Paradigm Shifts in Palliative Care Better Engagement with Patients Essential

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October 2018 FUTURE HOSPITALIST KEY CLINICAL QUESTION IN THE LITERATURE Volume 22 No. 10 Documentation and Evaluating and treating VTE in low-risk p7 coding p15 C. diff p18 patients

Paradigm shifts in palliative care Better engagement with patients essential

By Thomas R. Collins Ryan Greysen, MD, MHS, chief of hospital medicine, 57-year-old man is admitted to the hospital University of Pennsylvania with new back pain, which has been getting worse over the past 6 days. He had been diagnosed with stage 4 lung cancer in mid- A2017 and underwent treatment with a platinum-based double therapy. The man also has a history of heroin use – as recently as 2 years earlier – and he was divorced not long ago. He has been using an old prescription for Vicodin to treat himself, taking as many as 10-12 tablets a day. This man is an example of the kind of complicated patient hospitalists are called on to treat – complex pain in an era when opioid abuse is considered a public scourge. How is a hospitalist to handle a case like this? Pain cases are far from the only types of increasingly complex, often palliative, cases in which hospitalists are being asked to provide help. Care for the elderly is also becoming increasingly difficult as the U.S. population ages and as hospitalists step in to provide care in the absence of geriatricians. Pain management in the opioid era and the need for new approach- es in elderly care were highlighted at the Hospital Medicine 2018 annual conference, with experts drawing attention to subtleties that are often overlooked in these sometimes desperate cases. Continued on page 12 the-hospitalist.org Dan Burke PhotograPhy

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Plan now for PHYSICIAN EDITOR THE SOCIETY OF HOSPITAL MEDICINE Danielle B. Scheurer, MD, SFHM, MSCR; Phone: 800-843-3360 [email protected] Fax: 267-702-2690 Website: www.HospitalMedicine.org PEDIATRIC EDITOR outpatient diabetes Laurence Wellikson, MD, MHM, CEO Weijen Chang, MD, FACP, SFHM Vice President of Marketing & [email protected] Communications tech in the hospital COORDINATING EDITORS Lisa Zoks Dennis Chang, MD [email protected] The FuTure hospiTalisT Marketing Communications Manager By M. Alexander Otto there will be management of a sig- Jonathan Pell, MD Brett Radler Key CliniCal Guidelines [email protected] MDedge News nificant number of patients with Marketing Communications Specialist CONTRIBUTING WRITERS closed loop systems.” Felicia Steele Suzanne Bopp; Amanda Breviu, MD FROM ADA 2018 / ORLANDO / It’s To keep up, training for hospital [email protected] Claire Ciarkowski, MD; Thomas R. Collins SHM BOARD OF DIRECTORS inevitable that hospitalists will soon providers on the new technology is Jeffrey R. Dichter, MD, SFHM President be caring for patients who come in on now “mandatory at all levels,” Dr. Lida Fatemi, MD Nasim Afsar, MD, SFHM Leslie Flores, MHA, SFHM insulin pumps, continuous glucose Umpierrez said, and if they haven’t President-Elect Mirna Giordano, MD Christopher Frost, MD, SFHM monitors, and even closed loop sys- done so already, hospitals need Joshua Hanson, MD, MPH Treasurer tems, if they haven’t done so already. to put policies and procedures in William Hillman, MD Danielle Scheurer, MD, MSRC, SFHM A third or more of patients with place for when, and when not, to Stephen Jenkins, MD Secretary Tracy Cardin, ACNP-BC, SFHM Joshua LaBrin, MD, FACP, SFHM Immediate Past President type 1 diabetes Farrin A. Manian, MD, MPH Ron Greeno, MD, FCCP, MHM mellitus and Joshua Marr, MD, MPH Steven B. Deitelzweig, MD, MMM, FACC, growing num- Geetanjali Rajda, MD; Maria Reyna, MD FACP, SFHM Howard R. Epstein, MD, SFHM bers of patients We are going to see more Michael A. Roberts, MD Raj Sehgal, MD, FHM Kris Rehm, MD, SFHM with insulin-de- and“ more of these devices Jeffrey S. Vender, MD; Nathan Wanner, MD Bradley Sharpe, MD, FACP, SFHM pendent type 2 Jerome C. Siy, MD, SFHM in the hospital. FRONTLINE MEDICAL Rachel Thompson, MD, MPH, SFHM diabetes mellitus COMMUNICATIONS EDITORIAL STAFF Patrick Torcson, MD, MMM, SFHM patients are using ” Editor in Chief Mary Jo M. Dales FRONTLINE MEDICAL pumps and sen- Executive Editors Denise Fulton, COMMUNICATIONS ADVERTISING STAFF Kathy Scarbeck sor technology. allow patients to use their diabetes VP/Group Publisher; Director, Dr. Davis Editor Richard Pizzi FMC Society Partners The American equipment, and how to integrate it Creative Director Louise A. Koenig Mark Branca Diabetes Association advocates al- into care. Director, Production/Manufacturing Directors, Business Development lowing patients who are physically Among many things to consider, Rebecca Slebodnik Valerie Bednarz, 973-206-8954 cell 973-907-0230 and mentally able to continue to use patients must be well enough to EDITORIAL ADVISORY BOARD Geeta Arora, MD; Michael J. Beck, MD; [email protected] their pumps when hospitalized, and use their pumps and monitors, be Harry Cho, MD; Marina S. Farah, MD, Artie Krivopal, 973-206-8218 cell 973-202-5402 there’s general consensus that con- able to demonstrate their functions, MHA; Stella Fitzgibbons, MD, FACP, Classified Sales Representative FHM; Benjamin Frizner, MD, FHM; tinuous glucose monitors (CGM) can and also want to participate in their Heather Gonroski, 973-290-8259 Nicolas Houghton, DNP, RN, ACNP-BC; be used in the hospital. own care. [email protected] James Kim, MD; Melody Msiska, MD; All in all, it’s a good thing, accord- Contraindications to inpatient Linda Wilson, 973-290-8243 Venkataraman Palabindala, MD, SFHM; [email protected] ing to Guillermo E. Umpierrez, MD, pump use include impaired con- Raj Sehgal, MD, FHM; Rehaan Shaffie, Senior Director of Classified Sales professor of endocrinology at Emo- sciousness, critical illness, and hy- MD; Kranthi Sitammagari, MD; Tim LaPella, 484-921-5001 ry University and chief of endocri- perglycemic crises because insulin Amith Skandhan, MD, FHM; cell 610-506-3474 [email protected] Lonika Sood, MD, FACP, FHM; nology at Grady Memorial Hospital, requirements change too rapidly Advertising Offices 7 Century Drive, Amanda T. Trask, FACHE, MBA, MHA, Suite 302, Parsippany, NJ 07054-4609 both in Atlanta. and dramatically for pumps. Lack SFHM; Amit Vashist, MD, FACP; 973-206-3434, fax 973-206-9378 In a talk at the annual scientific of trained providers and supplies is Jill Waldman, MD, SFHM sessions of the American Diabetes another hurdle. Pumps also need to THE HOSPITALIST is the official newspaper of the Society THE HOSPITALIST (ISSN 1553-085X) is published monthly Association, Dr. Umpierrez reviewed come off for MRIs. of Hospital Medicine, reporting on issues and trends in for the Society of Hospital Medicine by Frontline Medical a number of studies showing that gly- CGM, meanwhile, has been shown hospital medicine. THE HOSPITALIST reaches more than Communications Inc., 7 Century Drive, Suite 302, Par- cemic control with the new technol- to improve glycemic control, de- 35,000 hospitalists, physician assistants, nurse practitioners, sippany, NJ 07054-4609. Print subscriptions are free for medical residents, and health care administrators interested Society of Hospital Medicine members. Annual paid sub- ogy is no worse in the hospital – and tecting both hyperglycemia and in the practice and business of hospital medicine. Content scriptions are available to all others for the following rates: sometimes even better – than with hypoglycemia more readily than for THE HOSPITALIST is provided by Frontline Medical Individual: Domestic – $175 (One Year), $327 (Two Years), traditional point-of-care glucose test- point-of-care testing. It’s good at Communications. Content for the Society Pages is provided by the Society of Hospital Medicine. $471 (Three Years) Canada/Mexico – $258 (One Year), ing and insulin administration. There picking up trends in glucose levels, $475 (Two Years), $717 (Three Years) Other Nations- is a lack of randomized, controlled tri- and Dr. Umpierrez anticipates a time Copyright 2018 Society of Hospital Medicine. All rights Surface – $319 (One Year), $615 (Two Years), $901 reserved. No part of this publication may be reproduced, (Three Years) Other Nations-Air – $410 (One Year), $795 als to prove the point definitively, but when readings will be transmitted stored, or transmitted in any form or by any means (Two Years), $1,204 (Three Years) what evidence does exist is promising. to nurses’ stations automatically to and without the prior permission in writing from the Institution: United States – $364; “This technology is rapidly ad- track blood glucose trends. “I think copyright holder. The ideas and opinions expressed in Canada/Mexico – $441 All Other Nations – $511 THE HOSPITALIST do not necessarily reflect those of the Student/Resident: $51 vancing, and I am very optimistic that’s the future,” he said. Society or the Publisher. The Society of Hospital Medicine Single Issue: Current – $35 (US), $47 (Canada/Mexico), and Frontline Medical Communications will not assume that we are going to see more and But, as with insulin pumps, there $59 (All Other Nations) Back Issue – $47 (US), $59 responsibility for damages, loss, or claims of any kind more of these devices in the hospi- are caveats. Among them, it’s un- (Canada/Mexico), $71 (All Other Nations) arising from or related to the information contained in this tal. If patients can manage them- clear how well CGM works during publication, including any claims related to the products, POSTMASTER: Send changes of address (with old mailing selves, allow them to use CGM, allow hypoxia, hypothermia, and hypo- drugs, or services mentioned herein. label) to THE HOSPITALIST, Subscription Services, P.O. Box 3000, Denville, NJ 07834-3000. them to use their pumps,” he said. tension. Thrombus formation and Letters to the Editor: [email protected] RECIPIENT: To subscribe, change your address, purchase As for closed loop systems – auto- infections have been reported with The Society of Hospital Medicine’s headquarters is located a single issue, file a missing issue claim, or have any at 1500 Spring Garden, Suite 501, Philadelphia, PA 19130. mated glucose sensing and insulin intravascular monitors, and a num- questions or changes related to your subscription, call administration – emerging evidence ber of agents can throw off some Editorial Offices: 2275 Research Blvd, Suite 400, Rockville, Subscription Services at 1-833-836-2705 or e-mail suggests they “allow you to have CGM devices, including acetamino- MD 20850, 240-221-2400, fax 240-221-2548 [email protected]. very good glucose control and less phen, heparin, and dopamine. BPA Worldwide is a global industry glycemic variability,” both inside Dr. Umpierrez disclosed relation- resource for verified audience data and The Hospitalist is a member. and outside of the ICU, he said. “I ships with AstraZeneca, Merck, Novo To learn more about SHM’s relationship with industry partners, visit www.hospitalmedicine.com/industry. am very hopeful before I retire that Nordisk, Sanofi, and other companies. October 2018 | 6 | The Hospitalist The Future Hospitalist ‘You have a pending query’ Specificity is essential in documentation and coding

