August 2021 PRACTICE MANAGEMENT IN THE LITERATURE DIAGNOSTIC TESTS Volume 25 l No. 8 HM adminstrators’ plans CPR in patients with POCUS for heart p3 for the future p18 COVID-19 p22 failure

Hospital disaster preparation confronts COVID Hospitalist groups should have emergency response plans

By Larry Beresford

ason Persoff, MD, SFHM, now a hospitalist at University of Colorado Hospital in Aurora and an amateur storm chaser, got a close look at how natural disasters can impact hospital care Jwhen a tornado destroyed St. John’s Regional Medical Center in Joplin, Mo., on May 22, 2011. He and a colleague who had been following the storm responded to injuries on the highway before reporting for a long day’s service at the other hospital in Joplin, Freeman Hospital West, caring for patients transferred from St. John’s on an impromptu unit without access to their medical records. “During my medical training, I had done emergency medicine as an EMT, so I was interested in how the system responds to emergencies,” he explained. “At Joplin I learned how it feels when the boots on the ground in a crisis are not connected to an incident command structure.” Another thing he learned was the essential role for hospitalists in a hospital’s re- sponse to a crisis – and thus the need to involve them well in advance in the hospital’s planning for future emergencies. “Disaster preparation – when done right – helps you ‘herd cats’ in a crisis situation,” he said. “The tornado and its wake served as defining moments for me. I used them as the impetus to improve health care’s re- sponse to disasters.” Part of that commitment was to help hospitalists understand their part in emergency preparation. Dr. Persoff is now the assistant medical director of emergency preparedness at University of Colorado Dr. Maria Frank is a hospitalist at Hospital. He also helped to create a position called Denver Health Hospital Authority physician support supervisor, which is filled by physi- and associate professor at the cians who have held leadership positions in a hospital University of Colorado. to help coordinate the disparate needs of all clinicians ® in a crisis and facilitate rapid response. Courtesy Denver HealtH the-hospitalist.org Continued on page 16

COMMENTARY HOSPITALIST INSIGHT

Taru Saigal, MD Sareer Zia, MD, MBA

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STD PRSRT COMMENTARY August 2021 Volume 25 l No. 8 ‘If only you knew’ PHYSICIAN EDITOR THE SOCIETY OF HOSPITAL MEDICINE Weijen W. Chang, MD, SFHM, FAAP Phone: 800-843-3360 [email protected] Fax: 267-702-2690 Website: www.HospitalMedicine.org By Swati Mehta, MD, FACP Patient: PEDIATRIC EDITOR Anika Kumar, MD, FHM, FAAP Chief Executive Officer You take time to ask about my fami- [email protected] Eric E. Howell, MD, MHM Patient: ly, about what I like to do COORDINATING EDITORS Alone in the Emergency Dept, I tell you all about Beatles & my Alan Hall, MD Director of Communications

The FuTure hospiTalisT Brett Radler breathless, I wait for you sweet grandkids [email protected] “The Hospitalist will admit you” says You sit & ask me “what matters most Keri Holmes-Maybank, MD, FhM the nurse, “she will come in a few.” to you” inTerpreTing DiagnosTic TesTs Communications Specialist Muffled voices – masked faces bus- I reply: getting well for the wedding CONTRIBUTING WRITERS Myles Daigneault Larry Beresford; Ajay Bhasin, MD; Megan [email protected] tle in & out of the room of my daughter “Sue” Brooks, MD, MPH, FHM; Jack Chase, MD, Loud beeping machines & the FAAFP, FHM; Steve Cimino; Chadi Cortas, SHM BOARD OF DIRECTORS rushed pace, fill me with gloom Physician: MD; Faye Farber, MD; J. Henry Feng, MD; President You walk in the room, lean in to in- I sense loneliness engulfing you at Herrick “Cricket” Fisher, MD, MPhil; Jerome C. Siy, MD, MHA, SFHM Esteban Gershanik, MD, MPH, MMSc, President-Elect troduce times FHM; Teena Hadvani, MD, FAAP; Danielle Rachel Thompson, MD, MPH, SFHM You tell me your name and what you Your fear and anxiety, I promise to Halpern, MD; Lubna Khawaja, MD, FHM; Treasurer will do help overcome Marina Kishlyansky, DO; Michelle A. Lopez, Kris Rehm, MD, SFHM MD, MPH, FAAP; Yasmin Marcantonio, MD; Secretary For a moment I’m more than a diag- I will help you navigate this complex Swati Mehta, MD, FACP; Shree Menon, Flora Kisuule, MD, MPH, SFHM nosis, an H&P, hospital stay MD; Jose R. Mercado, MD; Brent Mothner, Immediate Past President and then the fleeting connection Together we will fight this virus or MD, FAAP; Elizabeth Petersen, MD; Ricardo Danielle Scheurer, MD, MSCR, SFHM Quinonez, MD, FHM, FAAP; Sarah Ludwig Board of Directors passes, can’t you see? anything that comes our way Rausch; Taru Saigal, MD; Adam C. Schaffer, Tracy Cardin, ACNP-BC, SFHM You listen, seem hurried, but I think Each passing minute the line be- MD, MPH; Myrna Katalina Serna, MD; Bryce Gartland, MD, SFHM you care tween doctor and patient disap- Poonam Sharma, MD, SFHM; Laura Smith, Efren C. Manjarrez, MD, SFHM MD; Shela Sridhar, MD; Neil Stafford, MD; Mark W. Shen, MD, SFHM Would you sit with me while my sto- pears Ann-Marie Tantoco, MD, FAAP, FHM; Vicki Darlene Tad-y, MD, SFHM ry I share? That’s when we win over this virus, Uremovich, DO, FAAP; Adam Wachter, Chad T. Whelan, MD, MHSA, SFHM and hope replaces fear MD; Qian Ye, MD; Sareer Zia, MD, MBA Robert P. Zipper, MD, MMM, SFHM Physician: FRONTLINE MEDICAL FRONTLINE MEDICAL I do see you, I feel your fear & an- Patient: COMMUNICATIONS EDITORIAL STAFF Executive Editor Kathy Scarbeck, MA COMMUNICATIONS ADVERTISING STAFF guish Every day you come see me, tell me Editor Richard Pizzi Senior Director Business Development A moment to know you too, is all my numbers are improving Creative Director Louise A. Koenig Angelique Ricci, 973-206-2335 that I wish I notice your warm and kind eyes Director, Production/Manufacturing cell 917-526-0383 [email protected] Rebecca Slebodnik Recruitment Sales Representative How do I convince you that I truly behind that stifling mask Linda Wilson, 973-290-8243 care? When they light up as you tell me EDITORIAL ADVISORY BOARD Hyung (Harry) Cho, MD, SFHM; Marina [email protected] When, with all my tasks I have only I’m going home soon S. Farah, MD, MHA; Ilaria Gadalla, DMSc, Senior Director of Classified Sales minutes to spare I feel assured I mean more to you, PA-C; James Kim, MD; Ponon Dileep Tim LaPella, 484-921-5001 than a mere task Kumar, MD, FACP, CPE; Shyam Odeti, MD, cell 610-506-3474 [email protected] MS, FHM; Venkataraman Palabindala, MD, Patient: SFHM; Tiffani M. Panek, MA, SFHM, CLHM; Advertising Offices 7 Century Drive, Adhikari Ramesh, MD, MS; Raj Sehgal, Suite 302, Parsippany, NJ 07054-4609 You diligently ask questions from Physician: 973-206-3434, fax 973-206-9378 your checklist of H.P.I., Each day I visit, together we hum MD, FHM; Kranthi Sitammagari, MD; Amith Skandhan, MD, FHM; Lonika Sood, MD, Finalizing the diagnosis, when I hear “here comes the sun” FACP, FHM; Amit Vashist, MD, FACP your pager beep. I too open up and share with you, An admission awaits I know, but my favorite Beatles song please sit by my side Our visits cover much more than THE HOSPITALIST is the official newspaper of the THE HOSPITALIST (ISSN 1553-085X) is published Society of Hospital Medicine, reporting on issues monthly for the Society of Hospital Medicine by Could we make our new-found clinical medicine and trends in hospital medicine. THE HOSPITALIST Frontline Medical Communications Inc., 7 Century meeting, a little more deep? True connection & mutual soul heal- reaches more than 35,000 hospitalists, physician Drive, Suite 302, Parsippany, NJ 07054-4609. Print assistants, nurse practitioners, medical residents, and subscriptions are free for Society of Hospital Medi- ing begins, before long. health care administrators interested in the practice cine members. Annual paid subscriptions are avail- Physician: and business of hospital medicine. 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POSTMASTER: Send changes of address (with old job to me. I promise I’ll remember those kind Letters to the Editor: [email protected] mailing label) to THE HOSPITALIST, Subscription Services, P.O. Box 3000, Denville, NJ 07834-3000. eyes, and wave The Society of Hospital Medicine’s headquarters Tirelessly I work, giving patients my After all, you stood between me and is located at 1500 Spring Garden, Suite 501, RECIPIENT: To subscribe, change your address, Philadelphia, PA 19130. purchase a single issue, file a missing issue claim, all death or have any questions or changes related to your Drained, exhausted yet, for you, I’m indebted to you, it’s my life that Editorial Offices: 2275 Research Blvd, Suite 400, subscription, call Subscription Services at 1-833-836- Rockville, MD 20850, 240-221-2400, fax 240-221-2548 2705 or e-mail [email protected]. standing tall you did save! Our bond albeit short lived, is very BPA Worldwide is a global industry resource for verified audience data and important to me Dr. Mehta is director of quality and The Hospitalist is a member. Watching you get better each day, is performance and patient experience To learn more about SHM’s relationship with industry partners, visit www.hospitalmedicine.com/industry. fulfilling for me! at Vituity in Emeryville, Calif. August 2021 | 2 | The Hospitalist

02_03_04_HOSP21_08.indd 2 7/20/2021 2:15:30 PM PRACTICE MANAGEMENT Planning for 2021 and beyond COVID’s impact on hospital medicine administrators

By Sarah Ludwig Rausch scheduling needs in case a staff member couldn’t sure her staff has whatever they need to do their MDedge News come in. “For the pandemic, we created six teams jobs and that her providers have administrative with an escalation and de-escalation pattern so support. “The work that’s had to be done to fulfill he COVID-19 pandemic has given hospi- that we could be ready to face whatever changes those priorities has changed in light of COVID talists a time to shine. Perhaps few peo- came in,” Ms. Dede said. Thankfully, the communi- though,” she said. ple see – and value – this more than the ty wasn’t hit very hard by COVID-19, so the six new For example, she and her staff are all still off hospital medicine administrators who teams ended up being unnecessary, “but we were site, which she said has been challenging, espe- Twork to support them behind the scenes. fully prepared, and everybody was ready to go.” cially given the lack of preparation they had. “In “I’m very proud to have been given this oppor- Making staffing plans amidst all the uncertainty order to support my staff and to make sure they tunity to serve alongside these surrounding the pandemic was aren’t getting overwhelmed by being at home, wonderful hospitalists,” said a big challenge in planning for that means my job looks a little bit different, but Elda Dede, FHM, hospital med- 2021, said Tiffani Panek, CLHM, it doesn’t change my priorities,” said Ms. Panek. icine division administrator SFHM, hospital medicine di- By mid-summer, Ms. Dede said her main pri- at the University of Kentucky vision administrator at Johns ority has been onboarding new team members, Healthcare in Lexington. Hopkins School of Medicine, which she said is difficult with so many meetings As with everything else in Johns Hopkins Bayview Med- being held virtually. “I’m not walking around U.S. health care, the pandemic ical Center, in Baltimore. “We the hallways with these people and having op- has affected hospital medicine don’t know what next week portunities to get feedback about how their on- administrators planning for Ms. Dede Mr. Kharbanda is going to look like, let alone boarding is going, so engaging so many new team 2021 and subsequent years in a what 2 or 3 months from now members organically into the culture, the vision, big way. Despite all the challenges, some organi- is going to look like, so we’ve really had to learn to the goals of our practice, is a challenge,” she said. zations are maintaining equilibrium, while others be flexible,” she said. No longer is there just a Plan Taking advantage of opportunities for hospital are even expanding. And intertwined through it A that can be adjusted as needed; now there has to medicine is another administrative priority for all is a bright outlook and a distinct sense of team be a Plan B, C, and D as well. Ms. Dede. “For us to be able to take a seat at every support. Because the hospital medicine division’s budget possible table where decisions are being made, is tied to the hospital, Ms. Panek said there hasn’t participate in shaping the strategic vision of Pandemic impacts on 2021 planning been a negative impact. “The hospital supports the entire institution and be an active player in Though the Texas Health Physicians Group the program and continues to bringing that vision to life,” she (THPG) in Fort Worth is part of Texas Health Re- support the program, regardless said. “I feel like this is a crucial sources (THR), Ajay Kharbanda, MBA, SFHM, vice of COVID,” she said. The health moment for hospitalists.” president of practice operations at THPG, said system as a whole did have to Lean work, which includes that each hospital within the THR system decides reduce benefits and freeze rais- the new team efficiency plans, who that hospital will contract with for hospital- es temporarily to ensure em- is an administrative priority ist services. Because the process is competitive ployees could keep their jobs. for Ms. Smith, as it is for the and there’s no guarantee that THPG will get the However, she said they have entire organization. “I would contract each time, THPG has a large focus on the been fortunate in that their say that my biggest priority is value they can bring to the hospitals they serve staff has been able to – and will Ms. Panek Ms. Smith just supporting our team,” Ms. and the patients they care for. continue to – stay in place. Smith said. “We’ve been on a “Having our physicians engaged with their hos- As with others, volume fluctuation was an resiliency journey for a couple years.” pital entity leaders was extremely important this enormous hurdle in 2021 planning, said Larissa Their resiliency work involves periodic team year with planning around COVID because mul- Smith, adult hospitalist and palliative care man- training courtesy of Bryan Sexton, PhD, director tiple hospitals had to create new COVID units,” ager at The Salem (Ore.) Health Medical Group, of the Duke Center for Healthcare Safety and said Mr. Kharbanda. Salem Health Hospitals and Clinics. “It’s really Quality. The goal of resiliency is to strengthen With the pressure of not enough volume early highlighted the continued need for us to be agile positive emotion, which enables a quicker recov- in the pandemic, other hospitalist groups were in how we structure and operationalize our staff- ery when difficulties occur. “I can’t imagine where forced to cut back on staffing. “Within our health ing,” Ms. Smith said. “Adapting to volume fluctua- we would be, this far into the pandemic, without system, we made the cultural decision not to can- tions has been our main focus.” that work,” said Ms. Smith. “I think it has really cel any shifts or cut back on staffing because we To prepare for both high and low patient vol- set us up to weather the storm, literally and figu- didn’t want our hospitalists to be impacted neg- umes in 2021 and be able to adjust accordingly, ratively.” atively by things that were out of their control,” The Salem Health Medical Group finalized in Ensuring the well-being of his provider group’s Mr. Kharbanda said. December 2020 what they call “team efficiency physicians is a high administrative priority This commitment to their hospitalists paid plans.” These plans consist of four primary areas: for Mr. Kharbanda. Considering that the work off when there was a surge of patients during surge capacity, low census planning, right pro- they’ve always done is difficult, and the pandemic the last quarter of 2020. “We were struggling to viders and right patient collaboration, and right has been going on for such a long time, hospital- ensure there were adequate physicians available team size. ists are stretched thin. “We are bringing some ad- to take care of the patients in the hospital, but Ms. Smith is working on the “right providers ditional resources to our providers that relate to because we did the right thing by our physicians and right patient collaboration” component with taking care of themselves and helping them cope in the beginning, people did whatever it took to the trauma and acute care, vascular, and general with the additional shifts,” Mr. Kharbanda said. make sure there was enough staffing available surgery teams to figure out the best ways to uti- for that increased patient volume,” Mr. Kharban- lize hospitalists and specialists. “It’s been really Going forward da said. great collaboration,” she said. The hospital medicine team at University of Ken- The first priority for University of Kentucky tucky Healthcare was already in the process of Healthcare is patient care, said Ms. Dede. Before Administrative priorities during COVID-19 planning and adopting a new funds flow model, the pandemic, the health system already had a The pandemic hasn’t changed Ms. Panek’s ad- which increases the budget for HM, when the two-layer jeopardy system in place to deal with ministrative priorities, which include making Continued on following page the-hospitalist.org | 3 | August 2021

02_03_04_HOSP21_08.indd 3 7/20/2021 2:15:37 PM CLINICAL Tofacitinib shows mortality benefit in patients with COVID-19 pneumonia

By Steve Cimino desivir was superior to remdesivir dence interval, 0.41-0.97; P = .04). (12%) on placebo. Patients on tofaci- MDedge News alone, but ACTT-4 – which compared Death from any cause occurred in tinib suffered from events like deep baricitinib plus remdesivir with 2.8% of the tofacitinib group and vein thrombosis, acute MI, ventric- he Janus kinase inhibitor to- dexamethasone plus remdesivir – 5.5% of the placebo group (hazard ular tachycardia, and myocarditis, facitinib reduces the risk of was stopped for futility in April 2021. ratio, 0.49; 95% CI, 0.15-1.63). The each of which affected one person, both death and respiratory To assess the efficacy and safety median number of days treatment while one placebo patient each suf- failure in hospitalized adults of tofacitinib as a potential treat- was administered was 5 in the tofac- fered from hemorrhagic stroke and Twith COVID-19 pneumonia, a new ment for COVID-19, the researchers itinib group and cardiogenic shock. The incidence Brazilian study has found. launched a randomized, double-blind 6 in the placebo of serious infection was 3.5% in the “Whether the use of JAK in- trial made up of 289 patients from 15 group. The me- tofacitinib group and 4.2% in the hibitors is superior or additive to sites in Brazil. The Study of Tofaci- dian duration of placebo group. other specific immunomodulatory tinib in Hospitalized Patients With hospital and ICU “There is a lot of interest in re- therapies in patients hospitalized COVID-19 Pneumonia (STOP-COVID) stays were similar purposing a variety of disease-mod- with COVID-19 remains to be deter- split its participants into two groups: across groups. ifying antirheumatic drugs for mined,” Patrícia O. Guimarães, MD, one (n = 144) received 10 mg of oral On the the treatment of COVID-19, which PhD, of the Hospital Israelita Albert tofacitinib twice daily and the other eight-level Na- includes JAK inhibitors,” Zachary S. Einstein in São Paulo, and coauthors (n = 145) received placebo. Treatment Dr. Wallace tional Institute Wallace, MD, of the rheumatology wrote. The study was published in was to be administered for up to 14 of Allergy and unit at Massachusetts General Hos- the New England Journal of Med- days or until hospital discharge. The Infectious Diseases ordinal scale of pital, Boston, said in an interview. icine (2021 Jun 16. doi: 10.1056/NEJ- participants’ mean age was 56 years, disease severity, the proportional “The ACTT-2 data was compelling; Moa2101643). and 34.9% were women. odds of having a worse score with it did suggest perhaps a benefit as- The results of previous trials that Over 89% of participants received tofacitinib, compared with placebo, sociated with baricitinib for COVID. tested JAK inhibitors as therapies glucocorticoids during hospitaliza- was 0.6 (95% CI, 0.36-1.00) at day 14 This study is more compelling.” for COVID-19 have been mixed. The tion, a significant increase, com- and 0.54 (95% CI, 0.27-1.06) at day 28. The trial was sponsored by Pfizer. second iteration of the Adaptive pared with ACTT-2’s 12%. Through Adverse events occurred in 26.1% of Several authors acknowledged po- COVID-19 Treatment Trial (ACTT-2) 28 days, death or respiratory failure the tofacitinib group and 22.5% of tential conflicts of interest, includ- found that a combination treatment occurred in 18.1% of the tofacitinib the placebo group, with serious ad- ing receiving grants and personal of baricitinib and the Food and Drug group and in 29.0% of the placebo verse events occurring in 20 patients fees from Pfizer and various other Administration–authorized rem- group (risk ratio, 0.63; 95% confi- (14.1%) on tofacitinib and 17 patients pharmaceutical companies.

