve how hospitalists address inpatient delirium, which has led to reductions in length of stay and cost, took center stage in the Best of RIV plenary session at HM19 in March.
The project, conducted at the University of California, San Francisco (UCSF), was presented alongside projects on alcohol detox at the Cleveland Veterans Affairs Medical Center and on medication reconciliation at Brigham and Women’s Hospital in Boston.
“The plenary is the top three of the 1,000 that are out there – so, impressive work,” said Benji Mathews, MD, SFHM, the chair of the Research, Innovations and Vignettes competition.
At UCSF, the project was meant to tackle the huge problem of delirium in the hospital, said Catherine Lau, MD, SFHM, associate professor of medicine there. Each year delirium affects more than 7 million people who are hospitalized, and hospital-acquired delirium is linked with prolonged stays and more emergency department visits and hospital readmissions. But research has found that as many as a third of these hospital-acquired cases can be prevented, Dr. Lau said.
New admissions and transfers – a total of more than 2,800 patients – were assessed for delirium risk, and those deemed high risk were entered into a delirium care plan, aimed at prevention with nonpharmacologic steps such as maximizing their mobility and helping them sleep at night.
All patients also were screened on every nursing shift for delirium, and those diagnosed with the disorder were placed in the delirium care plan, with notification of the patient’s team for treatment.
The average length of stay decreased by 0.8 days (P less than .001), with a decrease of 1.9 days in patients with delirium, compared with outcomes for nearly 2,600 patients before the intervention was implemented, Dr. Lau said. Researchers also found a decrease in $850 spent per patient (P less than .001), with a direct savings to the hospital of a total of $997,000, she said. The 30-day readmission rate also fell significantly, from 18.9% to 15.9% (P = .03).
The screening itself seemed to be the most important factor in the project, Dr. Lau said.
“Just the recognition that their patient was at risk for delirium or actually had delirium really raised awareness,” she said.
The project on alcohol detox used careful risk assessments at emergency department discharge, e-consults, protocols to limit benzodiazepine prescribing, and telephone follow-up to reduce hospital admissions and 30-day readmissions, as well as length of stay.
Researchers used scores on CIWA – a 10-question measurement of the severity of someone’s alcohol withdrawal – and history of complicated alcohol-use withdrawal to determine whether ED patients should be admitted to the floor or sent home with or without prescriptions for gabapentin and lorazepam, said Robert Patrick, MD, a hospitalist at the Cleveland VA.
Perhaps the most innovative feature of the program was using systolic blood pressure and heart rate in addition to CIWA to determine whether someone should receive a benzodiazepine, he said. Someone with a CIWA of 9-12, for instance, would be prescribed one of these drugs only if their vitals were elevated, Dr. Patrick said.
He encouraged other hospitalists to try a similar program at their centers.
“You don’t have to be at a VA to do this,” he said. “And most importantly, you don’t have to have a cooperative ED to do this. You can do this just within your hospitalist group.”
In another presentation, Jeffrey Schnipper MD, MPH, FHM, associate professor of medicine at Harvard Medical School, Boston, described the results from a project in which SHM’s MARQUIS program – an evidence-based “toolkit” on medication reconciliation – was implemented at 18 hospitals. The kit offers a plan to get the best possible medication history, give medication counseling on discharge, and identify patients at risk for medication discrepancies. The 18 sites were coached, with areas of improvement identified.
By months 13-18 of the study period, the number of medication discrepancies had fallen to 0.93 per patient for those who’d received at least one form of intervention, compared with 2.69 per patient among those who’d received none.
“The MARQUIS interventions, including the toolkit and mentored implementation,” Dr. Schnipper said, “are associated with a marked reduction in medication discrepancies.”
Delirium, alcohol detox, and med rec
Delirium, alcohol detox, and med rec
A project to improve how hospitalists address inpatient delirium, which has led to reductions in length of stay and cost, took center stage in the Best of RIV plenary session at HM19 in March.
The project, conducted at the University of California, San Francisco (UCSF), was presented alongside projects on alcohol detox at the Cleveland Veterans Affairs Medical Center and on medication reconciliation at Brigham and Women’s Hospital in Boston.
“The plenary is the top three of the 1,000 that are out there – so, impressive work,” said Benji Mathews, MD, SFHM, the chair of the Research, Innovations and Vignettes competition.
At UCSF, the project was meant to tackle the huge problem of delirium in the hospital, said Catherine Lau, MD, SFHM, associate professor of medicine there. Each year delirium affects more than 7 million people who are hospitalized, and hospital-acquired delirium is linked with prolonged stays and more emergency department visits and hospital readmissions. But research has found that as many as a third of these hospital-acquired cases can be prevented, Dr. Lau said.
New admissions and transfers – a total of more than 2,800 patients – were assessed for delirium risk, and those deemed high risk were entered into a delirium care plan, aimed at prevention with nonpharmacologic steps such as maximizing their mobility and helping them sleep at night.
All patients also were screened on every nursing shift for delirium, and those diagnosed with the disorder were placed in the delirium care plan, with notification of the patient’s team for treatment.
The average length of stay decreased by 0.8 days (P less than .001), with a decrease of 1.9 days in patients with delirium, compared with outcomes for nearly 2,600 patients before the intervention was implemented, Dr. Lau said. Researchers also found a decrease in $850 spent per patient (P less than .001), with a direct savings to the hospital of a total of $997,000, she said. The 30-day readmission rate also fell significantly, from 18.9% to 15.9% (P = .03).
The screening itself seemed to be the most important factor in the project, Dr. Lau said.