By Geetanjali Rajda, MD; Good documentation can lead Lida Fatemi, MD; and to better severity of illness (SOI) Maria Reyna, MD and risk of mortality (ROM) scores, better patient safety indicator (PSI) hroughout medical training, scores, better Healthgrades scores, you learn to write complete better University Hospital Consor- and detailed notes to com- tium (UHC) scores, and decreased municate with other phy- Recovery Audit Contractor (RAC) Tsicians. As a student and resident, denials as well as appropriate reim- you are praised when you succinct- bursement. Good documentation ly analyze and address all patient can even lead to improved patient Dr. Rajda Dr. Fatemi Dr. Reyna problems while justifying your care and better perceived treatment orders for the day. But notes do not outcomes. Dr. Rajda is medical director of clinical documentation and quality exist just to document patient care; It is no surprise that many hos- improvement for Mount Sinai Hospital in New York, and medical director they are the template by which our pital administrators invest time for DRG appeals for the Mount Sinai Health System. She serves as actual quality of care is judged and and money in staff to support the assistant professor of medicine at Icahn School of Medicine at Mount our patients’ severity of illness is proper usage of language in your Sinai. Dr. Fatemi is an assistant professor at the University of New Mexico, captured. notes. Of course, sometimes these Albuquerque. She is director of documentation, coding, and billing for Like it or not, ICD-10 coding, docu- well-meaning “queries” can throw the division of hospital medicine at UNM. Dr. Reyna is assistant professor mentation, denials, calls, and emails you into emotional turmoil as you in the division of hospital medicine and medical director for clinical from administrators are integral try to understand what was not documentation and quality improvement at Mount Sinai Medical Center. parts of a hospitalist’s day-to-day clear in your excellent note about job. Why? The specificity and com- your patient’s heart failure exacer- prehensiveness of diagnoses affect bation. In this article, we will try to Basics of billing show the true clinical picture is an such metrics as hospital length of help you take your specificity and Physicians do not need to become important skill set. Here are some stay, mortality, and Case Mix Index comprehensiveness of diagnoses to coders but it is helpful to have some tips to help understand and even documentation. the next level. understanding of what happens avoid calls for better documentation. behind the scenes. Not everyone • Use the terms “probable,” “pos- Table 1. Specificity in coding realizes that physician billing is sible,” “suspected,” or “likely” completely different from hospital in documenting uncertain diag- Hx: 98 y/o W with HX of HTN, advanced Alzheimer’s Dementia, dysphagia, Sacral DU billing. Physician billing pertains to noses (i.e., conditions for which Stage 3, is admitted with cough, fever, vomiting due to PNA. the care provided by the clinician, physicians find clinical evidence Dx: PNA whereas hospital billing pertains to that leads to a suspicion but not a the overall care the patient received. definitive diagnosis). If conditions Indicators: Below is an example of a case are ruled out or confirmed, clearly Progress Notes: Patient with PNA, advanced Alzheimer’s Dementia, dysphagia, vomiting. state so. If it remains uncertain, Speech and Swallow Consult pending. Patient placed on Aspiration Precautions. Diet: NPO. of pneumonia, (see Table 1) which On Vanco and azithromycin. shows the importance of specific- remember to carry this “possible” ity. Just by specifying ‘Aspiration’ or “probable” diagnosis all the way Query: Please clarify type of PNA treated. for the type of pneumonia, we through to the discharge summa- Response: Patient with Aspiration Pneumonia increased the SOI and the expect- ry or final progress note. DRG: 193 Simple Pneumonia and DRG: 177 Respiratory Infections and ed ROM appropriately. Also see a • Use linking of diagnoses when Pleurisy with MCC Inflammations with MCC change in relative weight (RW): Each appropriate. For example, if the RW: 1.4550 RW: 1.9934 diagnosis-related group (DRG) is as- patient’s neuropathy, nephropathy, SOI: 2 SOI: 3 signed a relative weight = estimated and retinopathy are related to use of resources, and payment per their uncontrolled insulin-depen- ROM: 2 ROM: 3 case is based on estimated resource dent diabetes, state “uncontrolled