Continued from previous page Positive takeaways from the pandemic Mr. Kharbanda sees how the pandemic has pandemic hit. “This is actually very good timing Ms. Dede feels that hospital medicine has en- brought his hospitalist team together. “I think for us,” noted Ms. Dede. “We are currently work- tered the health care spotlight with regard to having the conversations around well-being and ing on building a new incentive model that max- hospitalists’ role in caring for patients during the family safety were the real value as we learn to imizes engagement and academic productivity pandemic. “Every challenge is an opportunity survive the pandemic.” for our physicians, which in turn, will allow their for growth and an opportunity to show that you Ms. Smith said the pandemic has brought careers to flourish and the involvement with en- know what you’re made of,” she said. “If there was about changes for the better that will likely be terprise leadership to increase.” ever doubt that the hospitalists are the beating permanent, like having time-saving virtual meet- They had also planned to expand their teams heart of the hospital, this doubt is now gone. Hos- ings and working from home. “We’ve put a lot and services before the pandemic, so in 2021, pitalists have, and will continue to, shoulder most of resources into physical structures and that they’re hiring “an unprecedented number of hos- of the care for COVID patients.” takes away value from patients,” said Ms. Smith. pitalists,” Ms. Dede said. “If we’re able to shift people in different roles to Mr. Kharbanda said that COVID has shown work from home, that just creates more future how much impact hospitalists can have on a We’ve put a lot of resources into value for our community.” hospital’s success, which has further highlighted Ms. Dede also sees the potential benefits that their value. “Most of our programs are holding physical“ structures and that takes stem from people’s newfound comfort with vid- steady and we have some growth expected at away value from patients. eo conferencing. “You can basically have grand some of our entities, so for those sites, we are hir- rounds presenters from anywhere in the world,” ing,” he said. Budget-wise, he expected to feel the ” she said. “You don’t have to fly them in, you don’t pandemic’s impact for the first half of 2021, but The pandemic has also presented an opportu- have to host them and have a whole program for for the second half, he hopes to return to normal. nity at University of Kentucky Healthcare that a couple of days. They can talk to your people for Other than some low volumes in the spring, helps accomplish both physician and hospital an hour from the comfort of their home.” Salem Health has mostly maintained its typical goals. “Hospital medicine is currently being asked Ms. Dede says expanding telehealth options capacities and funds. “Obviously, we don’t have to staff units and to participate in leadership and figuring out how hospitals can maximize control over external forces that impact health committees, so this has been a great opportunity that use is a priority. “Telehealth has been on the care, but we really try to home in on how we for growth for us,” Ms. Dede said. minds of so many hospital medicine practices, utilize our resources,” said Ms. Smith. “We’re a The flexibility her team has shown has been a but there were many questions without answers financially secure organization and I think our positive outcome for Ms. Panek. “You never really about how to implement it,” she said. “During the lean work really drives that.” The Salem Hospital know what you’re going to be capable of doing un- pandemic, we were forced to find those solutions, is currently expanding a building tower to add til you have to do it,” she said. “I’m really proud of but a lot of the barriers have still not been elimi- another 150 beds, giving them more than 600 my group of administrative staff for how well that nated. I would recommend that groups keep their beds. “That will make us the largest hospital in they’ve handled this considering it was supposed eyes open for new technological solutions that Oregon,” Ms. Smith said. to be temporary.” may empower your expansion into telehealth.” August 2021 | 4 | The Hospitalist

02_03_04_HOSP21_08.indd 4 7/20/2021 2:15:43 PM Your Partner in Intensive Caring.

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HOSP_05.indd 1 7/15/2021 3:34:28 PM COMMENTARY “Enough English” to be at risk Clinicians need well-translated documents to treat LEP patients

By Taru Saigal, MD million Americans) have LEP.2 It’s a misunderstood by their physicians large and growing population that or ancillary staff, and less likely to hectic Friday morning at needs help overcoming language follow physician instructions.3-5 One the hospital seemed less barriers and the appropriate use of study analyzed over 1,000 adverse-in- stressful amid morning professional medical interpreter ser- cident reports from six Joint Com- greetings and humor from vices – a backbone to safe, quality, mission–accredited hospitals for LEP Acolleagues. In a team room full of and cost-effective patient care. and English-speaking patients and hospitalists, life and death are often The following day at bedside found that 49% of LEP patients expe- discussed in detail, ranging from rounds, the nurse reported that the rienced physical harm versus 29.5% medical discussions to joys and patient was looking and responding of English-speaking patients.6 frustrations of the day to philoso- better. She could cooperate with I updated the patient’s LEP status phy, politics, and more. It is almost interpreter services and could speak that was missing in the chart, likely impossible to miss something inter- “some English.” Over the years, one because of altered mental status at esting. thing that sounds more alarming the time of admission. Reliable lan- People breaking into their native than “no English” is “some English” guage and English proficiency data languages over the phone call from or “enough English.” Around noon are usually entered at the patient’s home always make me smile. The I received a page that the patient point of entry with documentation mention of a “complicated Indian was refusing intravenous Lasix. At of the language services required patient unable to use interpreter” the bedside, however, the patient during the patient-provider en- caught my attention. seemed unaware of the perceived counter. The U.S. Census Bureau’s Dr. Saigal is a hospitalist and My friend and colleague asked if I refusal. Further discussions with operational definition for LEP is clinical assistant professor of would be willing to take over the pa- the nurse lead to a familiar culprit, a a patient’s self-assessed ability to medicine in the division of hospital tient since I could speak Hindi. I was relatively common gesture in South speak English less than “very well,” medicine at the Ohio State doubtful if I would add anything to Asian cultures, a head bobble or but how well it correlates with a University Wexner Medical Center, make a meaningful difference, given shake. patient’s actual English ability needs Columbus. the patient wasn’t even participat- more study. Also, one’s self-assessed ing in a conversation. However, my perception of ability might vary colleague’s concern for the patient One way to bypass day to day, and language ability, by Exiting the room, I gently remind- and faith in me was enough to say, itself, is not static; it can differ from ed the RN to use the interpreter “Sure, let me add her to my list.” language“ barriers is to moment to moment and situation services. “Who has never been guilty At the bedside, it felt like a classic recognize the value added to situation. It may be easier to un- of using an ad hoc interpreter or “acute on chronic” hot mess situation. derstand words in English when the rushing through a long interpreter The patient presented with a gener- by hiring and training situation is simple and less stressful phone call due to time constraints?” alized rash, anasarca, renal failure, bilingual health care than when things are complicated I thought. A study from 2011 found multifocal pneumonia, and delirium. and stressful. that 43% of hospitalized patients All I could gather from the patient providers and fostering With a definition of LEP rather with LEP had communicated with- were some incomprehensible words cultural competence. vague and the term somewhat de- out an interpreter present during that sounded like Hindi. I called the ” rogatory, its meaning is open to in- admission, and 40% had communi- family to obtain some history and to terpretation. One study found that, cated without an interpreter present provide updates. Her son was excited The nurse reported that the pa- though speaking English less than after admission.8 In other words, a to hear from me, and it didn’t take tient shook her head side to side, “very well” was the most sensitive system in place does not mean ser- him long to guess that I was from seemed upset, and said “NO” when measure for identifying all of the vice in use. But, the use of a trained India. But that could still mean that trying to administer the medication. patients who reported that they interpreter is not only an obligation I might speak any of the 22 or more On the other hand, the patient re- were unable to communicate effec- for care providers but a right for Indian languages. ported that she was upset to be at tively with their physicians, it was patients as per legal requirements Answering my questions one by the hospital but had “NO” problem also the least specific.7 This lower of Title VI of the Civil Rights Act one in perfectly understandable with the medicine. specificity could lead to misclassi- and the Standards for Culturally English, he was short and sweet. My patient’s “some English” was fication of some patients as LEP and Linguistically Appropriate Ser- Suspicious of missing out on de- indeed “enough English” to put her who are, in fact, able to effectively vices (CLAS) by the Department of tails, I offered hesitantly, “You could at risk due to medical error, which communicate in English with their Health & Human Services’ Office of speak in Hindi with me.” Then came is highly likely when patients or physicians. This type of misclassifi- Minority Health.9 In January 2010, a flood of information with the de- providers can speak or understand a cation might lead to costly language The Joint Commission released a tails, concerns, questions, and what language to “get by” or to “make do.” assistance and carry the potential set of new and revised standards was lost in the translation. Like my patient, the LEP patient pop- to cause conflicts between patient for patient-centered communication We all attend to patients and fami- ulation is more likely to experience and provider. Telling a patient or as part of an initiative to advance lies with limited English proficiency medical errors, longer hospital stays, family that they may have a “limited effective communication, cultural (LEP), immigrants, and nonimmi- hospital-acquired complications, English proficiency” when they have competence, and patient- and fami- grants. LEP is a term used to de- surgical delays, and readmissions. believed otherwise and feel confi- ly-centered care. scribe individuals who do not speak They are also less likely to receive dent about their skills may come as Despite the requirements and English as their primary language preventive care, have access to reg- a challenge. Some patients may also availability of qualified medical in- and have a limited ability to read, ular care, or be satisfied with their pretend to understand English to terpreter services, there are multiple speak, write, or understand English.1 care. They are much more likely avoid being embarrassed about their perceived and experienced barriers Recent data from the American to have adverse effects from drug linguistic abilities or perceive that to the use of interpreter services. Community Survey (2005-2009) re- complications, poor understanding they might be judged on their abili- The most common one is that what port that 8.6% of the population (24 of diagnoses, a greater risk of being ties in general. comes as a free service for patients August 2021 | 6 | The Hospitalist

06_to_09_HOSP21_08.indd 6 7/20/2021 2:37:22 PM COMMENTARY

is a time commitment for providers. forms for medical procedures, post- errors in patients with LEP. Included 4. Gandhi TK et al. Drug complications in outpa- tients. J Gen Intern Med. 2000;15(3):149-54. doi: A long list of patients, acuity of the discharge instructions, prescription is the TeamSTEPPS LEP module to 10.1046/j.1525-1497.2000.04199.x. situation, and ease of use/availabili- and medical device labels, and drug help develop and deploy a custom- 5. Karliner LS et al. Do professional interpreters ty of translation aids can change the usage information may enhance ized plan to train staff in teamwork improve clinical care for patients with limited calculus. One may be able to bill a informed decision-making and safe- skills and lead a medical teamwork English proficiency? A systematic review of the 17 literature. Health Serv Res. 2007;42(2):727-54. prolonged service code (99354-99357) ty and reduce stress and medical improvement initiative. doi: 10.1111/j.1475-6773.2006.00629.x. in addition to the appropriate E/M errors. 6. Divi C et al. Language proficiency and adverse code, although a patient cannot be An unpopular and underused “Without my family, I was events in U.S. hospitals: A pilot study. Int J Qual billed for the actual service provided service needs it all: availability, con- scared that nobody would Health Care. 2007 Apr;19(2):60-7. doi: 10.1093/ intqhc/mzl069. by the interpreter. Longstanding venience, monitoring, reporting, and understand me” 7. Karliner LS et al. Identification of limited CMS policy also permits reimburse- team effort. Because of the sheer Back to the case. My patient was English proficient patients in clinical care. J Gen ment for translation/interpretation unpopularity and underuse of inter- recovering well, and I was tying up Intern Med. 2008;23(10):1555-60. doi:10.1007/ activities, so long as they are not preter services, institutions should loose ends on the switch day for the s11606-008-0693-y. included and paid for as part of the enhance ease of availability, monitor hospitalist teams. 8. Schenker Y et al. Patterns of interpreter use for 10 hospitalized patients with limited English profi- rate for direct service. the use and quality of interpreter “You will likely be discharged in a ciency. J Gen Intern Med. 2011 Jul;26(7):712-7. The patient, however, insisted services, and optimize reporting couple of days,” I said. She and the doi: 10.1007/s11606-010-1619-z. that she would rather have her of language-related errors. Ease of son as the interpreter on the 3-way availability goes hand in hand with over the phone (OPI) conference tapping local resources. Over the call for interpretation. “He speaks years, and even more so during the good English and knows my medical pandemic, in-person interpretation history well,” she said. I counseled has transitioned to telephonic or the patient on the benefits of using video interpretation because of interpreter services and explained availability, safety, and cost issues. how to use the call button light and There are challenges in translating the visual aids. a language, and the absence of a Placing emphasis on educating visual channel adds another layer of es

patients about the benefits of using, complexity. g ma I and risks of not using, interpreter The current body of evidence does etty

services is as essential as empha- not indicate a superior interpreting /G nc I sizing that care providers use the method. Still, in one study provid- aez l services. Some patients may volun- ers and interpreters exposed to all e P uis

tarily choose to provide their own three methods were more critical L ose interpreter. Use of family members, of remote methods and preferred J friends, or unqualified staff as in- videoconferencing to the telephone terpreters is one of the most com- as a remote method. The significant- family were grateful and satisfied 9. Office of Minority Health, U.S. Department of Health & Human Services. National Stand- monly reported causes of errors by ly shorter phone interviews raised with the care. She had used the in- ards for Culturally and Linguistically Appropriate frontline staff. Using in-language questions about the prospects of terpreter services and also received Services in Health Care: Final Report. Washing- collateral may help these patients miscommunication in telephonic ethnocultural and language concor- ton, D.C.: U.S. Department of Health & Human Services; 2001. https://minorityhealth.hhs.gov/ understand how medical interpre- interpretation, given the absence of dant and culturally competent care. assets/pdf/checked/finalreport.pdf. tation may create a better patient a visual channel.12 Reducing language barriers is one 10. www.medicaid.gov/medicaid/financial-man- experience and outcome. A short One way to bypass language bar- of the crucial ways to reduce racial agement/medicaid-administrative-claiming/ factsheet, in different languages, riers is to recognize the value added and ethnic disparities in quality of translation-and-interpretation-services/index. on qualified interpreters’ expected by hiring and training bilingual care and health outcomes, and it html. benefits: meaning-for-meaning com- health care providers and fostering starts – in many cases – with identi- 11. Schenker Y et al. The impact of language barriers on documentation of informed consent munication, impartiality, medical cultural competence. International fying LEP patients. Proper use and at a hospital with on-site interpreter services. privacy, and improved patient safety medical graduates in many parts of monitoring of interpreter services, J Gen Intern Med. 2007 Nov;22 Suppl 2(Suppl and satisfaction, can also come in the country aid in closing language reporting language-related errors, 2):294-9. doi: 10.1007/s11606-007-0359-1. handy. barriers. Language-concordant care hiring and testing bilingual staff’s 12. Locatis C et al. Comparing in-person, video, and telephonic medical interpretation. J Gen However, if the patient still refus- enhances trust between patients language proficiency, and educating Intern Med. 2010;25(4):345-50. doi:10.1007/ es, providers should document the and physicians, optimizes health staff on cultural awareness are es- s11606-009-1236-x. refusal of the offer of free language outcomes, and advances health sential strategies for caring for LEP 13. Dunlap JL et al. The effects of language services, the name of the interpreter equity for diverse populations.13-15 patients. concordant care on patient satisfaction and clin- designated by the patient, the in- The presence of bilingual providers At my weeks’ end, in my handoff ical understanding for Hispanic pediatric surgery patients. J Pediatr Surg. 2015 Sep;50(9):1586-9. terpreter’s relationship to the LEP means more effective and timelier note to the incoming providers, I doi: 10.1016/j.jpedsurg.2014.12.020. person, and the time or portions communication and improved pa- highlighted: “Patient will benefit 14. Diamond L et al. A systematic review of of the patient encounter that the tient satisfaction. But, according to from a Hindi speaking provider, the impact of patient–physician non-eng- interpreter’s services were used. Yet, a Doximity study, there is a signifi- Limited English Proficiency.” lish language concordance on quality of care and outcomes. J Gen Intern Med. 2019 language interpretation alone can cant “language gap” between those Aug;34(8):1591-1606. doi: 10.1007/s11606-019- be inadequate without document languages spoken by physicians and References 04847-5. 16 translation. According to one study, their patients. Hospitals, therefore, 1. Questions and Answers. Limited English Profi- 15. Ngo-Metzger Q et al. Providing high-qual- despite the availability of on-site should assess, qualify, and incentiv- ciency: A federal interagency website. www.lep. ity care for limited English proficient patients: gov/commonly-asked-questions. professional interpreter services, ize staff who can serve as on-site The importance of language concordance and 2. United States Census Bureau. Percent of interpreter use. J Gen Intern Med. 2007 Nov;22 hospitalized patients who do not medical interpreters for patients as people 5 years and over who speak English less Suppl 2(Suppl 2):324-30. doi: 10.1007/s11606- speak English are less likely to have a means to facilitate language con- than “very well.” www.census.gov/library/visual- 007-0340-z. signed consent forms in their medi- cordant care for LEP patients. izations/interactive/people-that-speak-english- 16. https://press.doximity.com/articles/first-ev- cal records.11 Health care profession- The Agency of Healthcare Re- less-than-very-well.html. er-national-study-to-examine-different-lan- guages-spoken-by-us-doctors. als, therefore, need well-translated search and Quality also has a guide 3. Jacobs EA, et al. Overcoming language barriers in health care: Costs and benefits 17. Agency for Healthcare Research and Quality. documents to treat LEP patients. on how hospitals can better identify, of interpreter services. Am J Public Health. Patients with Limited English Proficiency. www. Translated documents of consent report, monitor, and prevent medical 2004;94(5):866-9. doi: 10.2105/ajph.94.5.866. ahrq.gov/teamstepps/lep/index.html. the-hospitalist.org | 7 | August 2021

06_to_09_HOSP21_08.indd 7 7/20/2021 2:37:27 PM PRACTICE MANAGEMENT Hospitalists and medical malpractice A look at some sobering trends

By Adam C. Schaffer, MD, hospitalists, a recent study exam- claims, general surgery and orthope- MPH ined claims against hospitalists us- dic surgery are in the top five. The ing the Comparative Benchmarking extraordinary growth in the field of mong the pressures felt by System (CBS), a national database hospital medicine has meant a need hospitalists are concerns of malpractice claims containing to hire an increasing number of hos- about being subject to a approximately 30% of all U.S. mal- pitalists, leading to less-experienced malpractice claim. Anxiety practice claims, which is maintained physicians entering the field. Aabout malpractice influences the by CRICO, the malpractice insurer way hospitalists practice, giving rise for the Harvard-affiliated medical Making hospital medicine safer to defensive medicine. institutions.6 A more urgent question than what One survey, which asked hospital- Claims in the CBS database are ex- is driving the trends in hospitalist ists to retrospectively rate which of amined by trained nurse coders who claims rates is what can be done to their orders represented defensive review the claims, along with the avoid adverse events and make hos- medicine, found that 28% of orders associated medical and legal records, pital medicine safer. One potential were deemed defensive.1 Defensive to understand the contributing fac- answer is thoughtful collaboration medicine can lead to low-value med- tors behind the adverse event lead- arrangements with the surgical and ical care, drive up health care costs, ing to the claim. other specialties with whom hospi- and potentially subject patients to Contrary to the trends for nearly talists may be co-managing patients. unnecessary testing.2,3 all other physician specialties, the Questions about who responds Encouragingly, medical malprac- malpractice claims rates of hos- to what types of clinical issues Dr. Schaffer practices as a member tice claims rates have, overall, been pitalists were not downtrending, that might arise and specific do- of the Hospital Medicine Unit at downtrending. An analysis of data going from 1.77 claims per 100 phy- mains of responsibility should be Brigham and Women’s Hospital, from the National Practitioner sician-years for 2009-2013 to 2.08 defined in advance, so that a lack Boston, where he serves as of role clarity does not negatively an attending physician on the impact patient care. Given that inpatient general medicine hospitalists will be less comfortable services. An instructor at Harvard addressing more technical surgical Medical School, his academic issues, expectations about surgeons’ interests include research using availability should be established. large medical malpractice Nocturnists may be tasked with databases to examine temporal overnight cross-coverage of patients trends in medical malpractice. on services, such as oncology and cardiology, that subspecialty physi- cians have responsibility for during Clinical decision support (CDS) the day. Agreeing upon triggers for systems have shown promise in pro- when the nocturnist should contact moting guideline-concordant care.7 the daytime subspecialty attending However, the role of CDS in aiding (for example, if a rapid response is the higher-stakes clinical decisions called on their patient) should be that may be called into question considered, so that nocturnists are after an adverse outcome is not well not left deciding, in the moment, defined. Alerts that a patient may be hinkstock