“Just the recognition that their patient was at risk for delirium or actually had delirium really raised awareness,” she said.
The project on alcohol detox used careful risk assessments at emergency department discharge, e-consults, protocols to limit benzodiazepine prescribing, and telephone follow-up to reduce hospital admissions and 30-day readmissions, as well as length of stay.
Researchers used scores on CIWA – a 10-question measurement of the severity of someone’s alcohol withdrawal – and history of complicated alcohol-use withdrawal to determine whether ED patients should be admitted to the floor or sent home with or without prescriptions for gabapentin and lorazepam, said Robert Patrick, MD, a hospitalist at the Cleveland VA.
Perhaps the most innovative feature of the program was using systolic blood pressure and heart rate in addition to CIWA to determine whether someone should receive a benzodiazepine, he said. Someone with a CIWA of 9-12, for instance, would be prescribed one of these drugs only if their vitals were elevated, Dr. Patrick said.
He encouraged other hospitalists to try a similar program at their centers.
“You don’t have to be at a VA to do this,” he said. “And most importantly, you don’t have to have a cooperative ED to do this. You can do this just within your hospitalist group.”
In another presentation, Jeffrey Schnipper MD, MPH, FHM, associate professor of medicine at Harvard Medical School, Boston, described the results from a project in which SHM’s MARQUIS program – an evidence-based “toolkit” on medication reconciliation – was implemented at 18 hospitals. The kit offers a plan to get the best possible medication history, give medication counseling on discharge, and identify patients at risk for medication discrepancies. The 18 sites were coached, with areas of improvement identified.
By months 13-18 of the study period, the number of medication discrepancies had fallen to 0.93 per patient for those who’d received at least one form of intervention, compared with 2.69 per patient among those who’d received none.
“The MARQUIS interventions, including the toolkit and mentored implementation,” Dr. Schnipper said, “are associated with a marked reduction in medication discrepancies.”
A project to improve how hospitalists address inpatient delirium, which has led to reductions in length of stay and cost, took center stage in the Best of RIV plenary session at HM19 in March.
The project, conducted at the University of California, San Francisco (UCSF), was presented alongside projects on alcohol detox at the Cleveland Veterans Affairs Medical Center and on medication reconciliation at Brigham and Women’s Hospital in Boston.
“The plenary is the top three of the 1,000 that are out there – so, impressive work,” said Benji Mathews, MD, SFHM, the chair of the Research, Innovations and Vignettes competition.
At UCSF, the project was meant to tackle the huge problem of delirium in the hospital, said Catherine Lau, MD, SFHM, associate professor of medicine there. Each year delirium affects more than 7 million people who are hospitalized, and hospital-acquired delirium is linked with prolonged stays and more emergency department visits and hospital readmissions. But research has found that as many as a third of these hospital-acquired cases can be prevented, Dr. Lau said.
New admissions and transfers – a total of more than 2,800 patients – were assessed for delirium risk, and those deemed high risk were entered into a delirium care plan, aimed at prevention with nonpharmacologic steps such as maximizing their mobility and helping them sleep at night.
All patients also were screened on every nursing shift for delirium, and those diagnosed with the disorder were placed in the delirium care plan, with notification of the patient’s team for treatment.
The average length of stay decreased by 0.8 days (P less than .001), with a decrease of 1.9 days in patients with delirium, compared with outcomes for nearly 2,600 patients before the intervention was implemented, Dr. Lau said. Researchers also found a decrease in $850 spent per patient (P less than .001), with a direct savings to the hospital of a total of $997,000, she said. The 30-day readmission rate also fell significantly, from 18.9% to 15.9% (P = .03).
The screening itself seemed to be the most important factor in the project, Dr. Lau said.
“Just the recognition that their patient was at risk for delirium or actually had delirium really raised awareness,” she said.
The project on alcohol detox used careful risk assessments at emergency department discharge, e-consults, protocols to limit benzodiazepine prescribing, and telephone follow-up to reduce hospital admissions and 30-day readmissions, as well as length of stay.
Researchers used scores on CIWA – a 10-question measurement of the severity of someone’s alcohol withdrawal – and history of complicated alcohol-use withdrawal to determine whether ED patients should be admitted to the floor or sent home with or without prescriptions for gabapentin and lorazepam, said Robert Patrick, MD, a hospitalist at the Cleveland VA.
Perhaps the most innovative feature of the program was using systolic blood pressure and heart rate in addition to CIWA to determine whether someone should receive a benzodiazepine, he said. Someone with a CIWA of 9-12, for instance, would be prescribed one of these drugs only if their vitals were elevated, Dr. Patrick said.
He encouraged other hospitalists to try a similar program at their centers.
“You don’t have to be at a VA to do this,” he said. “And most importantly, you don’t have to have a cooperative ED to do this. You can do this just within your hospitalist group.”
In another presentation, Jeffrey Schnipper MD, MPH, FHM, associate professor of medicine at Harvard Medical School, Boston, described the results from a project in which SHM’s MARQUIS program – an evidence-based “toolkit” on medication reconciliation – was implemented at 18 hospitals. The kit offers a plan to get the best possible medication history, give medication counseling on discharge, and identify patients at risk for medication discrepancies. The 18 sites were coached, with areas of improvement identified.
By months 13-18 of the study period, the number of medication discrepancies had fallen to 0.93 per patient for those who’d received at least one form of intervention, compared with 2.69 per patient among those who’d received none.
“The MARQUIS interventions, including the toolkit and mentored implementation,” Dr. Schnipper said, “are associated with a marked reduction in medication discrepancies.”