consumption = relative weight x insulin-dependent DMII with A1c Table 2. Secondary diagnoses “blended rate for each hospital.” of 11 complicated with nephropa- In addition to specificity, it is thy, neuropathy, and retinopathy.” Hx: 75 y/o W with Hx of CREST, PVD s/p bilateral BKA also with HTN, HL, presenting to ED with important to include all secondary The coders cannot link these di- 5 days of watery diarrhea and 7 days of abdominal bloating and discomfort. Noted to have C-diff. diagnosis (know as cc/MCC – com- agnoses, and when you link them, Dx: Intestinal infection due to Clostridium difficile plication or comorbidity or a major you show a higher complexity of complication or comorbidity – in the your patient. Remember to link Indicators: BMI 16, albumin 1.8, total protein 4, on TPN, noted cachexia and anorexia coding world). Table 2 is an example the diagnoses only when they are of using the correct terms and doc- truly related – this is where your Query: Type and acuity of malnutrition. umenting secondary diagnosis. By medical knowledge and expertise Response: Patient with C-diff and anorexia/cachexia with protein calorie malnutrition, severe documenting the type and severity come into play. DRG: 373 Major Gastrointestinal disorders DRG: 371 Major Gastrointestinal disorders of malnutrition, we again increase • Use the highest specificity of evi- & Peritoneal infections W/O CC/MCC & Peritoneal infections W MCC the expected risk of mortality and dence that supports your medical RW: 0.8401 RW: 2.022 the severity of illness. decision making. You don’t need to ews Physicians often do a lot more be too verbose, all you need is evi- SOI: 2 SOI: 3 ge N than what we record in the chart. dence supporting your medical de- ROM: 1 ROM: 3 MD e D Learning to document accurately to Continued on following page the-hospitalist.org | 7 | October 2018 PRACTICE ECONOMICS

Continued from previous page 0.45% saline” is not acceptable. greater than 40, coders cannot mation needed to calculate import- cision making and treatment plan. The actual diagnosis has to be assume that patient is morbidly ant data, such as complexity and Think of it as demonstrating the written (i.e. “hypernatremia”). In obese. Physician documentation severity of patient illness and mor- logic of your diagnosis to another addition, coders cannot code from is needed to support the obesity tality risk. A patient with commu- physician. nursing, dietitian, respiratory, and code assignment. nity-acquired pneumonia without • Use acuity (acute, chronic, acute physical therapy notes. For exam- • Document all conditions that af- other comorbidities requires fewer on chronic, mild, moderate, ple, if nursing documents that a fect the patient’s stay, including resources and has a greater chance severe, etc.) per diagnosis. For patient has a pressure ulcer the complications and chronic condi- of a good outcome than does the example, if you say heart failure clinician must still document the tions for which medications have same patient with complications, exacerbation, it makes perfect diagnosis of pressure ulcer, loca- been ordered. These secondary such as acute heart failure. sense to your medical colleagues, tion, and stage. Although dietitian diagnoses paint the most accurate • Realize downcoding brings losses, but in the coding world, it means notes may state a body mass index clinical picture and provide infor- upcoding brings fines. Exagger- nothing. Specify if it is acute, or ating the severity of patient con- acute on chronic, heart failure. Table 3. Documentation pearls ditions can lead to payer audits, • Use status of each diagnosis. Is reimbursement take backs, and the condition improving, worsen- To capture complexity and severity of Think about documenting charges of abuse and fraudulent ing, or resolved? Status does not illness, instead of documenting … billing. Never stretch the truth. have to be mentioned in all prog- Make sure you can support every Altered mental status Metabolic encephalopathy ress notes. Try to include this de- diagnosis in the patient’s chart us- Urosepsis Sepsis secondary to UTI scriptor in the discharge summary ing clinical criteria. and the day of the event. Respiratory distress Respiratory failure (specify acute/chronic) You may be frustrated by the • Always document the clinical with or without hypoxia/hypercapnea need to choose specific words about significance of any abnormal Renal insufficiency Acute kidney injury diagnoses that seem obvious to laboratory, radiology reports, or Chronic kidney disease with stage you without these descriptors. But pathology finding. Coders cannot Congestive heart failure Acute/chronic, systolic/diastolic heart failure accurate documentation can make use test results as a basis for cod- Pneumonia Type of pneumonia (e.g., aspiration PNA) a huge difference in your hospital’s ing unless a clinician has reviewed, Known or suspected organism bottom line and published metrics. interpreted, and documented the Weight loss, muscle wasting Malnutrition (specify mild, moderate, severe) Understanding the relative impact of significance of the results in the changing your terminology can help Diabetes, hyperglycemia Poorly controlled diabetes progress note. Simply copying and you make these changes, until the Anemia due to gastrointestinal Acute blood loss anemia pasting a report in the notes is language becomes second nature (see

bleed, trauma, or surgery ews not considered clinical acknowl- Table 3). Your hospital administrators edgment. Shorthand notes like Shock Specify type (septic, hemorrhagic, ge N will be grateful – and you just might cardiogenic, hypovolemic) “Na=150, start hydration with MD e D cut down your queries!

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October 2018 | 8 | The Hospitalist INNOVATIONS | By Suzanne Bopp Reducing alarm fatigue Monitoring from a centralized location

ospitalists hearing the constant noise They’ve established a “mission control” center, problems and accurately notified on-site staff from cardiac telemetry monitoring sys- where off-site personnel monitor sensors and for 79% of 3,243 events, which included a rhythm tems can experience alarm fatigue – a high-definition cameras and vital signs such as and/or rate change within 1 hour or less of the nationwide phenomenon that can lead blood pressure, heart rate, and respiration. On- event. Accurate notification to on-site hospital Hto an increase in patient deaths. site action is requested when appropriate; unim- staff was more than 84%. The American Heart Association reports that portant alarms are dismissed. Since then, improvements to the system have fewer than one in four adults survived an in-hos- In August 2016, results from the first 13 months continued, according to Cleveland Clinic, and in- pital cardiac arrest in 2013; other studies showed of the Cleveland Clinic program were published clude doubling the number of monitored patients that up to 44% of inpatient cardiac arrests were in JAMA. They revealed that the monitoring per technician and improved clinical outcomes. not detected appropriately, according to the system could help reduce rates of unimportant Cleveland Clinic. alarms with no increase in cardiopulmonary ar- Reference Clinicians at the Cleveland Clinic have tried rest events. The centralized unit monitored 99,048 Cleveland Clinic: Consult QD – An update on the centralized centralized monitoring to address the problem. patient orders, and ultimately detected serious cardiac telemetry monitoring unit. Helping alleviate Launching a surgical hospitalist burnout comanagement project Focusing on systemic factors Improving quality, patient satisfaction

or hospitalists, burnout is physicians, limiting unnecessary hen hospital med- a widespread and ongoing intrusions into a physician’s practice icine and surgical problem. In 2011, a Mayo Clinic that do not impact medical care. departments (usually study found that 45% of U.S. “It would remove the burden of ex- orthopedics or neuro- Fphysicians had at least one symptom cessive documentation and allow for Wsurgery) have joined in comanage- of professional burnout; by 2014, that physicians to get reinspired by the ment programs, improvements in ock ks T number had risen to 54%. practice of medicine, an inherently quality metrics and patient satis- “Burnout among physicians altruistic profession,” Dr. Katz said. faction have often resulted. has been shown to be linked to Changes might include elimi- At the Level 1 regional trauma egaflopp /T hi N

quality of care, impacting medical nating excessive clerical demands center in which he works, Charles L. M errors, mor- and improving EHRs to allow phy- Kast, MD, and his colleagues want- tality ratios in sicians to return to the bedside. ed to try a comanagement agree- over age 65 years, had multiple hospitalized Workloads would be geared toward ment between hospital medicine chronic medical conditions, or were patients, and quality in care and not focused and trauma surgery. on high-risk medications were pref- ages M

i lower patient on improving the bottom line of a “The surgical team identified a erentially selected. Approximately

TT y satisfaction,” health care system. need within their own department, 10 patients were seen daily. e said Ingrid One health system Dr. Katz wrote which was to improve patient mor- The comanagement program was ages / g