/t whether to call the daytime attend- developing sepsis is one type of CDS ing. Measures such as this ensure that has been extensively studied

merznatalia that everyone’s expectations are and has been shown to be of some aligned. In addition, new hospitalists benefit.8 The importance of clinical Data Bank, which is a repository of claims per 100 physician-years for need to be offered support, in the judgment to whether payment is all paid malpractice claims against 2014-2018. The overall claims rate for form of training and mentorship. made on a malpractice claim can individual physicians, found that hospitalists was significantly high- CBS malpractice data, which inform risk management strategies. malpractice claims rates decreased er than that for internal medicine includes the contributing factors Hospitalists should document the by 55.7% from 1992 to 2014 among all subspecialists (though roughly the underlying what went wrong, illumi- thought process behind their deci- specialties, and by 46.1% for internal same as the claims rate for nonhos- nates potential targets for programs sion-making in the chart, especially medicine physicians.4 The data used pitalist general internal medicine designed to enhance patient safety. for important clinical decisions. A in this analysis did not separate physicians). These sobering findings In the recent hospitalist malpractice note showing that the clinician was hospitalists from other internal raise the important question of why study, the two contributing factors thoughtfully weighing the risks and medicine physicians. An older study hospitalists claims rates are heading that were the best predictors of a benefits using the data available of malpractice claims against hos- in the wrong direction. hospitalist malpractice claim closing at the time will help make a case pitalists found that hospitalists had One possible answer relates the with payment to the claimant were defensible if an adverse outcome significantly lower claims rates than ever-broadening scope of hospital- clinical judgment errors and com- occurs. nonhospitalist internal medicine ist practice. Hospitalists are being munication breakdowns. Identifying The effect of communication physicians.5 asked to care for surgical patients measures that are effective in pro- breakdowns on hospitalist case and other patient populations that moting patient safety by refining outcomes highlights the impor- Current malpractice they may have less familiarity with, the clinical judgment of clinicians tance of measures to improve and environment for hospitalists increasing the risk of medical errors. is a challenge, and there are limited systematize communication among Seeking to shed light on the current Among the other specialties most data demonstrating what programs clinicians, particularly at vulnerable malpractice environment faced by commonly also named in hospitalist are effective in this area. junctures – such as handoffs from August 2021 | 8 | The Hospitalist

06_to_09_HOSP21_08.indd 8 7/20/2021 2:37:34 PM PRACTICE MANAGEMENT

the day team to the night team, study, in addition to general surgery malpractice claim include a poor medical liability system. Health Aff (Mill- wood). 2010;29(9):1569-77. doi: 10.1377/ and transitions from one care set- and orthopedic surgery, the other relationship with the physician – hlthaff.2009.0807. ting to another. An example of an clinical services most commonly specifically, a lack of empathy from 4. Schaffer AC et al. Rates and characteristics intervention to improve handoffs subject to claims along with hos- the physician, feeling deserted by of paid malpractice claims among U.S. physi- with cogent evidence to support it pitalists were nursing, emergency the physician, and feeling devalued cians by specialty, 1992-2014. JAMA Intern 11 Med. 2017;177(5):710-8. doi: 10.1001/jamaint- is I-PASS, which is an approach to medicine, and cardiology. Another by the physician. These findings ernmed.2017.0311. handoffs between teams in which observation was that physician support the use of programs that 5. Schaffer AC et al. Liability impact of the hospi- information about the patient’s ill- assistants and nurse practitioners assist physicians in compassionately talist model of care. J Hosp Med. 2014;9(12):750- ness severity, clinical background, are increasingly being named in disclosing adverse events to pa- 5. doi: 10.1002/jhm.2244. and contingencies is conveyed and hospitalist claims. This information tients. Among inpatient physicians, 6. Schaffer AC et al. Rates and characteristics of medical malpractice claims against hospitalists. synthesized in a structured manner. is crucial to guiding who needs to be patient satisfaction survey ques- J Hosp Med. 2021 Jul;16(7):390-6. doi: 10.12788/ A study of the effect of implementa- in the room with hospitalists when tions about the time the physician jhm.3557. tion of I-PASS among nine pediatric efforts are undertaken to enhance spent with the patient and the phy- 7. Poon EG. Clinical decision support: A tool of residency programs demonstrated patient safety within hospital med- sician’s concern for the patient are the hospital trade. J Hosp Med. 2015;10(1):60-1. doi: 10.1002/jhm.2295. a 30% reduction in preventable ad- icine. better predictors of the physicians’ 9 8. Makam AN et al. Diagnostic accuracy verse events. An understandable response to risk management performance than and effectiveness of automated electronic the finding that hospitalist claims is the question about the skill of the sepsis alert systems: A systematic review. J Applying insights from rates are not decreasing is for hos- physician.12 In the aftermath of an Hosp Med. 2015;10(6):396-402. doi: 10.1002/ jhm.2347. malpractice claims analysis to pitalists to seek ways to lower their adverse event, focusing on main- 9. Starmer AJ et al. Changes in medical errors clinical practice risk of being named in a malpractice taining a strong patient-physician after implementation of a handoff program. N The systematic review of malprac- claim. Of course, avoiding adverse relationship is not only the right the Engl J Med. 2014;371(19):1803-12. doi: 10.1056/ tice cases to determine the con- events by providing the safest pos- thing to do, the data tell us that it is NEJMsa1405556. tributing factors and other case sible care is paramount. Even when also a sensible approach to reducing 10. Localio AR, et al. Relation between malprac- tice claims and adverse events due to negli- attributes is an important source of patients do suffer adverse events medicolegal risk. gence. Results of the Harvard Medical Practice patient safety insights. The process due to a physician negligence, only Study III. N Engl J Med. 1991;325(4):245-51. doi: breakdowns described by the con- rarely, less than 5% of the time, does References 10.1056/NEJM199107253250405. 10 11. Beckman HB et al. The doctor-pa- tributing factors can inform the de- this result in a malpractice claim. 1. Rothberg MB et al. The cost of defensive tient relationship and malpractice. Lessons medicine on 3 hospital medicine services. JAMA sign of patient safety initiatives. In Important lessons in risk manage- from plaintiff depositions. Arch Intern Intern Med. 2014;174(11):1867-8. doi: 10.1001/ addition, malpractice data provide ment can be learned from examin- Med. 1994;154(12):1365-70. doi: 10.1001/ jamainternmed.2014.4649. information on which specialties ing why patients decide to sue when archinte.1994.00420120093010. 2. Kachalia A et al. Overuse of testing in preop- 12. Stelfox HT et al. The relation of patient and what types of clinicians are be- mistakes lead to bad outcomes. erative evaluation and syncope: A survey of satisfaction with complaints against physi- ing named together in malpractice An analysis of plaintiffs’ deposi- hospitalists. Ann Intern Med. 2015;162(2):100- cians and malpractice lawsuits. Am J 8. doi: 10.7326/M14-0694. claims. tions found that the key reasons Med. 2005;118(10):1126-33. doi: 10.1016/j. In the hospitalist malpractice that patients decided to file a 3. Mello MM et al. National costs of the amjmed.2005.01.060.

I joined SHM because I was looking for my professional home, which I can say with certainty that I found! As a practicing hospitalist for the last 7 years, I wanted to be in the company of like-minded physicians who were having similar experiences as myself. At SHM, we exchange ideas and support each other as we improve our field together! To me, SHM isn’t just a Society, it’s a family!

Together, We Are the

Payal Parikh, MD SHM Member Power of Care. We invite you to join our SHM family. hospitalmedicine.org/join

the-hospitalist.org | 9 | August 2021

06_to_09_HOSP21_08.indd 9 7/20/2021 2:37:40 PM CAREER Microlearning during the pandemic How to become a hospitalist

By Jose R. Mercado, MD; Learning from our colleagues endproduct for our trainees and cli- medical journals are typically a sum- J. Henry Feng, MD With the initial webinars and train- nicians required more thought. mary of the publication’s content ing sessions for our staff, we assessed and are less engaging. Alternatively, he vast amounts of informa- our learners’ motivations and back- From theory to application podcasts produced by independent tion generated this past year ground in managing in a hospital Microlearning allows for faster de- creators are certainly engaging and related to the COVID-19 pan- medicine capacity. Overall, we discov- livery of information – fewer things entertaining, and have a wealth of demic was a feat of wonder ered that our trainees and clinicians to write means shorter course information, but the line is often T– recommendations and guidelines have an innate drive to learn; all of distribution times, allowing the blurred between just that: educa- on the hospital level and on the na- them recognized the importance learner to respond faster to chang- tion and entertainment. In both tional level came in a flurry, more of keeping up with evidence-based ing educational goals and training instances, there is no follow-up or often overwhelming and confusing information. However, the difficulty demands. Microlearning is flexible feedback offered to the learner in than clarifying for the frontline highlighted was the individual time – “micro-courses” can give a broad the form of surveys, or other types provider. In addition, “routine” hos- available to dedicate to acquiring overview of a subject or cover com- of feedback, which is arguably an pital care for noninfected patients new information and awareness of plex topics broken down into simple important piece in any form of ped- and improvement processes had to new information being available to parts. In addition, micro-learning agogy. Thus, we sought to strike a continue as we all dealt with the the health care sector during the promotes retention of key concepts balance between the two forms for whirlwind of increasing COVID cas- chaotic times of the pandemic. – given the length of each lesson, our purposes. es, torrents of new guidelines, and From our section’s perspective, we repetition of the topic by the learner educating our trainees. had a difficulty with coordinating is possible at any point in time. The Process of two podcasts Thus, the individual-level ques- among multiple professional devel- whole experience is similar to check- Our section was aware of the two tion: How does a clinician stay opment groups within our hospi- ing your favorite social media appli- aims during the pandemic – (1) dis- engaged and distill the relentless tal, cost, and resources to execute cation on your smartphone. seminate new information regard- stream of new information? training. These difficulties between Certainly, many examples of the ing COVID-19 to the rest of our staff In Spring 2020, when the first pa- members and trainees as quickly tients with COVID were admitted, as possible, and (2) maintain and our hospital medicine section was Podcasting is a well-received medium of information improve the current quality of care tasked to create a surge plan. This in- transfer“ that is convenient for both the learner and the of our patients. Thus, we sought to cluded organizing, orienting, and ed- apply the reach and efficiency of ucating off-service providers on how content creator. the podcasting medium to provide to become hospitalists. Undoubtedly, ” ongoing education and feedback the call to arms for our center was providing knowledge and receiving application of microlearning are with respect to these two aims. heard, and many responded. Howev- knowledge have already been ex- available in the health care sector “The Cure” podcast: We recognized er, backgrounds were diverse in spe- pertly analyzed.1 – pharmaceutical and nursing train- the constant flow of new COVID-19 cialty – clinicians and trainees from Parallel to this, the pedagogic ing both have utilized the theory information and updates, and we psychiatry, general surgery, and var- paradigm shifts as we progress extensively.3,4 However, in many wanted to find a readily accessible ious fellowships all answered. It was through our careers – the methods instances, individuals were still platform to reach staff with timely an exhausting and inefficient effort and skills we used in school contrast required to sit at a workstation to updates. Our marketing and com- to produce the material, hold webi- in many ways with those we use on complete modules and lessons. We munications team later helped us nars, and schedule training, especial- a daily basis when it comes to learn- envisioned our application of micro- realize that the content we wanted ly for those who were more removed ing. Instead of dedicating hours learning to be “on-the-go,” without to share was relevant to our patients from a hospital medicine experience. at a time to new challenges in our necessarily requiring a computer and the community, so we formatted We knew we had to come up with an workflow or our interests, we watch workstation or laptop to complete. the material to be practical and easily alternative plan moving forward. videos, search retailers for product In thinking about how social digestible – something that may help Thus, the systems-level question: solutions, check our email corre- media attracts and influences cli- an individual make decisions at the How does a health care system spondence, and peruse social media nicians, many content creators on bedside as well as have conversations educate its clinicians, or any other accounts several times a day. Infor- social media come to mind. In addi- at the dinner table. Most recently, we health care providers, when reallo- mation comes at us very quickly, but tion, most, if not all, have branched engaged with our human resources cation of their talents and skills is in small pieces. into various social media platforms department to use our platform in both necessary and time-sensitive, One such innovation in pedagogy – podcasting, blogging, YouTube, orienting new hires with the goal of and occuring during a period where is the practice of microlearning. for example. In thinking about our helping staff familiarize with the in- new information is constantly being This refers to the use of small lesson colleagues and trainees, we wanted stitutions policies, procedures, and job produced and changing? modules and short-term activities a platform that they could take on aids that keep staff and patients safe. To reach the most clinicians as intended to teach and reinforce the go, without the need to focus “Antibiotry” podcast: Prior to the possible, with the most succinct concepts.2 It is the opposite of “mac- their visual attention (such as while COVID-19 pandemic, our antibiotic and distilled information, we had rolearning,” which is the principle of driving or running). Ultimately, we stewardship group noticed an in- to come up with a method to do so. dedicating reading material, struc- believe the podcast would be the crease in antibiotic use on our medi- Ultimately, in considering the situa- tured coursework, and traditional best platform to disseminate our cal floors. This is monitored not only tion at hand, we had to understand knowledge evaluation in the form of information. through internal metrics by our who we were as the provider of the exams to reinforce learning. Certain- Podcasting is not foreign to med- pharmacy department, but also via information, and who the recipient ly, microlearning has other names as icine. A variety of medical podcasts the SAAR (standardized antibiotic would be. We would like to share the well – “just-in-time,” “just-enough,” exist, whether produced by major administration ratio). Both sources initiatives and processes by which and “micro-courses” are a few syn- medical journals or by various inde- demonstrated an increase in antibi- we constructed our solution to onyms seen in the current literature. pendent health care practitioners. otic use, greater than expected. An the two questions – microlearning Though a highly relevant concept Both, however, have their drawbacks initiative was formed between our through hospital podcasting. for our situation, translating it to an – the podcasts created by major hospital medicine and infectious dis- August 2021 | 10 | The Hospitalist

10_thru_15_HOSP21_08.indd 10 7/20/2021 2:51:27 PM CAREER

ease sections, and our pharmacy de- The interdisciplinary nature of partment to raise awareness of this continued medical education cannot increase in use, provide education be stressed enough. With the help of to our trainees, and create systems our professional development team solutions for clinicians. and their educators, we were able Initially, we sought to hold in-per- to centralize our podcast and attach son sessions once a month for our surveys and additional graphics trainees. This was led by a senior for each episode, if appropriate. resident at the time. Topics of dis- This additional detail allowed for cussion were geared toward clinical engagement with our learners and decision-making regarding empiric the chance to provide additional ed- antibiotic use on the hospital med- ucational points, if the learner was icine service. At the same time, our interested. Given the integrated na- team published empiric antibiotic ture of this platform, quality metrics use guidelines, accessible through could easily be recorded and various Dr. Mercado Dr. Feng our electronic medical record. In other more conventional metrics, addition, the resident leader gave a such as listener counts and the du- voluntary survey at the end of the ration of each podcast played. Dr. Mercado is medical director at Alice Peck Day Memorial Hospital, and session to assess not only confidence associate hospital epidemiologist, Dartmouth-Hitchcock Medical Center, of antibiotic use, but also baseline Future initiatives both in Lebanon, N.H., and assistant professor at the Geisel School knowledge regarding antibiotics in Thus far, we have had great success of Medicine at Dartmouth, Hanover, N.H. Dr. Feng is a Fellow in the various clinical scenarios. This sur- in the reception and use of both Leadership/Preventive Medicine Program in the Department of Internal vey was repeated at the end of the podcasts within our institution as Medicine at Dartmouth-Hitchcock Medical Center. resident group’s month-long rotation. an application of microlearning. Altogether, each in-person session “The Cure” has been widely listened was no longer than 10 minutes. to by all hospital staff from various ual clinical expertise, presentation Conclusion Unfortunately, the initiative was services; it has caught the attention skills, and technical skills ought to Medicine is ever-changing – the just gaining momentum when the of state-wide radio programs, and be carefully weighed to sustain our guidelines and criteria for pa- pandemic was declared. However, plans to expand it into the commu- podcasts most efficiently, and per- tient care and pathology that we we sought to take this challenge and nity are being discussed. haps expand them through differ- learned in medical school have translate it into an opportunity. As for “Antibiotry” podcast, the ent social media platforms. likely changed. There is no single We directed our focus toward concept has been lauded by our Our objective for sustainability is “best” method of learning new stewardship during pandemic times. medical educators. Given its central- through the continued outreach to information in medicine, simply Initially, our resident leader sent out ization within our institution, we and recruitment of residents and because of the breadth and volume email primers, approximately 3- to are able to publish institution-based medical students, who can play key of such information generated on a 5-minute reads, as a substitute for data as a form of professional and roles in the development of future daily basis. This poses both a chal- the in-person sessions. Our primers’ educational feedback to our trainees projects related to these educational lenge for present-day clinicians uniqueness was in its incorporation and staff physicians. This is current- innovations. Both podcasts were and trainees, and a stimulus for of prescription pattern data that ly coupled with the development of developed through planning, trial, change in the methods of acquir- were developed by our resident lead- a provider dashboard, visualizing error, and execution by two resident ing, absorbing, and applying new er and our initiative’s data analyst. In leaders. Their initiative and moti- information to clinical decision- doing so, we provided professional vation to educate our institution making and practice. feedback regarding our antibiotic use One of the key through these platforms were high- We have found that podcasting based on the clinical indication. This measures“ we would like to ly unique; their pathfinding set the is a well-received medium of infor- was a powerful tool to not only en- investigate is whether our foundation for sustainability and mation transfer that is convenient gage our learners and staff clinicians, expansion to other services. for both the learner and the con- but also benchmark continued quali- microlearning platform Of course, one of the key mea- tent creator. Through the podcast ty improvement. translates to improved sures we would like to investigate format, we were able to distill non- But email primers are not en- is whether our microlearning plat- engaging pieces of education and gaging, and despite the ubiquity of patient outcomes. form translates to improved patient information and transform them teleconferencing, it was difficult to ” outcomes. Regarding “Antibiotry,” into short-duration lessons that the ask our housestaff to break from antibiotic prescriptions and narrow- we hope to see a decrease in unnec- learner can listen to at their own their morning rounds for a 10-min- ing patterns of practice within our essary broad-spectrum antibiotic convenience. This proved to be es- ute tele-meeting. Thus, we devised a medicine department. We plan to ex- use by drawing attention to clini- pecially handy during the chaos of podcast method of education – 5- to pand “Antibiotry” to other services cian practice patterns. Quality and the pandemic, not only for dissemi- 10-minute audio clips with conversa- at the hospital. outcome metrics will continue to be nation of information regarding the tion regarding a topic of discussion. For both podcasts, the steps it developed and measured. In addi- management of COVID-19, but also This way, our trainees and learners took to achieve the final product tion to patient care metrics, further for sustaining quality improvement can access episodes of education from the microlearning concept investigation of pedagogical metrics goals within our institution. on their own time throughout the were possible through a combi- will be conducted, especially in the Further investigation on patient pandemic without disrupting their nation of institutional need and a evolving realm of graduate and con- outcomes and information quality workflow. Given the brevity of, but motivated team. We are fortunate tinuing medical education. are the planned next steps. In addi- high-yield content in, each episode, it to have highly energetic individuals, Measuring educational quality is tion, expansion of other micro- would be convenient not only for lis- making the coordination and plan- neither a new ethical nor philosoph- learning media, such as group SMS teners to access and repeat, but also ning with our hospitalists, various ical debate – neither does it carry a texting, YouTube videos, and Twit- for the podcaster (our resident lead- sub-specialists, and professional definitive answer. Further help from ter, ought to be considered. Though er) to create, as recording of the au- development teams straightforward. education experts may be needed many publications discuss the theo- dio portion takes anywhere between As the team grows with more indi- to assess the quality of the informa- ry, potential benefits, and predicted 10 and 20 minutes for each episode, viduals interested in the initiatives, tion provided and its impact on our pitfalls of microlearning, few assess with postprocessing similarly fast. keen insight into interests, individ- learners. Continued on following page the-hospitalist.org | 11 | August 2021

10_thru_15_HOSP21_08.indd 11 7/20/2021 2:51:32 PM PEDIATRICS Major musculoskeletal surgery in children with medically complex conditions A review of the International Committee’s guide

By Ann-Marie Tantoco, MD, need for ongoing, open communi- derstanding how the child appears FAAP, FHM; and Ajay Bhasin, cation between providers, patients, and responds when in pain or dis- MD and families to set goals and expec- comfort, especially for a child with tations, discuss potential complica- limited verbal communication. The he International Committee tions, and describe outcomes and module provides pain assessment on Perioperative Care for the recovery process. tools, tailored to verbal and nonver- Children with Medical Com- The module elaborates on several bal patients in both the inpatient plexity developed an online key factors that must be evaluated and outpatient settings. The module Tguide, “Deciding on and Preparing and addressed long before surgery also shares guidance on establishing for Major Musculoskeletal Surgery to ensure success. Baseline nutri- communication and goals with the Dr. Tantoco Dr. Bhasin in Children With Cerebral Palsy, tion is critical and must be evalu- family and within the care team Neurodevelopmental Disorders, ated with body composition and on how the child appears when and Other Medically Complex Con- anthropometric measurements. in distress and how he/she/they Dr. Tantoco is a med-peds ditions,” published on Dec. 20, 2020, Respiratory health must be assessed respond to pain medications. The hospitalist at Northwestern detailing how to prepare pediatric with consideration of pulmonol- pain plan should encompass both Memorial Hospital and Ann & patients with medical complexity ogy consultation, specific testing, pharmacologic and nonpharmaco- Robert H. Lurie Children’s Hospital prior to musculoskeletal surgery. and ventilator or assistive-device logic therapeutics. Furthermore, as of Chicago, and instructor of The guide was developed from a pain and discomfort may present medicine (hospital medicine) dearth of information regarding Family and social from multiple sources, not limited and pediatrics in Northwestern optimal care practices for these pa- to the regions involved in the proce- University, in Chicago. She is also tients. assessments“ must not be dure, understanding how the child a member of the SHM Pediatrics The multidisciplinary committee neglected prior to surgery, responds to urinary retention, con- Special Interest Group Executive included members from orthopedic stipation, dyspnea, and uncomfort- Committee. Dr. Bhasin is a med- surgery, general pediatrics, pediatric as these areas may also able positions is important to care. peds hospitalist at Northwestern hospital medicine, anesthesiology, affect surgical outcomes. Postoperative immobilization must Memorial Hospital and Ann & critical care medicine, pain medicine, ” also be addressed as it may lead to Robert H. Lurie Children’s Hospital, physiotherapy, developmental and optimization. Moreover, children pressure injury, manifesting as be- and assistant professor of medicine behavioral pediatrics, and families with innate muscular weakness or havioral changes. (hospital medicine) and pediatrics of children with cerebral palsy. restrictive lung disease should have The module also presents labora- in Northwestern University. Mirna Giordano, MD, FAAP, FHM, baseline physiology evaluated in an- tory testing as part of the preoper- associate professor of pediatrics at ticipation of potential postoperative ative health assessment. It details Columbia University, New York, and complications, including atelectasis, the utility or lack thereof of several approach transportation, medical International Committee member, hypoventilation, and pneumonia. common practices and provides equipment, and school transitions. helped develop these recommenda- Coexisting chronic medical con- recommendations on components The module is available for review tions to “improve quality of care in ditions must also be optimized in that should be part of each patient’s in OPEN Pediatrics (www.openpedi- the perioperative period for children anticipation of expected deviations assessment. It also contains videos atrics.org), an online community for with medical complexities and neu- from baseline. showcased from the Courage Par- pediatric health professionals who rodisabilities all over the world.” In anticipation of peri- and post- ents Network on family and provid- share peer-reviewed best practices. The guide meticulously details operative care, the medical team er perceptions of spinal fusion. “Our aim is to disseminate the rec- the steps required to successful- should be aware of details surround- Family and social assessments ommendations as widely as possible ly prepare for an operation and ing patients’ indwelling medical must not be neglected prior to to bring about the maximum good postoperative recovery. It includes devices, such as cardiac implantable surgery, as these areas may also to the most,” Dr. Giordano said. The an algorithm and comprehensive devices and tracheostomies. Par- affect surgical outcomes. The mod- International Committee on Periop- assessment plan that can be imple- ticular attention should be paid to ule shares several screening tools erative Care for Children With Med- mented to assess and optimize the baclofen pumps, as malfunction or that care team members can use to ical Complexity is planning further child’s health and well-being prior mistitration can lead to periproce- screen for family and social issues. guides regarding perioperative care, to surgery. It encourages shared dural hypotension or withdrawal. Challenges to discharge planning particularly for intraoperative and decision-making and highlights the Of paramount importance is un- are also discussed, including how to postoperative considerations.

Continued from previous page these moments and fill them with approach is valuable to keeping an 2. Filipe HP et al. Microlearning to improve CPD learning objectives. Clin Teach. 2020 the real-world application of micro- essential pieces of information. audience engaged. In the future, we Dec;17(6):695-9. doi: 10.1111/tct.13208. learning to the clinical setting for We offer these suggestions as a hope to be able to correlate micro- 3. Hegerius A et al. E-Learning in pharmacov- medical education. place to start. The microlearning learning courses to provider per- igilance: An evaluation of microlearning-based So what did we learn? We should platform allows for the collection formance and measurable patient modules developed by Uppsala Monitoring think of microlearning as moments of data on the interaction between outcomes. Centre. Drug Saf. 2020 Nov;43(11):1171-80. doi: 10.1007/s40264-020-00981-w. when you turn to your smartphone user and course content. The data 4. Orwoll B et al. Gamification and micro- or tablet in order to discover some- collected can be used for continuous References learning for engagement with quality thing, answer a question, or complete quality improvement of the curric- 1. Duggan F and Banwell L. Constructing a improvement (GAMEQI): A bundled digi- a task. These are moments when ulum. Microlearning is a dynamic model of effective information dissemination in tal intervention for the prevention of central a crisis. Information Research. 2004;9(3). Paper line–associated bloodstream infection. Am decisions are made and knowledge platform where creative ideas are 178 [Available at http://InformationR.net/ir/9-3/ J Med Qual. Jan/Feb 2018;33(1):21-9. doi: is reinforced. The goal is to capture encouraged and a multidisciplinary paper178.html]. 10.1177/1062860617706542. August 2021 | 12 | The Hospitalist

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HOSP_13.indd 1 7/21/21 1:56:26 PM COMMENTARY Weathering this storm and the next Perspectives on disaster preparedness amid COVID-19

By Teena Hadvani, MD, FAAP; Vicki Uremovich, DO, FAAP; Ricardo Quinonez, MD, FHM, FAAP; Michelle A. Lopez, MD, MPH, FAAP; Brent Mothner, MD, FAAP

he COVID-19 pandemic has tested disaster preparedness in hospitals across the na- Dr. Hadvani Dr. Uremovich Dr. Quinonez Dr. Lopez Dr. Mothner tion. The pandemic brought Tmany unique disaster planning Dr. Hadvani is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas challenges not commonly seen Children’s Hospital, Houston. Dr. Uremovich is assistant professor of pediatrics in the section of hospital medicine at with other emergencies disasters. Baylor College of Medicine, Texas Children’s Hospital. Dr. Quinonez is associate professor of pediatrics and chief of These included an uncertain and pediatric hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Lopez is assistant professor prolonged time frame, the imple- of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Mothner mentation of physical distancing, is associate professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s and the challenges of preserving Hospital, and is the pediatric hospital medicine medical director for the main campus. the health care work force. But how do we prepare for the next disaster when the health Disaster preparedness staffing con- vital – bidirectional Disaster Preparedness Cycle care system and staff are already siderations communication be- stretched thin? Here, we discuss the Management, communication, and tween physicians and concept of maintaining a state of staffing issues are critical to disaster hospital leadership op- preparedness through and beyond response. Key leadership responses timizes preparedness Assess COVID-19, using a disaster prepared- during COVID-19 included providing plans. These measures Ongoing Prepare for ness cycle – including continuous frequent and transparent commu- will help staff feel sup- assessments of vulnerabilities, nication, down-staffing for physical ported before, during, Needs While Disaster dynamic staffing adjustments to distancing during low census, and and after a disaster. Recovering Needs support patient and hospital needs, prioritizing staff well-being. These and broadening of the pandemic measures serve as a strong founda- Dynamic disaster response to incorporate planning for tion moving into preparations for response the next disaster. the next disaster.8 Supporting patient and D y To ensure adequate staffing hospital needs n

a Adjust to advani Disaster preparedness and during an unexpected natural di- The next step in the m H

assessing ongoing needs saster, we recommend creating disaster preparedness i Changing eena c . t Disaster preparedness cycle and “ride-out” and “relief teams” as part cycle is adjusting to r Needs During : d 9,10

Hazard Vulnerability Assessment of disaster staffing preparedness. changing needs during redit The disaster preparedness cycle il- The ride-out team provides the ini- the disaster. The pedi- the Disaster C lustrates that disaster preparedness tial care, and these providers are ex- atric inpatient popu- is continuous (see graphic). Disaster pected to stay in the hospital during lation was less affected initiallyFigure by 1: Disasterpatient Preparedness population, Cycle and therefore, preparedness is achieved with the the primary impact of the event. COVID-19, allowing hospitalists to can adapt to where the clinical need nonstop cycle of planning, coordi- Once the initial threat of disaster is support the unpredicted needs of may be. Optimizing and expanding nating, and recognizing vulnera- over and it is deemed safe to travel, the pandemic. A dynamic and flexi- our skill sets can bring value to the ble areas.1-5 Hazard vulnerability the relief team is activated and of- ble physician response is important hospital system during uncertain analysis (HVA) can play a critical fers reprieve to the ride-out team. to disaster preparedness. times. role in recognizing areas in which a Leaders and backup leaders within As there has been a continued Hospitalists are also instrumental hospital system has strengths and these teams should be identified in shift to telehealth during the pan- for patient flow during the pan- weaknesses for different disaster the event teams are activated. These demic, our group has engaged in demic. To address this, our group scenarios. There are several tools assignments should be made at the telehealth calls related to COVID-19. partnered with hospital leadership available, but the overarching goal is start of the year and updated yearly Seizing these new opportunities not from many different areas including to provide an objective and system- or more frequently, if needed. only provided additional services administration, nursing, emergency atic approach to evaluate the poten- While the COVID-19 pandemic to our patients, but also strength- medicine, critical care, and ancillary tial damage and impact a disaster did not significantly affect children, ened community support, physician services. By collaborating as one co- could have on the health care sys- our ride-out and relief teams would worth, and the hospital’s financial hesive hospital unit, we were able to tem and surrounding community. have played a significant role in state. This is also an opportunity for efficiently develop, implement, and The HVA can also be utilized to re- case a surge of pediatric cases had higher-risk clinicians or quarantined update best clinical care guidelines assess system or personnel vulnera- occurred. faculty to offer patient care during and algorithms for COVID-19–relat- bilities that may have been exposed Other considerations for disaster the pandemic. ed topics such as testing indications, or highlighted during the pandem- staffing include expanding backup Cram et al. describe the impor- admission criteria, infection control, ic.6,7 These vulnerabilities must be coverage and for multisite groups, tance of “unspecializing” during the and proper personal protective addressed during preparations for identifying site leads to help field COVID-19 pandemic.11 Starting dis- equipment use. Lastly, working with the next disaster while concurrently specific questions or concerns. Last- cussions early with adult and pedi- specialists to consolidate teams “assuming the incident happens at ly, understanding the staffing needs atric critical care colleagues is vital. during a pandemic presents an the worst possible time.”7 of the hospital during a disaster is Hospitalists take care of a broad opportunity for hospitalists to high- August 2021 | 14 | The Hospitalist

10_thru_15_HOSP21_08.indd 14 7/20/2021 2:51:44 PM COMMENTARY

5. Environmental health in emergencies and light expertise while bringing value to account for the uncertain time bilities, collaboration with hospital disasters: A practical guide. World Health to the hospital. frame of an event like the COVID-19 leadership, and remaining flexible as Organization, Geneva. 2002:9-24. Edited by B. pandemic is critical. Several articles hospitalists are critical components Wisner and J. Adams. https://apps.who.int/iris/ handle/10665/42561. Unique staffing situations in the national news posed similar for successful preparedness amid 6. U.S. Department of Health & Human Services. related to COVID-19 questions, although these publica- disasters. A dynamic and responsive Topic collection: Hazard vulnerability/risk Different from other disasters, the assessment. https://tinyurl.com/vtjd8bd3). COVID-19 pandemic affected older How do we adequately plan, maintain a dynamic 7. Hospital Association of Southern California. or immunocompromised staff in Hazard and vulnerability analysis. https://tinyurl. com/c596y8up). a unique way. Buerhaus et al. note response,“ and continue to efficiently move through the 8. Meier K et al. Pediatric hospital medi- that 20% of the physician work- disaster staffing cycle during an event like the COVID-19 cine management, staffing, and well-being force in the United Sates is between in the face of COVID-19. J Hosp Med. 2020 55 and 64 years of age, and 9% are pandemic? Being aware of current vulnerabilities and May;15(5):308-10. doi: 10.12788/jhm.3435. 65 years and older.12 Hospitalist 9. Newman B and Gallion C. Hurricane Harvey: addressing gaps at the department and hospital level Firsthand preparedness in graduate medical groups should focus on how to opti- are vital to disaster preparedness. education. Acad Med. 2019 Sep;94(9):1267-9. mize and preserve their workforce, doi: 10.1097/ACM.0000000000002696. specifically those that are higher ” 10. Brevard S et al. Analysis of disaster response risk due to age or other health con- tions focused mainly on the Federal disaster plan has been vital amid plans and the aftermath of Hurricane Katrina: Lessons learned from a level I trauma center. J ditions. Emergency Management Agency COVID-19, and for the next disasters Trauma. 2008 Nov;65(5):1126-32. doi: 10.1097/ We used a tiered guide to safely and the governmental response to we will certainly encounter. TA.0b013e318188d6e5. accommodate our physicians that prepare for the next disaster when 11. Cram P et al. All hands on deck learning to were determined to be at higher risk resources are already stretched.13-15 “un-specialize” in the COVID-19 pandemic. J References Hosp Med. 2020 May;15(5):314-5. doi: 10.12788/ for complications of COVID-19; these How do we adequately plan, 1. Malilay J et al. The role of applied epidemiol- jhm.3426. recommendations included limiting maintain a dynamic response, ogy methods in the disaster management cycle. 12. Buerhaus P et al. Older clinicians and the exposure to patients with acute re- and continue to efficiently move Am J Public Health. 2014;104(11):2092-102. doi: surge in novel coronavirus disease 2019 (COVID- 10.2105/AJPH.2014.302010. spiratory illnesses and shifting some through the disaster staffing cycle 19). JAMA. 2020 May 12;323(18):1777-8. doi: 2. Federal Emergency Management Agency. 10.1001/jama.2020.4978. providers to a different clinical en- during an event like the COVID-19 Developing and maintaining emergency oper- 13. VOX Media. Imagine Hurricane Katrina vironments with a lower exposure pandemic? Being aware of current ations plans. 2010 Nov. https://tinyurl.com/2m- during a pandemic. 2020 May 27. https://tinyurl. risk, such as telemedicine visits. vulnerabilities and addressing gaps bacw5h. com/uj4r5sr). Other COVID-19 preparedness at the department and hospital level 3. Federal Emergency Management Agency. 14. The Hill. Democratic lawmakers ask how considerations that affected our are vital to disaster preparedness. National preparedness system. 2020 Jul 31. FEMA is planning to balance natural disasters, www.fema.gov/emergency-managers/nation- COVID-19 response. 2020 Apr 20. https://tinyurl. group in particular include the For example, we reassessed disas- al-preparedness/system). com/ys7ea46b. changes in learner staffing. Similar ter (ride-out/relief) teams and the 4. Federal Emergency Management Agency. 15. The Atlantic. What happens if a “big one” to attending down-staffing to en- minimum number of staff needed to National preparedness goal. 2011 Sep. www. strikes during the pandemic? 2020 May 9. courage physical distancing during maintain safe and quality care, and fema.gov/pdf/prepared/npg.pdf. https://tinyurl.com/85ja5bcf). low census, learners (residents, what in-house arrangements would medical students, and physician as- be needed (food, supplies, sleeping sistant students) also experienced arrangements) while having to decreased hours or suspension maintain physical distance. of rotations. For optimal patient Newman and Gallion explain “in care, adjusting to changing disas- disaster planning, having as many ter needs may include assessing physicians as possible on hand attendings’ capacity to assume re- may seem like an advantage, but sponsibilities typically supported being overstaffed in tight quarters by learners. was almost as bad as being under- The Glycemic Control Because of the ongoing nature staffed.”9 This has been particularly of the pandemic, we have had to true during the COVID-19 pandemic. eQUIPS Program maintain a dynamic response while It is crucial to have backup plans adjusting to changing and ongoing for faculty that are unable to serve Benchmark against 100 sites to optimize glycemic needs during recovery. Creating a ride-out duties from unexpected is- control and minimize hyper- and hypoglycemia. measured and staggered approach sues – such as availability, illnesses/ helps facilitate a smooth transition quarantines, childcare/dependents. “We use data from the program to identify areas of back to nonemergent activities. The Also, it is important to be aware opportunity. Our timeliness of hypoglycemia resolution education of learners, academic and that some supply chains are already has has improved drastically, consistently within 30 scholarly work, and administrative strained because of the pandemic minutes. To say the GC eQUIPS data has been ‘valuable’ duties will resume, but likely in a and how this may play a role in is an understatement.” different steady state. Also, aware- the availability of certain supplies. - Community Hospital of the Monterey Peninsula ness of physician burnout and Being aware and proactive about To learn more and register, visit: fatigue is critical as an institution specific constraints allows for a bet- hospitlalmedicine.org/gc enters a phase of recovery. ter level of preparedness. Continued collaboration and communication Preparing for the next disaster with other services to provide care during the pandemic should be ongoing throughout the This brings us back to the beginning disaster preparedness cycle. of the disaster preparedness cycle and the need to plan for the next Conclusion disaster. Current disaster prepared- Providing and maintaining optimal ness plans among physician groups and safe patient care should be and hospitals are likely focused on the overarching goal throughout an individual disaster scenario, but disaster preparedness. Being aware adjusting current disaster plans of group and institutional vulnera- the-hospitalist.org | 15 | August 2021