M T. Katz, MD, about instituted a team-based tality and satisfaction in the inpa- well received by trauma surgeons, MHS, assistant model; under this system medical tient setting,” said Dr. Kast, who is who talked about improved patient eople i

p professor of assistants gather data and reconcile based at North Shore University communication and a fostered medicine at medications, allowing physicians Hospital, Manhasset, N.Y. “Their sense of collegiality. Preliminary Harvard Medical School, Boston, to focus on performing physical ex- leadership sought out our hospital quality and patient satisfaction and coauthor of a recent column on ams and making medical decisions. medicine leadership team, who then metrics were also positive. the subject published in the New “Burnout will diminish when phy- worked together to synthesize their A top takeaway is that the benefits England Journal of Medicine. sicians are empowered to be part of metrics. We were able to identify of surgical comanagement can be Widespread burnout is caused the solution and hospital systems other quality indicators, such as demonstrated in “atypical” collabora- by systemic factors, not individual make changes that recognize the readmission rates and hospital-ac- tions, depending on the needs of the failures. totality of the challenges that phy- quired conditions, which we felt department and the hospital’s vision. “These systemic factors range sicians face,” Dr. Katz said, adding could also benefit from our services “The gains in improved patient from excessive clerical burden to that hospitalists are in a unique po- in order to help them improve.” quality metrics are only half of the ‘work beyond work,’ where people sition to promote such changes on Five hospitalists became mem- story,” Dr. Kast said. “Collaborating end up taking work home at night a systemic level. “Leadership needs bers of the comanagement team. in surgical comanagement improves and are often found interfacing to be willing to inform and engage A single hospitalist rotated for 2 the satisfaction of the hospitalists with the EHR well after their nor- their physicians, monitor well-be- weeks at a time, during which they and surgeons involved and can mal work day,” Dr. Katz said. “Many ing of physicians as closely as they were relieved of routine hospital lead to future quality improvement also express their disdain for the monitor quality in care, and imple- medicine rounding responsibilities. projects or original research, both of model of practice that no longer ment changes when needed.” The hospitalist attended daily inter- which we are currently pursuing.” values autonomy, which was seen disciplinary rounds with the trau- as inherent in the profession prior Reference ma surgery team, during which he/ Reference to the current model of care.” 1. Katz IT et al. Beyond burnout – Redesigning she identified patients that could Kast C et al. The successful development of care to restore meaning and sanity for physi- a hospital medicine-trauma surgery co-man- Moving toward a better framework cians. N Engl J Med. 2018 Jan 25. doi: 10.1056/ benefit from hospital medicine agement program (abstract). J Hosp Med. would require an inherent trust in NEJMp1716845. comanagement: Patients who were 2017;12(suppl 2). Accessed Feb. 2, 2018. the-hospitalist.org | 9 | October 2018 INNOVATIONS | By Suzanne Bopp Focus on patient experience Quick Byte: to cut readmission rates Palliative care Incorporate patient-reported quality measures Rapid adoption of a key program

ospitalists have focused much attention the care received during the index hospitalization n 2015, 75% of U.S. on reducing 30-day readmission rates, were less likely to be readmitted; participants hospitals with at a time when 15%-20% of health care reporting that doctors “always listened to them more than 50 beds ock ks T dollars spent on those readmissions is carefully” also were less likely to be readmitted. had palliative care Hconsidered potentially preventable. “These findings are important since they sug- Iprograms – a sharp /T hi N hcu T

But until very recently, no study has explored gest that engaging patients in an assessment of increase from the T patient perceptions of the likelihood of read- communication quality, unmet needs, concerns, 25% that had pallia- or mission during index admission. Now, that’s and overall experience during admission may tive care in 2000. homas N

changed. help to identify issues that might not be cap- “The rapid adop- T “Our objective was to examine associations tured in standard postdischarge surveys when tion of this high-val- between patient perceptions of care during in- the appropriate time for quality improvement ue program, which is voluntary and runs counter dex hospital admission and 30-day readmission,” interventions has passed,” Dr. Carter said. “Incor- to the dominant culture in U.S. hospitals, was cata- says Jocelyn Carter, MD, of Massachusetts Gen- porating patient-reported measures during index lyzed by tens of millions of dollars in philanthropic eral Hospital, Boston, and lead author of Novem- hospitalizations may improve readmission rates support for innovation, dissemination, and profes- ber 2017 study in BMJ Quality & Safety. and help predict which patients are more likely sionalization in the palliative care field,” according Enrolled in the study were 846 patients at two to be readmitted.” to research published in Health Affairs. inpatient adult medicine units at Massachusetts General, Boston; 201 (23.8%) of these patients Reference Reference were readmitted within 30 days. In multivariable Carter J et al. The association between patient experience factors Cassel JB et al. Palliative care leadership centers are key to the models adjusting for baseline differences, respon- and likelihood of 30-day readmission: A prospective cohort study. diffusion of palliative care innovation. Health Aff. 2018 Feb. doi: dents who reported being “very satisfied” with BMJ Qual Saf. 2017 Nov 16. Accessed Feb 2, 2018. 10.1377/hlthaff.2017.1122.

Practice Management The new SoHM report is here, and it’s the best yet! Survey content more wide ranging than ever

By Leslie Flores, MHA, SFHM August we were saying, “Enough al- more diversity this year with regard ready; when will this ever end?” to HMG employment models, we n behalf of SHM’s Prac- But we finally have a baby, and have been able to reintroduce find- tice Analysis Committee, what proud parents we are! Here are ings by employment model. I’m thrilled to introduce a couple of key things you should The 2018 SoHM report is now the 2018 State of Hospital know about the 2018 SoHM: just about every other aspect of available for purchase at www.hos- OMedicine Report (SoHM) and the • The total number of HMGs par- hospitalist group structure and pitalmedicine.org/sohm. I encourage resumption of this monthly Survey ticipating in this year’s survey operations imaginable. In addition you to obtain the SoHM report for Insights column written by commit- was marginally lower than in 2016 to traditional questions regarding yourself; you’ll almost certainly tee members. (569 this year vs. 595 in 2016), scope of services, staffing and find more than one interesting and It’s a bit like but the respondent groups are scheduling models, leadership con- useful tidbit of information. Use the giving birth. A much more diverse. While more figuration, and financial support, report to assess how your practice 9-month–long than half of respondent HMGs this year’s report includes new compares to your peers, but always process that start- (52%) are employed by hospitals or information on: keep in mind that surveys don’t tell ed last January health systems, multistate man- 1. Hospitalist comanagement roles you what should be – they tell you with the excite- agement companies employ 25%, with surgical and medical subspe- only what currently is. ment of launch- and universities or their affiliates cialties. New best practices not reflect- ing the survey employ 12%. More pediatric hospi- 2. Information about unfilled posi- ed in survey data are emerging all and encouraging talist groups (38) and HMGs that tions and how they are covered the time, and the ways others do Ms. Flores hospital medicine serve both adults and children (31) (including locum tenens use). things won’t always be right for groups (HMGs) to participated this year, compared 3. Utilization of dedicated daytime your group’s unique situation and participate. Then the long, drawn- with 2016, and almost twice as admitters. needs. Whether you are partners or out process of validating and ana- many academic HMGs participat- 4. Prevalence of geographic or unit- employees, you and your colleagues lyzing data, and organizing it into ed as in the previous survey (96 based assignment models. “own” the success of your practice tables and charts, watching our this year vs. 59 in 2016). 5. Responsibility for CPT code selec- and are the best judges of what is baby grow and take shape before • The survey content is more wide tion. right for you. our eyes, with a few small hiccups ranging than ever. As usual, SHM 6. Amount of financial support per along the way. Then graphic design licensed hospitalist compensa- wRVU. Leslie Flores, MHA, SFHM, is a and the agonizing process of copy tion and productivity data from The report has retained its color- partner with Nelson Flores Hospital editing – over and over until our the Medical Group Management ful, easy-to-read report layout and Medicine Consultants, and a member eyes crossed – and printing. Association for inclusion in this the user-friendly interface of the of the SHM Practice Analysis Like all expectant parents, by report, and the SoHM also covers digital version. And because we have Committee. October 2018 | 10 | The Hospitalist ENVISION PHYSICIAN SERVICES HAS ... EXCELLE T T TIE AND A GREAT CAREER PATH TO LEADERSHIP

DOLLY ABRAHAM, MD, MBA, SFHM HOSPITAL MEDICINE

FEATURED HOSPITAL MEDICINE LEADERSHIP POSITIONS

Aventura Hospital and Medical Center Miami, FL

Raulerson Hospital Okeechobee, FL

Palmdale Regional Medical Center Palmdale, CA

Parkland Medical Center Derry, NH

Sentara Albemarle Medical Center Elizabeth City, NC

COAST-TO-COAST LEADERSHIP AND STAFF POSITIONS

Critical Care/Intensivist  Hospitalist Nocturnist  Observation Medicine SNF Specialist

844.819.5483 EnvisionPhysicianServices.com/Hospitalist2018 Palliative care Continued from page 1

James Risser, MD, medical director that doesn’t mean the patient still increased perception of pain and hospitalists, he said. of palliative care at Regions Hospital won’t have problems with overuse lower pain tolerance. More attention must be paid to in Minneapolis, said the complex of pain medication. “This is not a character flaw,” the potential harms of hospital- problems of the 57-year-old man “We have a lot of patients now liv- Dr. Davis affirmed. The increased based care to older patients: de- with back pain amounted to an ex- ing post cancer who have been put sensitivity to pain does not resolve creased muscle strength and aero- ample of “pain’s greatest hits.” on methadone or have been put on with opioid cessation; it can last bic capacity, vasomotor instability, That particular case underscores Oxycontin, and now we’re trying to for decades. Clinicians may need to lower bone density, poor ventilation, the need to identify individual types figure out what to do with them,” he spend more time interacting with altered thirst and nutrition, and of pain, he said, because they all said. “I don’t think it’s that clear any- certain patients to get a sense of the fragile skin, among others, Dr. Grey- need to be handled differently. If more that there’s a massive differ- physical and nonphysical pain from sen said. hospitalists don’t consider all the ence between cancer and noncancer which they suffer. In a study published in 2015, Dr. different aspects of pain, a patient pain, especially for those survivors.” “Consistent, open, nonjudgmental Greysen assessed outcomes for el- might endure more suffering than Clinicians, he said, should “fix communication improves not only derly patients who were assessed necessary. what can be fixed” – and with the the information we gather from before hospitalization for functional “All of this pain is swirling around right tools. “If you have a patient patients and families, but it actually impairment. The more impaired in a very complicated patient,” Dr. who’s got severe lower abdominal changes the adherence,” Dr. Davis they were, the more likely they were Risser said, noting that it is im- pain because they have a bladder said. “Ultimately the treatment out- to be readmitted within 30 days of portant to “tease out the individual full of urine, really the treatment comes are what all of this is about.” discharge – from a 13.5% readmission parts” of a complex patient’s history. would probably not be … opioids. It rate for those with no impairment up “Pain is a very complicated con- probably would be a Foley catheter,” Paradigm shift to 18.2% for those considered to have struct, from the physical to the he said. Another palliative care role that “dependency” in three or more activi- neurological to the emotional,” Dr. Hospitalists should treat patients hospitalists often find themselves in ties of daily living.1 Risser said. “Pain is a subjective based on sound principles of pain is “comforter” of elderly patients. In another analysis, severe func- experience, and the way people in- management, Dr. Risser said, but Ryan Greysen, MD, MHS, chief of tional impairment – dependency in teract with their pain really depends “while you try to create a diagnostic hospital medicine at the University at least two activities of daily living not just on physical pain but also framework, know that people contin- of Pennsylvania, Philadelphia, said – was associated with more post- their psychological state, their social ually defy the boxes we put them in.” hospitals must respond to a shift acute care Medicare costs than neu- state, and even their spiritual state.” Indeed, in an era of pain-medica- in the paradigm of elderly care. To rologic disorders or renal failure.2 Understanding this array of caus- tion addiction, it might be a good explain the nature of this change, he Acute care for the elderly (ACE) es has led Dr. Risser to approach idea to worry about prescribing opi- referenced the “paradigm shift” mod- programs, which have care specifi- the problem of pain from different oids, but clinicians have to remem- el devised by the philosopher of sci- cally tailored to the needs of older angles – including perspectives that ber that their goal is to help patients ence Thomas Kuhn, PhD. According patients, have been found to be might not be traditional, he said. get relief – and that they themselves to Kuhn, science proceeds in a settled associated with less functional de- “One of the things that I’ve gotten bring biases to the table, said Amy pattern for many years, but on the cline, shorter lengths of stay, fewer better at is taking a spiritual histo- Davis, DO, MS, of Drexel University, rare occasions, when there is a fun- adverse events, and lower costs and ry,” he said. “I don’t know if that’s Philadelphia. damental drift in thinking, new prob- readmission rates, Dr. Greysen said. part of everybody’s armamentarium. In a presentation at HM18, Dr. Da- lems present themselves and put These programs are becoming But if you’re dealing with people vis displayed images of a variety of the old model in a crisis mode, which more common, but they are not who are very, very sick, sometimes patients on a large screen – differ- prompts an intellectual revolution spreading as quickly as perhaps they that’s the fundamental fabric of ent races and genders, some in busi- and a shift in the paradigm itself. should, he said. In part, this is be- how they live and how they die. If ness attire, some rougher around “This is a way of thinking about cause of the “know-do” gap, in which there are unresolved issues along the edges. changes in scientific paradigms, but practical steps that have been shown those lines, it’s possible they could “Would pain decisions change I think it works in clinical practice to work are not actually implement- be experiencing their pain in a dif- based on what people look like?” as well,” Dr. Greysen said. ed because of assumptions that they ferent or more severe way.” she asked. “Can you really spot who The need for a paradigm shift in are already in place or the mistaken the drug traffickers are? We need the care of elderly inpatients has belief that simple steps could not Varieties of pain to remember that our biases play a largely to do with demographics. possibly make a difference. Treatment depends on the pain huge role not only in the treatment By 2050, the number of people aged Part of the paradigm shift that’s type, Dr. Risser said. Somatic pain of our patients but in their outcomes. 65 years and older is expected to be needed, Dr. Greysen said, is an ap- often responds to nonsteroidal anti- I’m challenging everybody to start about 80 million, roughly double preciation of the concept of “post- inflammatories or steroids. thinking about these folks not as what it was in 2000. The number hospitalization syndrome,” which Neuropathic pain usually re- drug-seekers but as comfort-seekers.” of people aged 85 years and up is is composed of several domains: sponds poorly to anti-inflammato- When it comes right down to it, expected to be about 20 million, or sleep, function, nutrition, symptom ries and to opioids. There is some she said, patients want a better life, about four times the total in 2000. burden such as pain and discom- research suggesting methadone not their drug of choice. In 2010, 40% of the hospitalized fort, cognition, level of engagement, could be helpful, but the data are “That is the nature of the disease. population was over 65 years. In psychosocial status including emo- not very strong. The most com- [The illegal drug] is not what they’re 2030, that will flip: Only 40% of in- tional stress, and treatment burden mon medications prescribed are looking for in reality because that patients will be under 65 years. This including the adverse effects of antiseizure medications and anti- does not provide a good quality of will mean that hospitalists must care medications. depressants, such as gabapentin life,” Dr. Davis said. “The [practice of for more patients who are older, and Better patient engagement in dis- and serotonin, and norepinephrine medicine] is supposed to be about the patients themselves will have charge planning – including asking reuptake inhibitors. helping people live their lives, not more complicated medical issues. patients about whether they’ve had The question of cancer pain ver- just checking off boxes.” “To be ready for the aging century, help reading hospital discharge–re- sus noncancer pain can be tricky, Dr. People with an opioid use dis- we must be better able to adapt and lated documents, their level of educa- Risser said. If a person’s life expec- order are physically different, she address those things that affect tion, and how often they are getting tancy is limited, there can be a rea- said. The processing of pain stimuli seniors,” Dr. Greysen said. With out of bed – is one necessary step to- son, or even a requirement, to use by their brain and spinal cord is the number of geriatricians falling, ward change. Surveys of satisfaction higher-risk medications. But, he said, physically altered – they have an much more of this care will fall to Continued on following page October 2018 | 12 | The Hospitalist CLINICAL

Challenging Dogma The banana bag Necessary, or just another pretty fluid?