10_thru_15_HOSP21_08.indd 15 7/20/2021 2:51:49 PM Disaster Continued from page 1 But then along came the COVID pitals emerged as a recognized ed, because patients know they can of the department of critical care pandemic – which in many locales medical specialization in the 1970s. obtain care there. medicine at the Cleveland Clinic, and around the world was unprecedent- Initially it was largely considered One of the fundamental tools for coauthor of an article in the journal ed in scope. Dr. Persoff said his hos- the realm of emergency physicians, crisis response is the incident com- Chest last year outlining 10 prin- pital was fairly trauma services, or critical care doc- mand system (ICS), which spells out ciples of emergency preparedness well prepared, tors. Resources such as the World how to quickly establish a command derived from its experience with after a decade Health Organization, the Federal structure and assign responsibili- the COVID pandemic. Some of these of engagement Emergency Management Agency, ty for key tasks as well as overall include: don’t wait; engage a variety with emergency and similar groups recommend leadership. The National Incident of stakeholders; identify sources of planning. It drew an all-hazards approach, a broad Management System organizes truth; and prioritize hospital em- on experience and flexible strategy for managing emergency management across all ployees’ safety and well-being. with H1N1 and emergencies that could include government levels and the private Part of the preparation is doing ta- the Ebola virus, natural disasters – earthquakes, sector to ensure that the most ble-top exercises, with case scenar- which killed 11,323 Dr. Persoff storms, tornadoes, or wildfires – or pressing needs ios or actual situations presented, people, primarily human-caused events, such as mass are met and pre- working with clinicians on brain- in West Africa, from 2013 to 2016, as shootings or terrorist attacks. The cious resources storming and identifying opportu- models. In a matter of days, the CU Joint Commission requires accred- are used without nities for improvement, Dr. Khouli division of hospital medicine was ited hospitals to conduct several duplication. ICS said. “These drills are so important, able to modify and deploy its exist- disaster drills annually. is a standardized regardless of what the disaster turns ing disaster plans to quickly respond The U.S. Hospital Preparedness approach to com- out to be. We’ve done that over the to an influx of COVID patients. Program was created in 2002 to en- mand, control, years. We are a large health system, “Basically, what we set out to do hance the ability of hospitals and and coordination very process and detail oriented. was to treat COVID patients as if health systems to prepare for and Dr. Khouli of emergency Our emergency incident command they were Ebola patients, cordoning respond to bioterrorism attacks on response using structure was activated before we them off in a small area of the hos- civilians and other public health a common hierarchy recognized saw our first COVID patient,” he pital. That was naive of us,” he said. emergencies, including natural di- across organizations, with advance said. “We weren’t able to grasp the scale sasters and pandemics. It offers a training in how it should be de- “This was a crisis like never before, at the outset. It does defy the imag- foundation for national prepared- ployed. with huge amounts of uncertainty,” ination – how the hospital could fill ness and a primary source of federal he noted. “But I believe the Cleveland up with just one type of patient.” funding for health care system pre- A crisis like never before Clinic system did very well, measured paredness. The hospital, at the heart Nearly every hospital or health sys- by outcomes such as surveys of What is disaster planning? of the health care system, is expect- tem goes through drills for an emer- health care teams across the system, Emergency preparation for hos- ed to receive the injured and infect- gency, said Hassan Khouli, MD, chair which gave us reassuring results, and

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August 2021 | 16 | The Hospitalist

01_16_17_HOSP21_08.indd 16 7/20/2021 2:14:03 PM clinical outcomes with lower ICU hospitalists to ER physicians, travel will allow you to face adverse cir- mitment, Dr. Frank said. What’s not and hospital mortality rates.” nurses, operation managers, and cumstances,” he said. consistent is the participation of Christopher Whinney, MD, SFHM, the National Guard. Our command “We actually became quite effi- hospitalists. “Even when a disaster department chair of hospital center did a phenomenal job of al- cient early on in the pandemic, able is 100% trauma related, consider a medicine at Cleveland Clinic, said locating and obtaining resources. It to adapt in the moment. We were hospital like mine that has at least hospitalists worked hand in hand helped to have a structure that was able to build an effective bridge be- four times as many hospitalists as with the health system’s incident already established and to rely on tween workers on the ground and surgeons at any given time. The hos- command structure and took re- the resources of the health system,” our incident command structure, pitalists need to take overall man- sponsibility for managing non-ICU Dr. Polepalli said. Not every hospital which seemed to reduce a lot of agement for the patients who aren’t COVID patients at six hospitals in has a structure like Northwell’s. stress and create situational aware- actually in the operating room.” the system. “We’re not out of the pandemic ness. We implemented ICS as soon “Hospitalists yet, but we’ll as we heard that China was building Time to debrief had a place at continue with a COVID hospital, back in February Dr. Frank recommends debriefing the table, and we disaster drills and of 2020.” on the hospital’s and the hospital- collaborated well planning,” he said. When one thinks about mass ist group’s experience with COVID. with incident “We must contin- trauma, such as a 747 crash, Dr. Per- “Look at the biggest challenges your command, enter- ue to adapt and soff said, the need is to treat burn group faced. Was it staffing, or time prise redeploy- have converted victims and trauma victims in large off, or the need for day care? Was it ment committees, our temporary fa- numbers. At that point, the ED burnout, lack of knowledge, lack of and emergency cilities to COVID downstairs is filled with medical pa- [personal protective equipment]?” Dr. Whinney and critical care testing centers, Dr. Burger tients. Hospital medicine can rapidly Each hospital could use its own colleagues,” he antibody infusion admit those patients to clear out COVID experience to work on iden- noted. Hospitalists were on the lead- centers, and vaccination centers.” room in the ED. Surgeons are also tifying the challenges and the prob- ership team for a number of plan- For Alfred Burger, MD, SFHM, a dedicated to rapidly treating those lems, she said. “I’d encourage each ning meetings, and key stakeholders hospitalist at Mount Sinai’s Beth patients, but what about patients department and division to do this for bringing information back to Israel campus in New York, hospi- who are on the floor following their exercise individually. Then come to- their groups. tal medicine is still feeling its way surgeries? Hospitalists can offer gether to find common ground with “First thing we did was to look at through hospital and health care consultations or primary manage- other departments in the hospital.” our workforce. The challenge was system transformation. ment so the surgeons can stay in the This debriefing exercise isn’t just how to respond to up to a hundred “My group is an academic, multi- OR, and the same in the ICU, while for doctors – it’s also for nurses, COVID admissions per day – how to campus hospitalist group employed safely discharging hospitalized pa- environmental services, security, mobilize providers and build surge by the hospital system. When I meet tients in a timely manner to make and many other departments, she teams that incorporated primary other hospitalists at SHM confer- room for incoming patients. said. “COVID showed us how crisis care providers and medical trainees. ences, whether they come from pri- “The lessons of COVID have been response is a group effort. What We onboarded 200 providers to do vately owned, corporately owned, or hard-taught and hard-earned. No will bring us together is to learn the hospital care within 60 days,” he said. contracted models, they vary widely good plan survives contact with the challenges each of us faced. It was “We realized that communication in terms of how involved the hos- enemy,” he said. “But I think we’ll be amazing to see hospitalists doing with patients and families was a big pitalists are in crisis planning and better prepared for the next pan- what they do best.” Post pandemic, part of the challenge, so we assigned their ability to respond to crises. At demic.” hospitalists should also consider people with good communication large academic medical centers like Maria Frank, MD, FACP, SFHM, a publishing research, in order to skills to fill this role. While we were ours, one or more doctors is tasked hospitalist at Denver Health who share their lessons. fortunate not to get the terrible with being involved in preparing for chairs SHM’s Disaster Management “One of the things we learned is surges they had in other places, we the next disaster,” he said. Special Interest Group, says she got that hospitalists are very versatile,” felt we were prepared for the worst.” “I think we responded the best we the bug for disaster preparation Dr. Frank added. But it’s also good could, although it was difficult as during postresidency training as an for the group to have members spe- Challenges of surge capacity we lost many patients to COVID. We internist in emergency medicine. cialize, for example, in biocontain- Every disaster is different, said were trying to save lives using the “I’m also the medical director for ment. “We are experts in discharging Srikant Polepalli, MD, associate hos- tools we knew from treating pneu- our biocontainment unit, created patients, in patient flow and op- pitalist medical director for Staten monias and other forms of acute for infections like Ebola.” SHM’s erations, in coordinating complex Island University Hospital in New inflammatory lung injuries. We used SIG, which has 150 members, is now medical care. We would naturally York, part of the Northwell Health every bit of our training in situa- writing a review article on disaster take the lead in opening a geograph- system. He brought the experience tions where no one had the right planning for the field. ic unit or collaborating with other of being part of the response to Su- answers. But disasters teach us how “I got a call on Dec. 27, 2019, about specialists to create innovative mod- perstorm Sandy in October 2012 to to be flexible and pivot on the fly, this new pneumonia, and they said, els. That’s our job. It’s essential that the COVID pandemic. and what to do when things don’t go ‘We don’t know what it is, but it’s a we’re involved well in advance.” “Specifically for hospitalists, the our way.” coronavirus,’ ” she recalled. “When I COVID may be a once-in-a-lifetime biggest challenge is working on got off the phone, I said, ‘Let’s make experience, but there will be other surge capacity for a sudden influx of What is disaster response? sure our response plan works and disasters to come, she said. “If your patients,” he said. “But with North- Medical response to a disaster es- we have enough of everything on hospital doesn’t have a disaster plan well as our umbrella, we can triage sentially boils down to three main hand.’ ” Dr. Frank said she was ex- for hospitalists, get involved in estab- and load-balance to move patients things: stuff, staff, and space, Dr. pecting something more like SARS lishing one. Each hospitalist group from hospital to hospital as needed. Persoff said. Those are the corner- (severe acute respiratory syndrome). should have its own response plan. With the pandemic, we started with stones of an emergency plan. “When they called the public health Talk to your peers at other hospitals, one COVID unit and then expanded “There is not a hazard that exists emergency of international concern and get involved at the institutional to fill the entire hospital.” that you can’t take an all-hazards for COVID, I was at a Centers for level. I’m happy to share our plan; Dr. Polepalli was appointed med- approach to dealing with funda- Disease Control and Prevention just contact me.” Readers can contact ical director for a temporary field mental realities on the ground. No meeting in Atlanta. It really wasn’t a Dr. Frank at [email protected]. hospital installed at South Beach plan can be comprehensive enough surprise for us.” Psychiatric Center, also in Staten to deal with all the intricacies of All hospitals plan for disasters, For a complete list of references, see Island. “We were able to acquire help an emergency. But many plans can although they use different names the online version of this article at and bring in people ranging from have the bones of a response that and have different levels of com- www.the-hospitalist.org. the-hospitalist.org | 17 | August 2021

01_16_17_HOSP21_08.indd 17 7/20/2021 2:14:08 PM CLINICAL

In the Literature Clinician reviews of HM-centric research

By Chadi Cortas, MD; Herrick “Cricket” Fisher, MD, MPhil; Esteban Gershanik, MD, MPH, MMSc, FHM; Danielle Halpern, MD; Marina Kishlyansky, DO; Elizabeth Petersen, MD; Myrna Katalina Serna, MD; Laura Smith, MD; Shela Sridhar, MD; Qian Ye, MD Brigham and Women’s Hospital, Boston

IN THIS ISSUE CITATION: Schweizer ML et al. Com- HbA1c results had higher incidence parative effectiveness of switching of underlying diseases. Optimal 1. Switching from vancomycin to daptomycin in MRSA bloodstream in- to daptomycin versus remaining cutoff points of fasting and ran- fections on vancomycin among patients dom blood glucose levels for MINS 2. Preop glucose but not HbA1c levels associated with MI after noncar- with methicillin-resistant Staph- were 141 and 174 mg/dL (sensitivity diac surgery ylococcus aureus (MRSA) blood- vs. specificity, 45.6% vs. 67.2% and 3. AHRQ Safety Program focusing on self-stewardship reduces antibiot- stream infections. Clin Infect Dis. 23.6% vs. 84%), respectively. Possible ic use in hospitals 2021:72(S1):S68-73. doi: 10.1093/cid/ explanations include acute hyper- 4. IL-6 receptor antagonists efficacious in critically ill patients with ciaa1572. glycemia–induced coronary micro- COVID-19 vascular dysfunction and oxidative 5. Aldosterone antagonists for people with chronic kidney disease re- Preop glucose but not HbA1c stress. HbA1c results may reflect se- quiring dialysis 2 levels associated with MI after lective HbA1c measurements, more 6. CPR in patients with COVID-19 who suffer from in-hospital cardiac noncardiac surgery clinical monitoring (given poorly arrest appears futile controlled chronic hyperglycemia), 7. Rifaximin prevents hepatic encephalopathy after TIPS CLINICAL QUESTION: Is MI after and relatively short-term follow-up. 8. Semaglutide with lifestyle intervention for weight loss in patients noncardiac surgery (MINS) associat- Other limitations include the single without diabetes ed with both preoperative hypergly- site (limited generalizability) obser- 9. Diastolic blood pressure targets in adults treated for hypertension cemia and hemoglobin A1c (HbA1c) vational study (unknown confound- 10. Consequences at 6 months of COVID-19 in patients discharged from levels? ers) design. hospital BACKGROUND: Although preop- BOTTOM LINE: Control of acute 11. Catheter ablation improves survival and quality of life in AFib pa- erative hyperglycemia, which is hyperglycemia may help prevent tients with heart failure associated with poor postoperative MINS and improve 30-day mortality outcomes, is common, there are lim- regardless of HbA1c levels. ited data to guide preoperative glu- CITATION: Park J et al. Associations By Chadi Cortas, MD acute kidney injury, osteomyelitis, cose management or to evaluate the between preoperative glucose and Switching from vancomycin and endovascular infections. A association between short-term vs. hemoglobin A1c level and myocardi- 1to daptomycin in MRSA statistically significant association chronic glucose control and clinical al injury after noncardiac surgery. J bloodstream infections was seen between early switching outcomes. Am Heart Assoc. 2021:10(7):e019216. to daptomycin and lower 30-day STUDY DESIGN: Observational co- doi: 10.1161/JAHA.120.019216. CLINICAL QUESTION: In patients mortality (hazard ratio, 0.48; 95% hort study. with methicillin-resistant Staphylo- confidence interval, 0.25-0.92 using SETTING: A total of 12,304 patients Dr. Cortas is a hospitalist at Brigham coccus aureus (MRSA) bloodstream multivariable Cox regression mod- from a larger SMC-TINCO (Sam- and Women’s Hospital and instructor infection (BSI), does switching from els). No benefit was seen with later sung Medical Center Troponin in of medicine at Harvard Medical vancomycin to daptomycin have a switching. Noncardiac Operation) deidentified School, both in Boston. mortality benefit compared with Retrospective cohort studies are registry of 43,019 patients at a single continued vancomycin? subject to selection bias and unable center in Seoul, South Korea, who By Herrick “Cricket” Fisher, BACKGROUND: MRSA BSIs are typ- to control for unmeasured con- had troponin levels measured before MD, MPhil ically initially treated with vanco- founders. Because exclusion criteria or within 30 days after noncardiac AHRQ Safety Program mycin, but patients may be switched included death in the first 3 days surgery between January 2010 and 3 focusing on self-stewardship to daptomycin, particularly in the of antibiotic therapy (when many June 2019. reduces antibiotic use in hospitals setting of increased vancomycin MRSA BSI–related deaths occur) and SYNOPSIS: Out of 12,304 patients, minimum inhibitory concentration, daptomycin switch was defined as the 3,980 with hyperglycemia (fast- CLINICAL QUESTION: Is partic- treatment failure (e.g., persistent receiving 3 doses or more within 3-5 ing greater than 140 mg/dL; random ipation in the Agency for Health- bacteremia), or toxicity. consecutive days, bias favoring dap- greater than 180 mg/dL) had higher care Research and Quality Safety STUDY DESIGN: Retrospective co- tomycin is possible. Methodologic MINS incidence (27.6% vs. 18.7%; Program for Improving Antibiotic hort study. concerns with prior observational odds ratio, 1.29; P less than .001 af- Use (AHRQ Safety Program), which SETTING: 124 Department of Veter- studies comparing daptomycin ter inverse probability weighting emphasizes education and empow- ans Affairs hospitals between 2007 and vancomycin include different [IPW]) and 30-day mortality (5.1% erment of antibiotic stewardship and 2014. timelines and definitions of clinical vs. 2%; HR, 1.77; P less than .001 after teams and frontline clinicians, asso- SYNOPSIS: Out of 7,411 patients failure. The authors note the lack of IPW) compared with other patients. ciated with lower rates of antibiotic with MRSA BSI, 8% switched from a universal consensus among infec- No association was seen based on use? vancomycin to daptomycin; 1.5% tious disease clinicians on whether HbA1c greater than 6.5% among BACKGROUND: Top-down antibiot- switched within 3 days of starting switching to daptomycin improves 4,373 patients with HbA1c results. ic stewardship programs (ASPs) are vancomycin (i.e., early switching). outcomes. IPW led to a balancing of covari- common across the United States Factors more common among BOTTOM LINE: Further studies are ates. Patients with hyperglycemia but are limited in their potential patients who switched included needed to assess the benefit and op- tended to have higher age, diabetes, impact because there are finite vancomycin minimum inhibitory timal timing of switching antibiotics hypertension, stroke, and preop- resources to provide real-time assis- concentration 2 mg/L or more, in patients with MRSA BSI. erative ICU treatment; those with tance with all antibiotic prescribing August 2021 | 18 | The Hospitalist