By Raj Sehgal, MD, FHM, and • Magnesium. Patients with AUD current recommendations suggest Joshua Hanson, MD, MPH are also at higher risk for magne- higher doses given more frequent- sium deficiency attributable to in- ly because of the relatively short The dogma creased excretion. While decreased half-life of parenteral thiamine.5 Patients with alcohol use disorders magnesium levels could theoret- (AUD) are at risk for nutritional and ically increase the risk of alcohol The takeaway vitamin deficiencies and may suffer withdrawal symptoms, a Cochrane The banana bag is a “one-size-fits- from linked disease states, including review found no evidence to sup- all” approach that offers too much Wernicke’s encephalopathy. These port routine supplementation.3 of some of its ingredients and not Dr. Sehgal Dr. Hanson conditions may be underrecognized; • Multivitamin. Despite theoret- enough of others. It’s better to infor instance, an autopsy study sug- ical advantages in these (often) dividualize treatment based on a Dr. Sehgal and Dr. Hanson are gests that Wernicke’s encephalopa- malnourished patients, there are patient’s needs and consider high- clinical associate professors of thy may have a prevalence rate of no published studies on the ben- dose thiamine (500 mg one to three medicine in the division of general 12.5% among alcoholics.1 efit or harm of administering a times daily) for those at risk for, or and hospital medicine at the South When patients with AUD are hos- “pan-vitamin” injection. The stan- showing signs of, Wernicke’s enceph- Texas Veterans Health Care System pitalized, they have often already dard IV formulation is slightly dif- alopathy. and UT-Health San Antonio. Dr. received a standard IV solution (100 ferent than an oral vitamin (the IV Sehgal (@rtsehgal) is a member mg of thiamine, 1 mg of folate, 1-2 g contains vitamin K, for instance, References of the editorial advisory board for of magnesium, and a multivitamin and lacks calcium), but the bio- 1. Torvik A et al. Brain lesions in alcoholics: a The Hospitalist. dissolved in saline or dextrose). The availability should be roughly the neuropathological study with clinical correla- tion. J Neurol Sci. 1982 Nov;56(2-3):233-48. practice is common enough that the same, except in rare patients with 4 2. Schwab RA et al. Prevalence in folate defi- 4. Krishel S et al. Intravenous vitamins for alco- solution is informally referred to as intestinal malabsorption. ciency in emergency department patients with holics in the emergency department: a review. J a “banana bag,” because of the yellow • IV fluids. Pharmacies typically alcohol-related illness or injury. Am J Emerg Emerg Med. 1998 May-Jun;16(3):419-24. hue imparted by thiamine and multi- mix these ingredients in a liter Med. 1992 May;10(3):203-7. 5. Donnino MW et al. Myths and misconceptions vitamin. These fluids might then be of normal saline or 5% dextrose. 3. Sarai M et al. Magnesium for alcohol with- of Wernicke’s encephalopathy: what every emer- drawal. Cochrane Database Syst Rev. 2013 Jun gency physician should know. Ann Emerg Med. readministered daily during the in- Once again, though, individual pa- 5;(6):CD008358. 2007;50(6): 715-21. patient stay. But what is the evidence tients will have different needs. A supporting this widespread practice? dehydrated patient would benefit more from normal saline, a patient The evidence with alcoholic ketoacidosis would While the banana bag (or “rally benefit more from dextrose, and pack,” as it’s also colloquially known) a patient with alcohol-related car- hanging at the patient’s side may diomyopathy likely shouldn’t be look cool, it may not be helping her. getting large volume IV fluids at all. Let’s break down the ingredients: • Thiamine. Thiamine deficiency is • Folate. Patients with alcohol use likely the most common and most disorder are at higher risk for concerning vitamin deficiency in folate deficiency (attributable to this patient population. The typ- poor intake and decreased absorp- ical banana bag contains 100 mg tion), but overall rates of folate of thiamine, which has been the deficiency are still quite low.2 In traditional recommended daily addition, most oral and parenteral amount for Wernicke’s treatment. multivitamins already contain at This dosage, however, was appar- least 400 mcg folate – the benefit ently chosen arbitrarily in the of adding further intravenous fo- 1950s (based on what the authors late is not clear. considered to be a high dose) and

Continued from previous page treatment preferences, communi- using tablets and patient portals is cate with providers across sites, and another option, Dr. Greysen said. provide needed social supports.”3 The patients of the future will like- Get the resources you need for ly prompt their own change, he said, References teaching quality and safety. quoting from a 2013 publication. 1. Greysen SR et al. Functional impairment and “Possibly the most promising hospital readmission in medicare seniors. JAMA Register before November 27, 2018 for early-bird rates! predictor for change in delivery of Intern Med. 2015 Apr;175(4):559-65. care is change in the patients them- 2. Greysen SR et al. Functional impairment: An unmeasured marker of medicare costs for selves,” the authors wrote. “Baby postacute care of older adults. J Am Geriatr Soc. boomers have redefined the norms 2017 Sep;65(9):1996-2002. at every stage of their lives. ... They 3. Laura A. Levit, Erin P. Balogh, Sharyl J. Nass, shmqsea.org will expect providers to engage and Patricia A. Ganz, eds. Delivering High-Qual- ity Cancer Care: Charting a New Course for a them in shared decision making, System in Crisis. (Washington, D.C.): National elicit their health care goals and Academies Press [US], Dec 27, 2013). the-hospitalist.org | 13 | October 2018 CLINICAL

Analysis Is respiratory compromise the new ‘sepsis’? Hospitalists can play a key role in prevention