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and durability of stewardship prac- By Esteban Gershanik, MD, of 1.61 (95% CI, 1.25-2.08) comparing sterone antagonists beneficial to tices is unclear. MPH, MMSc, FHM pooled IL-6 receptor antagonist with people with chronic kidney disease STUDY DESIGN: Qualitive improve- IL-6 receptor antagonists the control group. Limitations in- (CKD) requiring hemodialysis or ment program over 1 year. 4 efficacious in critically ill clude patient selection: Patients are peritoneal dialysis compared with SETTING: U.S. hospitals. patients with COVID-19 primarily men (73%), average age of placebo? SYNOPSIS: Including many with 61.4, White (72%) or Asian (17%) who BACKGROUND: There are several limited resources, 402 hospitals CLINICAL QUESTION: Do interleu- must be enrolled within 24 hours studies to suggest that aldosterone completed the intervention: 42% kin-6 (IL-6) receptor antagonists after starting organ support (com- antagonists would provide a helpful were community hospitals, 21% (“monoclonal antibodies”) – specifi- pared with prior studies) and poten- treatment option for people with critical access cally, tocilizumab tial evolving ICUs standards of care. CKD on dialysis. hospitals, 35% and sarilumab BOTTOM LINE: In the most severe- This population is rural location, – improve out- ly, critically ill adult patients with at very high risk and 43% without comes and sur- COVID-19 who receive organ sup- of cardiovascular infectious disease vival in critically port in ICUs, treatment within 24 disease, morbid- specialists. The ill patients with hours with IL-6 receptor antagonist, ity, and mortal- intervention in- coronavirus in addition to standard of care, im- ity, all of which cluded support disease 2019 proves outcomes including survival. these agents establishing local (COVID-19)? CITATION: The REMAP-CAP In- have shown to be Dr. Fisher ASPs and educa- Dr. Gershanik BACKGROUND: vestigators. Interleukin-6 receptor Dr. Halpern helpful against tional content for The use of mono- antagonists in critically ill pa- in other popu- clinicians on antibiotic stewardship clonal antibodies has been clinically tients with Covid-19. N Engl J Med. lations. There has not yet been a (webinars and educational mate- described for use in COVID-19 pa- 2021;384(16):1491-502. doi: 10.1056/NEJ- comprehensive study evaluating the rials). Data were analyzed using a tients and presumed to potential- Moa2100433. efficacy and potential harms of al- linear mixed model with random ly be beneficial because of their dosterone antagonists in the dialysis hospital unit effects. inhibition of IL-6, which serves as Dr. Gershanik is medical director of population. When comparing January and Feb- part of the acute-phase response quality, safety, and equity at Brigham STUDY DESIGN: Meta-analysis. ruary with November and Decem- to infection. However, randomized and Women’s Hospital. SETTING: A total of 16 parallel ran- ber 2018, antibiotic use decreased controlled trials to date evaluating domized controlled studies, cross- from 900.7 to 870.4 days of therapy their clinical use in these settings By Danielle Halpern, MD over randomized controlled trials, (DOT) per 1,000 patient-days (–30.3 have largely been negative. This trial Aldosterone antagonists for and quasi–randomized controlled DOTs; 95% CI, –52.6 to –8.0 DOT; P focused on their effectiveness, in ad- 5 people with chronic kidney trials comparing aldosterone an- = .008). The largest decrease was in dition to standard of care, on surviv- disease requiring dialysis tagonists with placebo or standard the first months after the initiative al and organ support in the severely, care in people with CKD on dialysis began and was sustained during critically ill patients with COVID-19 CLINICAL QUESTION: Are aldo- Continued on following page following months. In subgroup and not currently receiving respiratory secondary analyses, there were sig- support. nificant reductions in fluoroquino- STUDY DESIGN: Randomized, lone use (–20.4 DOT; P = .009) and prospective, cohort, international, hospital-onset Clostridioides difficile adaptive platform trial with mul- infections (–19.5%; P = .03). Hospitals tiple interventions across various more actively engaged in the pro- domains [Part of the Randomized, gram were more likely to demon- Embedded, Multifactorial Adaptive strate an effect. Platform Trial for Community Ac- Limitations include the lack of con- quired Pneumonia (REMAP-CAP)]. trol group, although there were not SETTING: Intensive care units at 113 significant reductions in antibiotic sites across six countries. Your path to leadership use in the Premier Healthcare Data- SYNOPSIS: As a domain of RE- base cohort during the same period, MAP-CAP (which previously begins at SHM. and potential inaccuracies with data demonstrated glucocorticoids im- collection. proving outcomes in patients with BOTTOM LINE: Participation in the COVID-19), 895 patients, 18 years of Be Recognized for Promoting Excellence, AHRQ Safety Program was associ- age or older with COVID-19 with- ated with durable improvements in 24 hours after starting organ Innovation, & Improving the Quality of Patient Care in clinician self-stewardship with support in the intensive care unit, decreased rates of antibiotic use, in- were randomly assigned to receive Apply for SHM Awards of Excellence cluding in lower-resource hospitals standard-of-care treatment with or Nominate yourself or a colleague for an across the United States. without IL-6 receptor antagonists, Award of Excellence across an array of categories. CITATION: Tamma PD et al. Associa- tocilizumab or sarilumab. Statistical hospitalmedicine.org/awards tion of a safety program for improv- analysis incorporating a Bayesian ing antibiotic use with antibiotic statistical model demonstrated SHM Class of 2022 Fellows Program use and hospital-onset Clostridioi- IL-6 receptor antagonists with an Make 2022 your year by applying to become an SHM Fellow. des difficile infection rates among OR greater than 1 representing Applications are now open to all qualifying members of the U.S. hospitals. JAMA Netw Open. improved survival and more organ hospital medicine team. 2021;4(2):e210235. doi: 10.1001/jama- support–free days compared with hospitalmedicine.org/fellows networkopen.2021.0235. standard care. Findings showed a median adjusted cumulative OR of Dr. Fisher is an attending hospitalist 1.64 (95% CI, 1.24-2.14) for tocilizumab Apply Today. and director of the Integrated and 1.76 (95% CI, 1.17-2.91) for sarilum- Teaching Unit, Brigham and Women’s ab compared with control. Analysis Hospital. of 90-day survival showed an HR the-hospitalist.org | 19 | August 2021

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Continued from previous page the outcomes after in-hospital car- SHORT TAKES entered in the Cochrane Kidney and diac arrest among patients with Transplant Register of Studies up to COVID-19? Admission patterns between abdominal pain may limit general- Aug. 5, 2020. A total of 1,446 partici- BACKGROUND: The COVID-19 ED physicians and advanced izability of these results to differ- pants were involved. pandemic, which is caused by SARS practice providers ent chief complaints and practice SYNOPSIS: The included studies CoV-2 virus, has accounted for al- Observational cohort study settings. compared spironolactone with pla- most 200,000 showed little variation in diag- CITATION: Pines J et al. Emergen- cebo or standard care (13 studies) or deaths in the nostic testing and hospitalization cy physician and advanced prac- eplerenone with placebo (1 study). United States as rates between physicians and tice provider diagnostic testing Based on these studies, aldosterone of Sept. 1, 2020. advanced practice providers see- and admission decisions in chest antagonists were seen to proba- While knowledge ing patients for chest pain and pain and abdominal pain. Acad bly reduce the risk of death from about the dis- abdominal pain in the ED. Stan- Emerg Med. 2921;28(1):36-45. doi: any cause for people with CKD ease is evolving, dardized protocols for chest and 10.1111/acem.14161. requiring dialysis with a moderate there is paucity certainty of evidence (9 studies, of data on the 1,119 participants; risk ratio, 0.45; Dr. Kishlyansky characteristics By Elizabeth Petersen, MD of overt hepatic encephalopathy 95% CI, 0.30-0.67; I² = 0%). When and outcomes of Rifaximin prevents hepatic after transjugular intrahepatic por- broken down by specific causes, COVID-19–related in-hospital cardi- encephalopathy after TIPS tosystemic shunt: A randomized aldosterone antagonists decreased ac arrests in the United States. 7 controlled trial. Ann Intern Med. the risk of cardiovascular death, as STUDY DESIGN: Retrospective co- CLINICAL QUESTION: Does rifaxi- 2021 May;174(5):633-40. doi: 10.7326/ well as cardiovascular and cerebral hort study. min prevent overt hepatic enceph- M20-0202. morbidity, with a moderate certain- SYNOPSIS: Single-center, multihos- alopathy (HE) after transjugular ty of evidence (former outcome: 6 pital, rural Southwest Georgia. intrahepatic portosystemic shunt Dr. Petersen is an attending studies, 908 participants; RR, 0.37; Synopsis: Of patients with a diagno- (TIPS)? hospitalist at Boston Children’s and 95% CI, 0.22-0.64; I² = 0%; latter out- sis of COVID-19, 63 were included in BACKGROUND: Rifaximin is ef- Brigham and Women’s Hospitals comes: 3 studies, 328 participants; this study. All patients experienced ficacious and widely used for the and an instructor at Harvard Medical RR, 0.38; 95% CI, 0.18-0.76; I² = 0%). an in-hospital cardiac arrest with at- secondary prevention of HE in School. Notably, there was an increased tempted resuscitation; 90.5% of the patients with cirrhosis. Up to half risk of gynecomastia in multiple patients were African Americans, of patients who By Myrna Katalina Serna, MD studies. However, there was no the median age was 66 years, and undergo TIPS Semaglutide with lifestyle increased risk of hyperkalemia in 49.2% were males. experience post- 8 intervention for weight loss in study participants (9 studies, 981 Additionally, 84% of cardiac ar- procedure HE, but patients without diabetes participants; RR, 1.41; 95% CI, 0.72- rests occurred in the ICU. The ini- no prophylactic 2.78; I² = 47%; low certainty of evi- tiation of advanced cardiovascular interventions CLINICAL QUESTION: Does dence). All told, in people with CKD life support was less than 1 minute have been shown once-weekly semaglutide 2.4 mg requiring dialysis who received for 100% of cardiac arrests in the to be effective in with lifestyle intervention help aldosterone antagonists there were ICU and less than 2 minutes for preventing HE adults with overweight or obesi- 72 fewer deaths from all causes per the remaining patients. Mortality Dr. Petersen after TIPS. ty and without diabetes achieve 1,000 participants (95% CI, 47-98) was 100%. This study has several STUDY DESIGN: weight loss? with number needed to treat for an limitations, including lack of data Randomized controlled trial. BACKGROUND: Chronic obesity is additional benefit of 14 (95% CI, 10- on quality of chest compressions. SETTING: Tertiary care hospitals in a public health 21). There were 26 events of gyneco- In addition, the study was conduct- France. challenge linked mastia per 1,000 participants (95% ed in a single-center setting, and a SYNOPSIS: Of patients with cir- to multiple com- CI, 15-39) with a number needed to majority of patients were African rhosis undergoing TIPS, 186 were plications, with harm of 38 (95% CI, 26-68). American, suggesting that the re- randomized to receive either rifax- limited pharma- BOTTOM LINE: Aldosterone an- sults may not be generalizable to imin or placebo starting 2 weeks cologic options. tagonists probably reduce the risk other settings and patient demo- preprocedure and continuing for 6 Semaglutide, a of all-cause death and morbidity graphics. months. GLP-1 analogue, is resulting from cardiovascular and This study raises important ques- The majority of patients (86%) approved for the cerebrovascular disease in people tions about the futility of advanced had alcohol-induced cirrhosis. Dr. Serna treatment of type with CKD requiring dialysis but cardiovascular life support mea- Overt HE, defined as grade 2 or 2 diabetes and with an increased risk of gyneco- sures in COVID-19 patients who higher by West Haven modified cri- was noted to induce weight loss. mastia. suffer from in-hospital cardiac teria or isolated asterixis, occurred STUDY DESIGN: Randomized, dou- CITATION: Hasegawa T et al. Aldo- arrest. in 34% (95% CI, 25%-44%) of patients ble-blind, placebo-controlled trial. sterone antagonists for people with BOTTOM LINE: In this study, pa- in the rifaximin group vs. 53% (95% SETTING: 129 sites in 16 countries. chronic kidney disease requiring tients with COVID-19 who suffered CI, 43%-63%) of patients in the SYNOPSIS: Of participants with dialysis. Cochrane Database Syst from in-hospital cardiac arrest and placebo group. There was no signif- obesity (body mass index 30 or Rev. 2021 Feb 15;2:CD013109. doi: received cardiopulmonary resuscita- icant difference in adverse events more) or overweight (BMI 27 or 10.1002/14651858.CD013109.pub2. tion had 100% mortality. or transplant-free survival between more) with one or more weight- CITATION: Shah P et al. Is cardio- groups. Given the prolonged dura- related coexisting conditions, 1,961 Dr. Halpern is an attending hospitalist pulmonary resuscitation futile tion of treatment and high cost of were randomly assigned to receive at Brigham and Women’s Hospital. in coronavirus disease 2019 pa- rifaximin, further study is needed semaglutide (1,306 participants) or tients experiencing in-hospital to determine the cost-effectiveness placebo (655 participants) as an ad- By Marina Kishlyansky, DO cardiac arrest? Crit Care Med. of this approach. junct to lifestyle intervention for 68 CPR in patients with 2021 Feb 1;49(2):201-8. doi: 10.1097/ BOTTOM LINE: Rifaximin should weeks. Exclusion criteria included 6 COVID-19 who suffer from CCM.0000000000004736. be considered for prophylaxis of diabetes. The mean change in body in-hospital cardiac arrest appears post-TIPS hepatic encephalopathy weight from baseline to week 68 was futile Dr. Kishlyansky is an attending in patients with alcoholic cirrhosis. –14.9% in the semaglutide group, hospitalist at Brigham and Women’s CITATION: Bureau CB et al. The compared with –2.4% in the placebo CLINICAL QUESTION: What are Hospital. use of rifaximin in the prevention group, a statistically significant dif- August 2021 | 20 | The Hospitalist

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ference. Nausea and diarrhea were Patients were divided into sub- effects of patients hospitalized failure (HF), compared with drug the most common adverse events groups of treated DBP at intervals with COVID-19. Some data have therapy (rate or rhythm control observed with semaglutide and re- of less than 60, 60-70, 70-80, and 80+ suggested persistence of symptoms drugs)? sulted in 4.5% of participants in this mm Hg. up to 3 months; however, little has BACKGROUND: Studies have group discontinuing treatment. SYNOPSIS: A total of 7,515 patients been defined beyond that period. shown that CA improves all-cause BOTTOM LINE: Once-weekly were analyzed. A mean treated The study aimed to describe the mortality, quality of life, and semaglutide 2.4 mg plus lifestyle DBP of less than 60 mm Hg was long-term consequence of COVID-19 freedom from AFib recurrence in intervention is associated with sus- associated with a significantly stratified by disease severity, as patients with tained weight loss in patients with increased risk of the primary out- well as potential risk factors during AFib and HF overweight or obesity and without come – a composite of all-cause hospitalization, for any long-term with reduced diabetes. death, nonfatal myocardial infarc- consequences. ejection fraction. CITATION: Wilding JPH et al. tion, and nonfatal stroke (HR, 1.45; STUDY DESIGN: Ambidirectional There have been Once-weekly semaglutide in adults 95% CI, 1.13-1.9; P = .004). Patients cohort study. no randomized with overweight or obesity. N Engl with a DBP of greater than 80 mm SETTING: Jin Yin-tan Hospital in controlled trials J Med. 2021 Mar 18;384(11):989. doi: Hg did not have a significantly Wuhan, Hubei, China. comparing CA 10.1056/NEJMoa2032183. increased risk of the primary out- SYNOPSIS: Of patients from Jin- with drug ther- come. However, a nonlinear asso- Yin-tan hospital with COVID-19, Dr. Ye apy in patients Dr. Serna is a hospitalist at Brigham ciation between treated DBP and 2,469 aged 47-65 years old were with HF with and Women’s Hospital. the primary outcome was observed followed over 6 months. Follow-up preserved ejection fraction (HF- (P = .003), which may support a included symptom questionnaires, pEF). By Laura Smith, MD J-shaped phenomenon for DPB. 6-minute physical walk tests, blood STUDY DESIGN: Open label, multi- Diastolic blood pressure The nominally lowest risk was ob- samples, and CT. At 6 months, 76% center, randomized controlled trial. 9 targets in adults treated for served for patients who achieved of patients reported at least one SETTING: International, multicenter hypertension a DBP of between 70 and 80 mm symptom at follow-up. Of patients trial. Hg. This study is limited as a post who required high-flow nasal can- SYNOPSIS: Using a prespecified CLINICAL QUESTION: What is the hoc analysis of two previously ran- nula, noninvasive ventilation, or subgroup analysis of 778 of the ideal diastolic blood pressure range domized trials and does not reveal intubation, 56% were noted to have 2,204 patients randomized in the for patients who have systolic blood a mechanism of the association lung diffusion impairment. Ground- CABANA trial who had HF defined pressures less than 130 mm Hg when of low-treated DBP and increased glass opacities and irregular lines as New York Heart Association class taking antihypertensives? risk. Also, only 6.3% of patients were found 6 months after acute II or greater, this study showed that BACKGROUND: had a DBP of 80 mm Hg or greater, disease, as well. CA produced clinically significant Historically, opti- which may be underpowered to Serology obtained indicated much reductions in all-cause mortality mal management demonstrate a significant differ- lower rates of neutralizing antibod- (43% relative reduction; HR, 0.57; of hypertension ence in outcomes. These findings ies at 6 months, compared with the 95% CI, 0.33-0.96) and AFib recur- has focused on do support that further prospec- acute phase, which raises concern rence (HR, 0.56; 95% CI, 0.42-0.74). Ab- management of tive studies are needed to deter- for severe disease with reinfection. lation patients also had significant systolic blood mine safe and optimal DBP. These results suggest a high suspi- improvement in quality of life. Me- pressure (SBP), BOTTOM LINE: A DBP of less than cion necessary for hospitalists eval- dian follow-up was 48.5 months. Al- and 2017 Ameri- 60 mm Hg is significantly associat- uating patients with prior COVID-19 though this study was not designed Dr. Smith can Heart Associ- ed with negative outcomes in pa- infection. to evaluate patients with HFpEF, ation guidelines tients with elevated cardiovascular BOTTOM LINE: Symptoms of 79% of patients in whom baseline list goal values for SBP but do risk who achieve a treated SBP of COVID-19 persisted at least 6 ejection fraction (EF) was available not provide recommendations for less than 130 mm Hg. Further in- months after hospitalization for had an EF greater than 50%. the ideal diastolic blood pressure vestigation is needed to determine acute disease. The most common The study results are concordant (DBP) range. The safe and optimal if DBP 70-80 mm Hg is the ideal symptoms were fatigue and muscle with prior observational data that DBP in treated hypertension is not range. weakness. New anxiety and depres- suggested similar efficacy of AFib known. Prior studies have suggest- CITATION: Li J et al. Evaluation of sion were also common. Finally, ablation in HF patients regardless of ed that DBPs less than 60 mm Hg optimal diastolic blood pressure severe disease was associated with their EF. However, a major limitation are associated with increased ad- range among adults with treated impaired pulmonary diffusion. of this study is that HFpEF was de- verse cardiovascular risks, such as systolic blood pressure less than CITATION: Huang C et al. 6-Month fined phenotypically by the enroll- death from myocardial infarction. 130 mm Hg. JAMA Netw Open. 2021; consequences of COVID-19 in ing clinicians based on their clinical However, it is unclear whether a 4(2):e2037554. doi: 10.1001/jamanet- patients discharged from hos- judgment. It is challenging to tease J-shape phenomenon of negative workopen.2020.37554. pital: A cohort study. Lancet. out how much of the patient’s func- outcomes exists for DBPs in treat- 2021;397(10270):220-32. doi: 10.1016/ tional impairment is attributable ed hypertension. Dr. Smith is hospitalist and instructor S0140-6736(20)32656-8. to HFpEF vs. AFib itself. The study STUDY DESIGN: Retrospective co- of medicine at Brigham and Women’s findings need to be confirmed in ad- hort study. Hospital and Harvard Medical School. Dr. Sridhar is a pediatric hospitalist at equately sized replication trials. SETTING: Researchers conducted Brigham and Women’s Hospital and BOTTOM LINE: In patients with a posthoc analysis of the outcomes By Shela Sridhar, MD Boston Children’s Hospital and an AFib and clinically defined HF, CA of the SPRINT and ACCORD-BP Consequences at 6 months instructor at Harvard Medical School. significantly reduces mortality and trials to determine whether there is 10of COVID-19 in patients recurrent AFib and improves quality a J-shaped phenomenon for cardio- discharged from hospital By Qian Ye, MD of life relative to drug therapy. vascular outcomes related to DBP Catheter ablation improves CITATION: Packer D et al. Ablation ranges for patients and establish CLINICAL QUESTION: What is the 11survival and quality of life versus drug therapy for atrial fibril- possible optimal goals for diastol- duration of symptoms in patients in AFib patients with heart failure lation in heart failure. Circulation. ic blood pressure. Patients who with COVID-19, and are there any 2021;143:1377-90. doi: 10.1161/CIRCU- achieved an SBP of less than 130 mm residual pulmonary effects of CLINICAL QUESTION: Does cathe- LATIONAHA.120.050991. Hg were retrospectively reviewed, COVID-19? ter ablation (CA) improve survival and their mean treated SBP, DBP, BACKGROUND: There are few and quality of life in patients with Dr. Ye is a hospitalist at Brigham and and pulse pressure were computed. data that define the long-term atrial fibrillation (AFib) and heart Women’s Hospital. the-hospitalist.org | 21 | August 2021

18_to_21_HOSP21_08.indd 21 7/20/2021 3:41:00 PM CLINICAL

Interpreting Diagnostic Tests Use of point-of-care ultrasound (POCUS) for heart failure