By Jeffrey S. Vender, MD of the Society of Hospital Medicine ment, substance abuse history, and guide for Reducing Adverse Drug other medication use are important linicians and even the Events Related to Opioids (RADEO), aspects to consider.” general public are aware emphasized in a podcast with the Although we have clearly recog- of the dangers of sepsis, Physician-Patient Alliance for nized a significant increase in re- the life-threatening illness Health & Safety the need to identify spiratory complications associated Ccaused by a body’s response to an patient conditions that pose a great- with opioid administration, there infection. Irrespective of one’s per- er risk of respiratory compromise. are other areas, which are non–opi- ception of pharmaceutical market- oid related, that can create respi- ing materials or the evidence-based ratory compromise. We view many medicine used, awareness about sep- More and more clinicians patients with stable or underlying sis has led to earlier diagnosis and are beginning to utilize respiratory conditions, whether it interventions that have likely saved be chronic obstructive pumlmonary countless patients’ lives. capnography, or CO2 disease, sleep apnea, or preexisting Moreover, hospitalists have monitoring, in the pathophysiology, where either due played a key role in sepsis preven- to sedative agents, or an acute ill- tion. In their research, “Improving expired gas to earlier ness – like pneumonia – they can go Dr. Vender is the emeritus Harris Survival From Sepsis in Noncriti- detect depressed from a stable condition to respirato- Family Foundation chairman of cal Units: Role of Hospitalists and respiratory rate and/or ry compromise and become at risk the department of anesthesiology Sepsis Team in Early Detection for respiratory failure. at NorthShore University Health and Initial Treatment of Septic apnea, as well as signs A classic example of that in my System in Evanston, Ill. He is Patients,” Adriana Ducci, MD, and of hypoventilation or world of anesthesia has been the clinical professor at the University her colleagues showed that a hos- well-recognized area of non–operat- of Chicago Pritzker School of pitalist-managed sepsis protocol inadequate ventilation. ing room anesthesia – in particular, Medicine and chairman, Clinical improved sepsis case notifications in endoscopy suites where numer- Advisory Committee, Respiratory and patient outcomes. ous endoscopy procedures are per- Compromise Institute. Dr. Vender Although sepsis and respiratory In particular, Dr. Frederickson formed under the administration has consulted with Medtronic. compromise are clearly very dif- pointed out the need to screen for of propofol or other anxiolytic-like ferent conditions, I believe that obstructive sleep apnea (OSA): “Pa- drugs. There has been a well-recog- greater awareness about respirato- tients with obstructive sleep apnea nized incidence of sentinel events There clearly are obstacles to con- ry compromise will lead to earlier are dependent upon their arousal related to oxygenation and ventila- tinuous patient monitoring, such as diagnosis and interventions, which mechanism in order to avoid re- tion, including death. the associated cost, the familiarity will theoretically improve patient spiratory depression and eventual Many clinicians see sedation as a with the utilization, and the benefit, outcomes. Moreover, as with the respiratory failure. When these benign introduction of relatively lim- as well as the limitations of specific sepsis awareness campaign, hos- patients receive opioid medication, ited-effect drugs, which isn’t always monitors in different clinical situa- pitalists can play a key role in rec- it decreases this ability for arousal. true. So, therefore, it is essential that tions, which mandates an education- ognizing respiratory compromise That puts them at risk for a sudden clinicians understand three things: al process to employ these. However, and in implementing appropriate spiral that includes respiratory in- 1. The drugs we employ as sedative currently, patient monitoring pro- interventions. sufﬁciency and respiratory arrest. agents can have variable effects on vides the best early indicator of a As defined by the Respiratory This can happen very quickly and individuals depending on their tol- patient’s deterioration and the possi- Compromise Institute, “respiratory part of the risk is that the tradition- erance and their underlying medical bility of respiratory compromise. compromise” is defined as a state al monitoring for sedation that we condition. In my field, we have become very in which there is a high likelihood use in the hospital – that is on a pe- 2. The dosages and particular comfortable with capnography of decompensation into respiratory riodic basis and depends upon nurs- combination of drugs employed may and patient monitoring, because failure and/or death, but, in which ing interventions and questioning cause an adverse event – for exam- for decades it’s been a standard of specific interventions – be it ther- – really becomes much less effective ple, the combination of opioids and care for monitoring in the operat- apeutic and/or monitoring – might in this patient population that can benzodiazepines. ing room. The role for utilization prevent or mitigate this decompen- have a respiratory arrest, because of 3. There are factors that can dis- of capnography for patients who sation. failure to arouse, very quickly. So, a tract from the clinical assessment are receiving an opioid or sedative A significant segment of patients monitoring regimen that takes place of routine vital signs, such as respi- agent outside of the operating who may be at risk for respiratory every 60 minutes is likely to be inef- ratory rate, heart rate, and blood room needs to be further assessed. compromise are those receiving fective.” pressure. For example, when pulse However, technology is not a silver opioids. The cost of opioid-related Patient conditions such as OSA oximetry is administered with ox- bullet and should be used as an ad- adverse events, in terms of both should be considered, along with ygen therapy, there can often be a junct to clinical judgment in at-risk human life and hospital expenses, other comorbidities. As the RADEO delay in the recognition of hypoven- populations. remains at the forefront of the pub- Guide states: “Before starting opi- tilation. Consequently, that’s why Simple recognition and greater lic eye. It has been estimated that oid therapy, either in surgical or more and more clinicians are begin- awareness of respiratory compro- yearly costs in the United States non-surgical settings, it is important ning to utilize capnography, or CO2 mise, just as with sepsis awareness associated with opioid-related post- to identify any real or potential monitoring, in the expired gas to campaigns, will mean more patients operative respiratory failure were risks of respiratory depression or earlier detect depressed respiratory are diagnosed earlier, more appro- estimated at $2 billion. other opioid-related adverse effects. rate and/or apnea, as well as signs priate interventions are made, and Thomas W. Frederickson MD, Patient comorbidities such as OSA, of hypoventilation or inadequate hopefully more adverse events and FACP, SFHM, MBA, the lead author neurologic disorders, organ impair- ventilation. patient deaths are averted. October 2018 | 14 | The Hospitalist CLINICAL

Key Clinical Question How do you evaluate and treat a patient with C. difficile–associated disease? Metronidazole is no longer recommended

By Michael A. Roberts, MD; William Hillman, MD; and Farrin A. Manian, MD, MPH Massachusetts General Hospital, Boston

factors for CDAD (see Table 1). test may reflect colonization with Clinical Case Exposure to antibiotics remains toxigenic C. difficile, not necessari- A 45-year-old woman on omepra- the greatest risk factor. It’s import- ly CDAD. Except in rare instances, zole for gastroesophageal reflux ant to note that, while most patients laboratories should accept only un- disease and recent treatment with develop CDAD within the first formed stools for testing. Since the ciprofloxacin for a urinary tract month after receiving systemic anti- choice of testing for C. difficile varies infection, who also has had sever- biotics, many patients remain at risk by institution, hospitalists should un- al days of frequent watery stools, for up to 3 months.4 Although expo- derstand the algorithm used by their is admitted. She does not appear sure to antibiotics, particularly in respective hospitals and familiarize ill, and her abdominal exam is be- health care settings, is a significant themselves with the sensitivity and nign. She has normal renal func- risk factor for CDAD, up to 30%-40% specificity of each test. tion and white blood cell count. of community-associated cases may Once a patient is diagnosed with

How should she be evaluated and eman not have a substantial antibiotic or CDAD, the hospitalist should assess treated for Clostridium difficile– health care facility exposure.5 the severity of the disease. The IDSA/ associated disease (CDAD)? Hospitalists should also not over- SHEA guidelines still use leukocyto-