By Faye Farber, MD; Yasmin Marcantonio, MD; Neil Stafford, MD; Megan Brooks, MD, MPH, FHM; Adam Wachter, MD; Shree Menon, MD; Poonam Sharma, MD, SFHM;

Brief overview of the issue Once mainly used by ED and criti- Key points cal care physicians, POCUS is now a tool that many hospitalists are • Studies have found POCUS Case using at the bedside. POCUS differs improves the diagnosis of acute A 65-year-old woman presents from traditional comprehensive decompensated heart failure to the emergency department ultrasounds in the following ways: in patients presenting with with a chief complaint of POCUS is designed to answer a spe- dyspnea. shortness of breath for 3 days. cific clinical question (as opposed to • Daily evaluation with POCUS Medical history is notable for evaluating all organs in a specific re- has decreased length of stay moderate chronic obstructive gion), POCUS exams are performed in acute decompensated heart pulmonary disorder, systolic by the clinician who is formulating failure. heart failure with last known the clinical question (as opposed • Credentialing requirements for ejection fraction (EF) of 35%, to by a consultative service such hospitalists to use POCUS for and type 2 diabetes complicated as cardiology and radiology), and clinical care vary by hospital.

by hyperglycemia when on ste- mages POCUS can evaluate multiple organ i

roids. You are talking the case etty systems (such as by evaluating a over with colleagues and they /g patient’s heart, lungs, and inferior lines per thoracic zone bilaterally suggest point-of-care ultra- vena cava to determine the etiology suggests cardiogenic pulmonary ongKaew sound (POCUS) would be useful K of hypoxia). edema. Scanning the IVC provides in her case. Hospitalist use of POCUS may a noninvasive way to assess volume itchayanan

P include guiding procedures, aiding status and is especially helpful in diagnosis, and assessing effective- when body habitus prevents accu- ness of treatment. Many high-quali- rate assessment of jugular venous ty studies have been published that pressure. support the use of POCUS and have Several studies have addressed the proven that POCUS can decrease utility of bedside ultrasound in the medical errors, help reach diagnoses initial assessment or diagnosis of in a more expedited fashion, and acute decompensated heart failure complement or replace more ad- (ADHF) in patients presenting with vanced imaging. dyspnea in emergency or inpatient A challenge of POCUS is that it settings. Positive B lines are a useful is user dependent and there are finding, with high sensitivities, high no established standards for hos- specificities, and positive likelihood pitalists in POCUS training. As the ratios. One large multicenter pro- Society of Hospital Medicine posi- spective study found LUS to have tion statement on POCUS points a sensitivity of 90.5%, specificity of out, there is a significant difference 93.5%, and positive and negative LRs between skill levels required to ob- of 14.0 and 0.10, respectively.1 An- tain a certificate of completion for other large multicenter prospective POCUS training and a certificate of cohort study showed that LUS was competency in POCUS. Therefore, it more sensitive and more specific Data to support your hospitalist is recommended hospitalists work than chest x-ray (CXR) and brain na- with local credentialing committees triuretic peptide in detecting ADHF.2 group’s transition from COVID-19 to delineate the requirements for Additional POCUS findings that to the new normal! POCUS use. have shown relatively high sensitiv- ities and specificities in the initial Use data from the 2020 SoHM Report and COVID-19 Overview of the data diagnosis of ADHF include pleural POCUS for initial assessment and effusion, reduced left ventricular Addendum to help chart a path forward. diagnosis of heart failure (HF) ejection fraction (LVEF), increased Use of POCUS in cases of suspect- left ventricular end-diastolic dimen- Order today! ed HF includes examination of the sion, and jugular venous distention. hospitalmedicine.org/sohm heart, lungs, and inferior vena cava Data also exist on assessments (IVC). Cardiac ultrasound provides of ADHF using combinations of an estimated ejection fraction. Lung POCUS findings; for example, lung ultrasound (LUS) functions to exam- and cardiac ultrasound (LuCUS) ine for B lines and pleural effusions. protocols include an evaluation for The presence of more than three B B lines, assessment of IVC size and August 2021 | 22 | The Hospitalist

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collapsibility, and determination of with the CXR group. Specifically, LVEF, although this has mainly been median LOS was 8 days in CXR examined in ED patients. For pa- group (range, 4-17 days) and 7 days tients who presented to the ED with in the LUS group (range, 3-10 days; P undifferentiated dyspnea, one such < .001). study showed a specificity of 100% when a LuCUS protocol was used to The impact of POCUS on length of diagnose ADHF while another study stay (LOS) and readmissions showed that the use of a LuCUS pro- There are increasing data that PO- tocol changed management in 47% CUS can have meaningful impacts Dr. Farber Dr. Marcantonio Dr. Stafford Dr. Brooks of patients.3,4 Of note, although each on patient-centered outcomes (mor- LuCUS protocol integrated the use bidity, mortality, and readmission) of lung findings, IVC collapsibility, while exposing patients to minimal and LVEF, the exact protocols varied discomfort, no venipuncture, and no by institution. Finally, it has been radiation exposure. First, multiple established in multiple studies that studies looked at whether perform- LUS used in addition to standard ing focused cardiac US of the IVC workup including history and phys- as a marker of volume status could ical, labs, and electrocardiogram has predict readmission in patients hos- been shown to increase diagnostic pitalized for ADHF.8,9 Both of these accuracy.2,5 trials showed that plethoric, non- Dr. Wachter Dr. Menon Dr. Sharma collapsible IVC at discharge were Using POCUS to guide diuretic ther- statistically significant predictors of apy in HF readmission. In fact, Goonewardena Dr. Farber is a medical instructor at Duke University and hospitalist at Duke To date, there have been multiple and colleagues demonstrated that Regional Hospital, both in Durham, N.C. Dr. Marcantonio is a medical small studies published on the util- patients who required readmission instructor in the department of internal medicine and department of ity of daily POCUS in hospitalized had an enlarged IVC at discharge pediatrics at Duke University and hospitalist at Duke University Hospital and patients with ADHF to help assess nearly 3 times more frequently (21% Duke Regional Hospital. Dr. Stafford and Dr. Brooks are assistant professors response to treatment and guide vs. 61%, P < .001) and abnormal IVC of medicine and hospitalists at Duke Regional Hospital. Dr. Wachter is diuresis by looking for reduction in collapsibility 1.5 times more fre- associate medical director at Duke Regional Hospital and assistant professor B lines on LUS or a change in IVC quently (41% vs. 71%, P = .01) as com- at Duke University. Dr. Menon is a hospitalist at Duke University. Dr. Sharma size or collapsibility. Volpicelli and pared with patients who remained is associate medical director for clinical education at Duke Regional Hospital colleagues showed that daily LUS out of the hospital.9 and associate professor of medicine at Duke University. was at least as good as daily CXR Similarly, a subsequent trial in monitoring response to therapy.6 looked at whether IVC size on ad- Similarly, Mozzini and colleagues mission was of prognostic impor- performed a randomized controlled tance in patients hospitalized for trial of 120 patients admitted for ADHF and showed that admission ADHF who were randomized to a IVC diameter was an independent Document CXR group (who had a CXR per- predictor of both 90-day mortality formed on admission and discharge) (hazard ratio, 5.88; 95% confidence with Improved and a LUS group (which was per- interval, 1.21-28.10; P = .025) and 90- formed at admission, 24 hours, 48 day readmission (HR, 3.20; 95% CI, Accuracy & hours, 72 hours, and discharge).7 1.24-8.21; P = .016).10 Additionally, LUS This study found that the LUS heart failure assessment for pulmo- group underwent a significantly nary congestion by counting B lines Quality higher number of diuretic dose also showed that having more than adjustments as compared with the 15 B lines prior to discharge was an CXR group (P < .001) and had a mod- independent predictor of readmis- est improvement in LOS, compared sion for ADHF at 6 months (HR, 11.74; 95% CI, 1.30-106.16).11 Additional reading A challenge of POCUS: Now Available: • Maw AM and Soni NJ. An- Obtaining competency nals for hospitalists inpatient As previously noted, there are not SHM’s Utilization Management and Clinical notes – why should hospitalists yet any established standards for Documentation for Hospitalists use point-of-care ultrasound? training and assessing hospitalists Ann Intern Med. 2018 Apr in POCUS. The SHM Position State- 17;168(8):HO2-HO3. doi: 10.7326/ ment on POCUS recommends the “ I plan to make this course a requirement for all newly M18-0367. following criteria for training5: The hired hospitalists and NPs/PAs who are less than 2 years • Lewiss RE. “The ultrasound training environment should be out from training. It covers multiple key documentation looked fine”: Point of care ul- similar to the location in which the issues we encounter in our hospital system and helps new trasound and patient safety. trainee will practice, training and team members understand the key roles of UM, physician AHRQ’s Patient Safety Net- feedback should occur in real time, advisors, and the CDI team.” − John Sparzo, MD, MBA work. WebM&M: Case Studies. the trainee should be taught specif- 2018 Jul 1. https://psnet.ahrq. ic applications of POCUS (such as gov/web-mm/ultrasound- cardiac US, LUS, and IVC US) as each looked-fine-point-care-ultra- application comes with unique skills Learn more at hospitalmedicine.org/documentation sound-and-patient-safety. and knowledge, clinical competence Continued on following page the-hospitalist.org | 23 | August 2021

22_thru_31_HOSP21_08.indd 23 7/20/2021 4:10:26 PM CLINICAL

Continued from previous page racy and facilitates volume assess- Quiz must be achieved and demonstrated, ment and management in acute and continued education and feed- decompensated heart failure. Testing your POCUS knowledge back are necessary once competence POCUS is increasingly prevalent in hospital medicine, but use varies is obtained.12 SHM recommends References among different disease processes. Which organ system ultrasound or lab residency-based training pathways, 1. Pivetta E et al. Lung ultrasound integrated test would be most helpful in the following scenario? training through a local or national with clinical assessment for the diagnosis of An acutely dyspneic patient with no past medical history presents to the acute decompensated heart failure in the emer- program such as the SHM POCUS gency department: A randomized controlled ED. Chest x-ray is equivocal. Of the following, which study best confirms certificate program, or training trial. Eur J Heart Fail. 2019 Jun;21(6):754-66. doi: a diagnosis of acute decompensated heart failure? through other medical societies for 10.1002/ejhf.1379. A. Brain natriuretic peptide hospitalists already in practice. 2. Pivetta E et al. Lung ultrasound-implemented B. Point-of-care cardiac ultrasound diagnosis of acute decompensated heart failure in the ED: A SIMEU multicenter study. Chest. C. Point-of-care lung ultrasound Application of the data to our 2015;148(1):202-10. doi: 10.1378/chest.14-2608. D. Point-of-care inferior vena cava ultrasound original case 3. Anderson KL et al. Diagnosing heart failure Targeted POCUS using the LuCUS among acutely dyspneic patients with cardiac, Answer protocol is performed and reveals inferior vena cava, and lung ultrasonogra- C. Point-of-care lung ultrasound phy. Am J Emerg Med. 2013;31:1208-14. doi: three B lines in two lung zones bi- 10.1016/j.ajem.2013.05.007. laterally, moderate bilateral pleural 4. Russell FM et al. Diagnosing acute heart fail- Multiple studies, including three systematic reviews, have shown that effusions, EF 20%, and a noncollaps- ure in patients with undifferentiated dyspnea: point-of-care lung ultrasound has high sensitivity and specificity to eval- ible IVC leading to a diagnosis of A lung and cardiac ultrasound (LuCUS) proto- uate for B lines as a marker for cardiogenic pulmonary edema. Point-of- col. Acad Emerg Med. 2015;22(2):182-91. doi: ADHF. Her ADHF is treated with in- 10.1111/acem.12570. care ultrasound of ejection fraction and inferior vena cava have not been travenous diuresis. She is continued 5. Maw AM et al. Diagnostic accuracy of point- evaluated by systematic review although one randomized, controlled on her chronic maintenance chronic of-care lung ultrasonography and chest radi- trial showed that an EF less than 45% had 74% specificity and 77% sen- obstructive pulmonary disorder reg- ography in adults with symptoms suggestive of sitivity and IVC collapsibility index less than 20% had an 86% specificity acute decompensated heart failure: A system- imen but does not receive steroids, atic review and meta-analysis. JAMA Netw and 52% sensitivity for detection of acute decompensated heart failure. avoiding hyperglycemia that has Open. 2019 Mar 1;2(3):e190703. doi: 10.1001/ This same study showed that the combination of cardiac, lung, and IVC complicated prior admissions. Over jamanetworkopen.2019.0703. point-of-care ultrasound had 100% specificity for diagnosing acute de- the next few days her respiratory 6. Volpicelli G et al. Bedside ultrasound compensated heart failure. In the future, health care providers could rely of the lung for the monitoring of acute and cardiac status is monitored us- decompensated heart failure. Am J Emerg on this multiorgan evaluation with point-of-care ultrasound to confirm ing POCUS to assess her response Med. 2008 Jun;26(5):585-91. doi: 10.1016/j. a diagnosis of acute decompensated heart failure in a dyspneic patient. to therapy and titrate her diuretics ajem.2007.09.014. to her true dry weight, which was 7. Mozzini C et al. Lung ultrasound in internal several pounds lower than her pre- medicine efficiently drives the management hand-carried ultrasound assessment of the infe- Nov;11(11):778-84. doi: 10.1002/jhm.2620. of patients with heart failure and speeds up rior vena cava and N-terminal pro-brain natriu- 11. Gargani L et al. Persistent pulmonary viously assumed dry weight. At dis- the discharge time. Intern Emerg Med. 2018 retic peptide for predicting readmission after congestion before discharge predicts rehos- Jan;13(1):27-33. doi: 10.1007/s11739-017-1738-1. charge she is instructed to use the hospitalization for acute decompensated heart pitalization in heart failure: A lung ultrasound new dry weight which may avoid 8. Laffin LJ et al. Focused cardiac ultrasound as failure. JACC Cardiovasc Imaging. 2008;1(5):595- study. Cardiovasc Ultrasound. 2015 Sep 4;13:40. 601. doi: 10.1016/j.jcmg.2008.06.005. readmissions for HF. a predictor of readmission in acute decompen- doi: 10.1186/s12947-015-0033-4. sated heart failure. Int J Cardiovasc Imaging. 10. Cubo-Romano P et al. Admission inferior 12. Soni NJ et al. Point-of-care ultrasound for 2018;34(7):1075-9. doi: 10.1007/s10554-018- vena cava measurements are associated with hospitalists: A Position Statement of the Soci- Bottom line 1317-1. mortality after hospitalization for acute decom- ety of Hospital Medicine. J Hosp Med. 2019 Jan POCUS improves diagnostic accu- 9. Goonewardena SN et al. Comparison of pensated heart failure. J Hosp Med. 2016 2;14:E1-6. doi: 10.12788/jhm.3079. ‘COVID toes’ lesions not related to COVID-19

By Megan Brooks None had evidence of current, er, at follow-up, all patients had full

. Jama past, or local SARS-CoV-2 infection. resolution. aL

hilblain-like lesions seen et “In our experience, chilblain-like Almost invariably, the lesions were V in adolescents during the lesions are not a manifestation of characterized by a triad of red dots, CCOVID-19 pandemic are non- IsCepoLo COVID-19, as shown by negative se- white rosettes, and white streaks on ischemic and not related to systemic rological and molecular specific for an erythematous background.

or localized SARS-CoV-2 infection, . ©2021 D SARS-CoV2,” Dr. Discepolo said. In more than half the patients

suggests a case series from Italy. ICense The lesions were bilaterally dis- (56%), red dots often appeared as These lesions are “most likely are tributed in 16 adolescents (94.1%) dotted and comma-shaped con-

benign” and resolve on their own CC-BY L and heel skin was involved in 7 gested vessels that surrounded the etwork mage I after 2-6 weeks, Valentina Discepolo, n (41.2%). Ulceration complicated one rosettes in the early stage of the MD, PhD, University of Naples Fed- Cyanotic lesions and swelling shown patient during the active phase of lesions. In later stages, red dots were erico II, said. here in one patient in the case series. the disease, and desquamation de- still present, but the rosettes had “They do not seem to be the man- veloped over time in three patients disappeared. ifestation of systemic inflammatory the COVID-19 pandemic and the (17.6%). Only two patients had con- Chilblain-like lesions have been or autoimmune phenomena. Accord- increasing number of chilblain-like current involvement of the fingers. one of the most commonly de- ing to our experience, they should lesions has led some in the media to Therapies included topical an- scribed cutaneous manifestations not require a SARS-CoV-2–specific call it “COVID toes.” However, data tibiotics and corticosteroids, dis- during the COVID-19 pandemic, but molecular or serological test since in on the association with SARS-CoV-2 infectants, and antifungal agents; their etiopathogenesis, including the all cases in our series they were neg- are controversial. systemic antibiotics or corticoste- role of SARS-CoV-2, has remained ative,” said Dr. Discepolo. For this report, Dr. Discepolo and roids were used rarely. elusive, the investigators wrote. The study was published online in colleagues evaluated 17 adolescents None of the therapies substantial- The findings in this case series do JAMA Network Open (doi: 10.1001/ who presented with chilblain-like ly changed the course of the lesions. not support the association of the jamanetworkopen.2021.11369). lesions of the toes during the first Duration was “extremely variable,” lesions with SARS-CoV-2 infection, The temporal association between wave of the pandemic in Italy. ranging from 49 to 145 days; howev- they concluded. August 2021 | 24 | The Hospitalist

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FOLLOW DR. ANDY JORDAN... CHALLENGE YOUR MIND... As he starts his new job as a hospitalist and With realistic medical case simulations attempts to make sense of his estranged designed to improve critical decision making grandfather's mysterious disappearance and advance care planning conversations

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w o r l d - r e n o w n e d a f f i l i a t i o n s | 2 5 m i n u t e s f r o m b o s t o n | q u a l i t y o f l i f e

MASSACHUSETTS Director of Clinical Operations Hospitalist Service

Find out why so many top physicians are practicing at Emerson Hospital. At Emerson Hospital you will find a desirable place to About Concord, MA and Emerson Hospital practice, strong relationships with academic medical centers, superb quality of life, top rated school districts, competitive financial packages and more… Emerson Hospital Emerson Hospital is seeking a full or part time Director of Clinical provides advanced medical services to Operations to join our well-established team of 12 attending more than 300,000 people in over physicians and 3 nurse practitioners. The hospitalist service 25 towns. We are a 179 bed hospital provides care to patients on the general inpatient medical service as with more than 300 primary care doctors and specialists. well as patients admitted to the behavioral health and transitional Our core mission has always been care units. to make high-quality health care accessible to those that live and work • Board Certification in Internal Medicine in our community. While we provide • Full or part time, will also work clinically as an attending physician most of the services that patients will • Responsibilities include: recruiting, oversight of budget and ever need, the hospitals strong clinical collaborations with Boston’s academic payroll, quality improvement initiatives related to inpatient care medical centers ensures our patients • Three plus years’ experience required as an attending physician have access to world-class resources • Experience preferred in both leadership and quality improvement for more advanced care. • Work in collaboration with the Medical Director of Hospital Medicine • Report to the Chief Medical Officer

For more information please contact:

Diane Forte Willis 318941 Director of Physician Recruitment and Relations 978-287-3002, [email protected]

Not a J-1 of H1B opportunity EMERSONHOSPITAL.ORG TT0521 August 2021 | 27 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

TeamHealth is Here for You We offer the tools and resources that allow you to succeed professionally making your well-being a top priority.

Join our team email [email protected] visit teamhealth.com/join call 855.879.3153

311191

Academic Hospitalists

The Division of Hospital Internal Medicine at Mayo Clinic in Rochester is growing and we are looking for exceptional physicians who are passionate about a career in academic hospital medicine.

Mayo Clinic offers: • A vibrant hospital practice with emphasis on physician wellness and work-life balance; • Opportunities to manage local, regional, national, and international patients who come for exceptional care; • Unparalleled opportunities to pursue research and quality improvement initiatives; • Teaching opportunities with learners of all levels, including medical students, residents, and fellows; • Committed mentorship for academic productivity and growth; • Very competitive salary, relocation benefits, and generous financial support for professional development and attendance at scientific meetings; and • Affordable cost of living in a family-friendly city with numerous restaurants, breweries, cultural attractions, and green spaces.

We have extensive systems in place to ensure employee, patient, and visitor safety. Staff at Mayo Clinic have the opportunity to be involved at the forefront of COVID-19 research and innovation.

Consider bringing your skills and experience to a position that will challenge you, an organization that will support you, and a community To advertise in that will welcome you with open arms. The Hospitalist or the To learn more about Mayo Clinic and apply, Journal of Hospital Medicine please visit: mayocareers.com/ExploreIM

For more details, contact Jennell Prentice Endrizzi CONTACT: Phone: 507-266-1130 Email: [email protected] Linda Wilson 973.290.8243 Post offer/pre-employment drug screening is required. Mayo Clinic is an equal opportunity [email protected] educator and employer (including veterans and persons with disabilities). © 2021 MFMER 319392 the-hospitalist.org | 28 | August 2021 Make your next smart move. Visit shmcareercenter.org.

Hospitalists/Nocturnists

Ochsner Health is seeking physicians to join our hospitalist team. BC/BE Internal Medicine and Family Medicine physicians are welcomed to apply. Highlights of our opportunities are: From the hospital to the • Hospital Medicine was established at Ochsner in 1992. home and everything We have a stable 50+ member group. in-between, Vituity • 7 on 7 off block schedule with exibility hospitalists deliver and • Dedicated nocturnists cover nights coordinate superior care. • Base plus up to 40 K in incentives • Average census of 14-18 patients • E-ICU intensivist support with open ICUs at the community hospitals • EPIC medical record system with remote access capabilities • Dedicated RN and Social Work Clinical Care Coordinators Hospitalists Needed • Community based academic appointment • The only Louisiana Hospital recognized by U.S. News and World Report Distinguished Seeking board eligible/certified IM Hospital for Clinical Excellence award in 3 medical specialties and FP physicians with inpatient • Co-hosts of the annual Southern Hospital Medicine Conference experience in the following areas: • We are a medical school in partnership with the University of Queensland providing Arizona, California, Illinois, clinical training to third and fourth year students. Indiana, Michigan, Missouri, • Leadership support focused on professional development, quality improvement, and Oregon, and South Carolina. academic committees & projects Competitive income plus annual • Opportunities for leadership development, research, resident and medical student profit sharing bonus with teaching premium benefits. • Skilled nursing and long term acute care facilities seeking hospitalists and mid-levels with an interest in geriatrics Impact change at the local level. • Paid malpractice coverage and a favorable malpractice environment in Louisiana • Generous compensation and bene ts package National network of support for Ochsner Health is a system that delivers health to the people of Louisiana, Mississippi and urgent clinical and non-clinical the Gulf South with a mission to Serve, Heal, Lead, Educate and Innovate. Ochsner Health needs that includes crisis support, equipment supplies, and burnout. is a not-for-pro t committed to giving back to the communities it serves through preventative screenings, health and wellness resources and partnerships with innovative organizations HM Administrative Fellowship, that share our vision. Ochsner Health healed more than 876,000 people from across the leadership opportunities and globe in 2019, providing the latest medical breakthroughs and therapies, including digital training available. medicine for chronic conditions and telehealth specialty services. Ochsner Health is a national leader, named the top hospital in Louisiana and a top children’s hospital by U.S. News & World Up to $150,000 sign-on bonus Report. As Louisiana’s leading healthcare educator, Ochsner Health and its partners educate for select locations. thousands of healthcare professionals annually. Ochsner Health is innovating healthcare by investing in new technologies and research to make world-class care more accessible, affordable, convenient and effective. Ochsner’s team of more than 26,000 employees and Why Vituity? For nearly 50 years, Vituity has been 4,500 providers are working to reinvent the future of health and wellness in the region. To a catalyst for positive change in learn more about Ochsner Health, please visit www.ochsner.org. To transform your health, healthcare. As a physician-led and please visit www.ochsner.org/healthyyou. -owned multispecialty partnership, our 5,000 doctors and clinicians care Interested physicians should apply to: for nearly 8 million patients each year https://ochsner.wd1.myworkdayjobs.com/en-US/OchsnerPhysician/job/ across 450 practice locations and nine acute care specialties. Learn about New-Orleans---New-Orleans-Region---Louisiana/Hospital-Medicine-Sourcing-Requisition our innovative solutions to healthcare ---all-regions_REQ_00022186 challenges at vituity.com. Sorry, no opportunities for J1 applications. Ochsner is an equal opportunity employer and all qualified Explore Jobs applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual vituity.com/careers orientation, disability status, protected veteran status, or any other characteristic protected by law. Questions? 318930 [email protected]

To learn more, visit www.the-hospitalist.org and click “Advertise” or contact Linda Wilson • 973-290-8243 • [email protected] 313447

August 2021 | 29 | The Hospitalist COMMENTARY

Hospitalist Insight Hospital medicine and the future of smart care

By Sareer Zia, MD, MBA What’s next? best practices and even allow some Based on these trends, it should be procedures to be performed outside People often overestimate what no surprise that digital health will the traditional OR setting. will happen in the next 2 years and become a vital sign for health care Additionally, we are seeing the de- underestimate what will happen in organizations. velopment of “smart” patient rooms. 10. – Bill Gates The next 12-24 months will set For example, one health system in new standards for digital health and Florida is working on deploying Am- he COVID-19 pandemic set play a significant role in defining azon Alexa in 2,500 patient rooms in motion a series of inno- the next generation of virtual care. to allow patients to connect more vations catalyzing the dig- There are projections that global easily to their care team members. ital transformation of the health care industry revenues will In the not-so-distant future, smart Thealth care landscape. exceed $2.6 trillion by 2025, with AI hospitals with smart patient rooms Telemedicine use exploded over and telehealth playing a prominent and smart ORs equipped with tele- the last 12 months to the point that role in this growth.2 According to medicine, AI, AR, mixed reality, and it has almost become ubiquitous. estimates, telehealth itself will be a computer-aided decision-making With that, we saw a rapid prolifer- $175 billion market by 2026 and ap- tools will no longer be an exception. ation of wearables and remote pa- proximately one in three patient en- Dr. Zia is a hospitalist, physician tient monitoring devices. Thanks to counters will go virtual.3,4 Moreover, Smart homes for smart care adviser, and founder of Virtual virtual care, care delivery is no lon- virtual care will continue to make Smart homes with technologies like Hospitalist – a telemedicine ger strictly dependent on having on- exciting transformations, helping gas detectors, movement sensors, company with a 360-degree care site specialists, and care itself is not to make quality care accessible to and sleep sensors will continue to model for hospital patients. confined to the boundaries of hospi- everyone in innovative ways. For evolve. According to one estimate, tals or doctors’ offices anymore. example, the University of Cincin- the global smart home health care We saw the formation of the dig- nati has recently developed a pilot market was $8.7 billion in 2019, and is evolved over the years and is still ital front door and the emergence project using a drone equipped with expected to be $96.2 billion by 2030.6 evolving. It should be no surprise of new virtual care sites like virtual video technology, artificial intelli- Smart technologies will have if, in the future, we work alongside urgent care, virtual home health, gence, sensors, and first aid kits to applications in fall detection and a digital hospitalist twin to provide virtual office visits, virtual hospital go to hard-to-reach areas to deliver prevention, evaluation of self-ad- better and more personalized care at home that allowed clinical care care via telemedicine.5 ministration of medicine, sleep to our patients. Change is uncom- to be delivered safely outside the rhythm monitoring, air quality fortable but it is inevitable. When boundaries of hospitals. Nonclinical Smart hospitals monitoring for the detection of ab- COVID hit, we were forced to find public places like gyms, schools, In coming years, we can expect the normal gas levels, and identification innovative ways to deliver care to and community centers were being integration of AI, augmented reality of things like carbon monoxide poi- our patients. One thing is for cer- transformed into virtual health care (AR), and virtual reality (VR) into soning or food spoilage. In coming tain: postpandemic (AD, or After portals that brought care closer to telemedicine at lightning speed – years, expect to see more virtual Disease) we are not going back to a the people. and at a much larger scale – that medical homes and digital health Before COVID (BC) state in terms of Inside the hospital, we saw a fu- will enable surgeons from different care complexes. Patients, from the virtual care. With the new dawn of sion of traditional inpatient care parts of the globe to perform proce- convenience of their homes, might digital era, the crucial questions to and virtual care. Onsite hospital dures remotely and more precisely. be able to connect to a suite of care- address will be: What will the future teams embraced telemedicine during AI is already gaining traction in givers, all working collaboratively to role of a hospitalist look like? How the pandemic for various reasons; to different fields within health care provide more coordinated, effective can we leverage technology and conserve personal protective equip- – whether it’s predicting length of care. The “hospital at home” model embrace our flexibility to adapt to ment (PPE), limit exposure, boost stay in the ICU, or assisting in triage that started with 6 hospitals has these trends? How can we apply the care capacity, improve access to decisions, or reading radiological im- already grown to over 100 hospitals lessons learned during the pandemic specialists at distant sites, and bring ages, to name just a few. The Mayo across 29 states. The shift from on- to propel hospital medicine into the family memberse to “webside” who Clinic is using AI and computer-aid- site specialists to onscreen special- future? And is it time to rethink our cannot be at a patient’s bedside. ed decision-making tools to predict ists will continue, providing greater role and even reclassify ourselves In clinical trials as well, virtual the risk of surgery and potential access to specialized services. – from hospitalists to Acute Care Ex- care is a welcome change. According post-op complications, which could With these emerging trends, it can perts (ACE) or Primary Acute Care to one survey,1 most trial partici- allow even better collaboration be- be anticipated that much acute care Physicians? pants favored the use of telehealth tween medical and surgical teams. will be provided to patients outside services for clinical trials, as these We hear about the “x-ray” vision the hospital – either under the hos- References helped them stay engaged, compli- offered to proceduralists using Ho- pital at home model, via drone tech- 1. www.subjectwell.com/news/data-shows- ant, monitored, and on track while loLens – mixed reality smartglasses nology using telemedicine, through a-majority-of-patients-remain-interested-in-clin- ical-trials-during-the-coronavirus-pandemic/. remaining at home. Furthermore, we – a technology that enables them to smart devices in smart homes, or via are seeing the integration of artifi- perform procedures more precisely. wearables and artificial intelligence. 2. ww2.frost.com/news/press-releases/tech- nology-innovations-and-virtual-consulta- cial intelligence (AI) into telehealth, Others project that there will be Hence, hospitals’ configuration in tions-drive-healthcare-2025/. whether it is to aid physicians in more sensors and voice recognition the future will be much different 3. www.gminsights.com/industry-analysis/tele- clinical decision-making or to gener- tools in the OR that will be used to and more compact than currently, medicine-market. ate reminders to help patients with gather data to develop intelligent and many hospitals will be reserved 4. www.healthcareitnews.com/blog/frost-sulli- chronic disease management. How- algorithms, and to build a safety for trauma patients, casualties of vans-top-10-predictions-healthcare-2021. ever, this integration is beginning net for interventionalists that can natural disasters, higher acuity dis- 5. www.uc.edu/news/articles/2021/03/virtu- al-medicine-new-uc-telehealth-drone-makes- to scratch the surface only of the notify them of potential hazards or eases requiring complex procedures, house-calls.html. combination of two technologies’ accidental sterile field breaches. The and other emergencies. 6. www.psmarketresearch.com/market-analysis/ real potential. insights gained will be used to create The role of hospitalists has smart-home-healthcare-market. August 2021 | 30 | The Hospitalist

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Ethics in HM An ethics challenge in hospital medicine

By Jack Chase, MD, FAAFP, likelihood of benefit from interven- Finally, I work to include other FHM; Lubna Khawaja, MD, FHM tions. In addition to the guideposts members of our team in these dis- of ethical principles, some hospitals cussions. The distress of nurses, s. S, an 82-year-old wom- have policies which advise clinicians social workers, and others are im- an with severe dementia, to avoid nonbeneficial care. portant to acknowledge, validate, was initially hospitalized Such situations are emotionally and involve in the process. in the ICU with acute intense and can trigger distress. Mon chronic respiratory failure. Prior Conscious and unconscious bias Question #3: If you were Ms. S’s to admission, Ms. S lived with her about a patient’s perceived quality hospitalist, what would you do? daughter, who is her primary care- of life undermines equity and can Dr. Khawaja: As the hospitalist car- Dr. Chase Dr. Khawaja giver. Ms. S is able to say her daugh- play a role in our recommendations ing for Ms. S, I would use the “four ter’s name, and answer “yes” and for patients of advanced age, with boxes” model as a helpful, clinically “no” to simple questions. She is bed cognitive impairment, and those relevant and systematic approach to Dr. Chase is associate professor, bound, incontinent of urine and fe- who live with a disability. managing ethical concerns. It gives Department of Family and ces, and dependent on her daughter us a practical framework to address Community Medicine, University for all activities of daily living. Question #2: How might you these ethical principles by asking of California San Francisco; and This admission, Ms. S has been meet the patient’s medical questions in four domains. co-chair, Ethics Committee, San re-intubated 4 times for recurrent needs in line with her goals? Medical indications: What is the Francisco General Hospital. Dr. respiratory failure. The nursing staff Dr. Khawaja: In order to provide nature of her current illness, and is it Khawaja is assistant professor, are distressed that she is suffering care consistent with the patient’s reversible or not? What is the proba- Department of Internal Medicine, physically. Her daughter requests to goals, the first step is to clarify bility of success of treatment options Baylor College of Medicine, continue all intensive, life-prolong- these goals with Ms. S’s surrogate like mechanical ventilation? Are Houston. The authors are ing treatment including mechanical decision-maker, her daughter. In a there adverse effects of treatment? members of SHM’s Ethics Special ventilation and artificial nutrition. previously autonomous but pres- Patient preferences: Since Ms. S Interest Group. During sign out, your colleague ently incapacitated patient, the lacks capacity, does her daughter remarks that his grandmother was previously expressed preferences in understand the benefits and bur- in a similar situation and that his the form of a written AD should be dens of treatment? What are the and the difficulty of uncertainty. family chose to pursue comfort care. respected. However, the AD is only goals of treatment? Prolonging life? I find it helpful to emphasize my He questions whether Ms. S has any a set of preferences completed at a Minimizing discomfort? Spending commitment to honesty and non- quality of life and asks if you think particular time, not medical orders. time with loved ones? What burdens abandonment. With recommenda- further intensive care is futile. The clinician and surrogate must would the patient be willing to en- tions about both disease-directed On your first day caring for Ms. consider how to apply the AD to dure to reach her goals? and palliative, comfort-focused S, you contact her primary care the current clinical circumstances. Quality of life: What would the interventions, the patient’s daughter provider. Her PCP reports that Ms. The clinician should verify that the patient’s quality of life be with and has an opportunity to engage vol- S and her daughter completed an clinical circumstances specified in without the treatments? untarily in discussion. When asked advance directive (AD) 10 years ago the AD have been met and evaluate Contextual features: My priorities about care that may have margin- which documents a preference for if the patient’s preferences have would be building a relationship al benefit, I suggest time-limited all life-prolonging treatment. changed since she originally com- of trust with Ms. S’s daughter – by trials. I do not offer nonbeneficial pleted the AD. educating her about her mother’s treatments, and if asked about such Question #1: What are the Surrogates are asked to use a clinical status, addressing her con- treatments, I note the underlying ethical challenges? Substituted Judgement Standard cerns and questions, and supporting motive and why the treatment is Dr. Chase: In caring for Ms. S, we (i.e., what would the patient choose her as we work through patient-cen- not feasible, offer preferable alterna- face a common ethical challenge: in this situation if known). This tered decisions about what is best tives, and leave space for questions how to respect the patient’s prior may differ from what the surrogate for her mother. Honest communi- and emotions. It is important not to preferences (autonomy) when the wants. If not known, surrogates cation is a must, even if it means force a premature resolution of the currently requested treatments are asked to use the Best Interest acknowledging uncertainties about situation through unilateral or coer- have diminishing benefits (benefi- Standard (i.e., what would bring the the course of disease and prognosis. cive decisions (i.e., going off service cence) and escalating harms (non- most net benefit to the patient by These are not easy decisions for does not mean I have to wrap up the maleficence). Life-prolonging care weighing benefits and risks of treat- surrogates to make. They should be existential crisis which is occurring.) can have diminishing returns at ment options). I often ask the surro- given time to process information A broader challenge is the grief and the end of life. Ms. S’s loss of deci- gate, “Tell us about your loved one.” and make what they believe are the other emotions which accompany sion-making capacity adds a layer of Or, “Knowing your loved one, what best decisions for their loved ones. illness and death. I can neither pre- complexity. Her AD was completed do you think would be the most im- It is critical for clinicians to provide vent death nor grief, but I can offer when she was able to consider deci- portant for her right now?” honest and complete clinical infor- my professional guidance and pro- sions about her care, and she might I would also caution against bias mation and avoid value judgments, vide a supportive space for the pa- make different decisions in her in judging quality of life in patients bias, or unreasonable time pressure. tient and family to experience this current state of health. Shared deci- with dementia, and using the term Dr. Chase: In caring for Ms. S, I transition. By acknowledging this, I sion-making with a surrogate can be “futility,” as these concepts are would use a structured approach center myself with the patient and complicated by a surrogate’s anxiety inherently subjective. In general, to discussions with her daughter, family and we can work together with making life-altering decisions when a colleague raises the issue of such as the “SPIKES” protocol. Using toward a common goal of providing or their desire to avoid guilt or lone- futility, I begin by asking, “… futile to open-ended questions, I would ask compassionate and ethical care. liness. Health care professionals face achieve what goal?” That can help about the patient’s and her daugh- For a complete list of references, the limits of scientific knowledge in clarify some of the disagreement ter’s goals, values, and fears and see the online version of this article delivering accurate prognostic esti- as some goals can be accomplished provide support about the respon- at www.the-hospitalist.org. mates, probabilities of recovery, and while others cannot. sibility for shared decision-making the-hospitalist.org | 31 | August 2021

22_thru_31_HOSP21_08.indd 31 7/20/2021 4:10:44 PM A VICIOUS CYCLE WITH SIGNIFICANT BURDEN

WHAT COULD BE THE CONSEQUENCES OF RECURRENT C. DIFFICILE INFECTION?

Learn why it requires aggressive action

THE CDC ACKNOWLEDGES IT RECURS IN UP TO 35% THE CONSEQUENCES OF C. DIFFICILE INFECTION AS A OF CASES WITHIN 8 WEEKS RECURRENCE ARE SIGNIFICANT, MAJOR AND URGENT THREAT.1 AFTER INITIAL DIAGNOSIS.2,3 POTENTIALLY DEADLY.2

Now is the time to learn how Ferring is shedding light on the link between disease and disruptions in the gut microbiome, exploring the potential for repopulating its diversity and restoring hope to patients.

References: 1. Centers for Disease Control and Prevention. 2019 Antibiotic Resistance Threats Report: Clostridioides Difficile. https://www.cdc. gov/drugresistancxqe/pdf/threats-report/clostridioides-difficile-508.pdf. Accessed April 8, 2021. 2. Lessa FC, Mu Y, Bamberg WM, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015;372(9):825-834. 3. Cornely OA, Miller MA, Louie TJ, Crook DW, Gorback SL. Treatment of first recurrence of Clostridium difficile infection: fidaxomicin versus vancomycin. Clin Infect Dis. 2012;55(suppl 2):s154-s161.

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