CDC/D r . H ol D look the association between proton sis and creatinine to separate mild pump inhibitor (PPI) use and the from severe cases; the presence of Brief overview difficile as well as alteration in the development of CDAD.3 Although the fever and hypoalbuminemia also C. difficile, a gram-positive anaero- colonic microbiota, often precipi- IDSA/SHEA guidelines do not recom- points to a more complicated course.3 bic bacillus that exists in vegetative tated by antibiotics. The vegetative mend discontinuation of PPIs solely The treatment of CDAD involves and spore forms, is a leading cause form of C. difficile can produce up for treatment or prevention of CDAD, a strategy of withdrawing the puta- of hospital-associated diarrhea. C. to three toxins that are responsible at the minimum, the indication for tive culprit antibiotic(s) whenever difficile has a variety of presenta- for a cascade of reactions beginning their continued use in patients with possible and initiating of antibi- tions, ranging from asymptomatic with intestinal epithelial cell death CDAD should be revisited. otics effective against C. difficile. colonization to CDAD, including followed by a significant inflam- Testing for CDAD ranges from Following the publication of two severe diarrhea, ileus, and megaco- matory response and migration of immunoassays that detect an en- randomized controlled trials demon- lon, and may be associated with a neutrophils that eventually lead to zyme common to all strains of C. strating the inferiority of metro- fatal outcome on rare occasions. The the formation of the characteristic difficile, glutamate dehydrogenase nidazole to vancomycin in clinical incidence of CDAD has been rising pseudomembranes.2 antigen (GDH), or toxins to nucleic cure of CDAD,2,7 the IDSA/SHEA since the emergence of a hypervir- Until recently, the mainstay acid amplification tests (NAATs), guidelines no longer recommend ulent strain (NAP1/BI/027) in the treatment for CDAD consisted of such as polymerase chain reaction).1,6 metronidazole for the treatment early 2000s, and not surprisingly, metronidazole and oral preparations GDH tests have high sensitivity but of CDAD. Instead, a 10-day course the number of deaths attributed to of vancomycin. Recent results from poor specificity, while testing for the of oral vancomycin or fidaxomicin CDAD has also increased.1 randomized controlled trials and the toxin has high specificity but lower has been recommended.2 Although CDAD requires acquisition of C. increasing popularity of fecal mi- sensitivity (40%-80%) for CDAD.1 fidaxomicin is associated with lower crobiota transplant, however, have Although NAATs are highly sensitive rates of recurrence of CDAD, it is Key Points changed the therapeutic landscape and specific, they often have a poor also substantially more expensive of CDAD dramatically. Not surpris- positive predictive value in low-risk than oral vancomycin, with a 10-day • Metronidazole is inferior to oral ingly, the 2017 Infectious Diseases populations (e.g., those who do not course often costing over $3,000.8 vancomycin and fidaxomicin for Society of America and the Society have true diarrhea or whose diarrhea When choosing oral vancomycin clinical cure of CDAD. The IDSA/ for Healthcare Epidemiology of resolves before test results return). for completion of therapy follow- SHEA guidelines now recom- America joint guidelines for CDAD In these patients, a positive NAAT ing discharge, hospitalists should mend a 10-day course of oral represent a significant change to the also consider whether the dis- vancomycin or fidaxomicin for treatment of CDAD, compared with Table 1. Risk factors for CDAD pensing outpatient pharmacy can nonfulminant cases of CDAD. previous guidelines.3 provide the less-expensive liquid • For fulminant CDAD, the IDSA/ Antibiotic use preparation of vancomycin. In re- SHEA guidelines suggest an Overview of data Advanced age source-poor settings, consideration increased dose of vancomycin and The hallmark of CDAD is a watery, Recent or prolonged hospitalization can still be given to metronidazole, the addition of IV metronidazole. nonbloody diarrhea. Given many an inexpensive drug, compared with Proton pump inhibitor use In such cases, surgical consulta- other causes of diarrhea in hospi- both oral vancomycin and fidaxo- tion should also be obtained. talized patients (e.g., direct effect Chemotherapy exposure micin. “Test of cure” with follow-up Chronic kidney disease • After the second recurrence of of antibiotics, laxative use, tube stool testing is not recommended. feeding, etc.), hospitalists should Feeding tubes or GI surgery For patients who require systemic Clostridium difficile infection, ews focus on testing those patients Inflammatory bowel disease antibiotics that precipitated their hospitalists should consider ge N referral for FMT where available. who have three or more episodes Low serum vitamin D levels CDAD, it is common practice to ex- of diarrhea in 24 hours and risk MD e D Continued on following page the-hospitalist.org | 15 | October 2018 CLINICAL | Key Clinical Question

Continued from previous page abdomen or concern for colonic recurrence rate, which may range than a repeat 10-day course of oral tend CDAD treatment by providing perforation, megacolon, shock, or from 15% to 30% or higher.11 The vancomycin.12 Although the treat- a “tail” coverage with an agent effec- organ system failure should obtain approach to recurrences is two- ment is unchanged for subsequent tive against CDAD for 7-10 days fol- prompt surgical consultation. Anti- fold: treatment of the C. difficile recurrences, the guidelines suggest lowing the completion of the inciting biotic treatment should consist of a itself, and attempts to restore the consideration of rifaximin after a antibiotic. A common clinical ques- combination of higher doses of oral colonic microbiome. The antibiotic course of vancomycin (see Table 2). tion relates to the management of vancomycin and intravenous metro- treatment of the first recurrence Probiotics have been investigated patients with prior history of CDAD nidazole (see Table 2). of CDAD consists of either a 10- as a means of restoring the colonic but in need of a new round of sys- In addition to occasional treat- day course of fidaxomicin or a microbiome. Use of probiotics for temic antibiotic therapy. In these pa- ment failures, a vexing charac- tapered, pulsed dose of vancomy- both primary and secondary pre- tients, concurrent prophylactic doses teristic of CDAD is its frequent cin, which may be more effective vention of CDAD has resulted in of oral vancomycin have been found conflicting data, with to be effective in preventing recur- Table 2. Recommended CDAD treatment regimens by severity or recurrence pooled analyses show- rence.9 The IDSA/SHEA guidelines ing some benefit, while conclude that “it may be prudent to Severity/recurrence Treatment regimen randomized controlled administer low doses of vancomycin Nonfulminant Oral vancomycin 125 mg four times daily for 10 days trials demonstrate less or fidaxomicin (e.g., 125 mg or 200 mg, OR fidaxomicin 200 mg two times daily for 10 days benefit.13 In addition, respectively, once daily) while sys- Fulminant* Oral (or nasogastric) vancomycin 500 mg four times daily (consider rectal reports of bloodstream temic antibiotics are administered.”3 vancomycin in the presence of ileus) infections with Lactoba- For patients whose presentation PLUS intravenous metronidazole cillus in frail patients and extends beyond diarrhea, the IDSA/ PLUS surgical consultation Saccharomyces in immu- SHEA guidelines have changed the Initial recurrence Oral vancomycin 125 mg four times daily for 10 days if metronidazole was used for nocompromised patients nomenclature for CDAD from “se- treatment of the initial episode and those with central vere, complicated” to “fulminant.” OR prolonged, tapered, and pulsed oral vancomycin regimen (e.g., 125 mg four venous catheters raise Although there are no strict defi- times daily for 10-14 days, two times daily for 1 week, once daily for 1 week, and doubts regarding their nitions, the IDSA/SHEA guidelines every 2 or 3 days for 2-8 weeks) safety in certain patient OR fidoxamicin 200 mg two times daily for 10 days if vancomycin was used for suggest that fulminant CDAD is populations.13 The IDSA/ treatment of the initial episode characterized by “hypotension or SHEA guidelines make shock, ileus, or megacolon.” In these Subsequent Oral vancomycin in a tapered and pulsed regimen no recommendations recurrences OR oral vancomycin 125 mg four times daily for 10 days followed by rifaximin patients, surgical intervention ews about the use of probiot- 400 mg three times daily for 20 days can be life saving, though mortal- ics for the prevention of OR fidaxomicin 200 mg two times daily for 10 days ge N 10 ity rates may remain over 50%. OR fecal microbiota transplantation (third or subsequent recurrences) CDAD at this time. Hospitalists whose patients with MD e D Fecal microbiota CDAD are experiencing an acute *Complicated by hypotension, shock, ileus, or megacolon transplant (FMT), how-

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October 2018 | 16 | The Hospitalist CLINICAL | Key Clinical Question

12 J Med. 2011 Feb 3;364:422-31. doi: 10.1056/ Table 3. Potential indications for fecal microbiota transplant NEJMoa0910812. 2. Burnham CA et al. Diagnosis of Clostrid- ium difficile 1. Recurrent or relapsing CDAD infection: an ongoing conundrum for clinicians and for clinical laboratories. Clin A. At least three episodes of mild to moderate CDAD and failure of a 6- to 8-week taper Microbiol Rev. 2013 Jul;26:604-30. doi: 10.1128/ with oral vancomycin with or without an alternative antibiotic (e.g., rifaximin) CMR.00016-13. B. At least two episodes of severe CDAD resulting in hospitalization and associated with 3. McDonald LC et al. Clinical Practice Guide- significant morbidity lines for Clostridium difficile infection in adults and children: 2017 update by the Infectious

2. Moderate CDAD not responding to standard oral vancomycin therapy for at least 1 week ews Diseases Society of America (IDSA) and Soci- ety for Healthcare Epidemiology of America Dr. Roberts Dr. Hillman 3. Severe (and perhaps even fulminant C. difficile colitis) not responding to standard therapy ge N (SHEA). Clin Infect Dis. 2018 Mar 19;66:987-94. after 48 hours MD e D doi: 10.1093/cid/ciy149. Dr. Roberts, 4. Hensgens MP et al. Time interval of increased Dr. Hillman, and Clostridium difficile ever, does appear to be effective, not responding to standard therapy. risk for infection after exposure to antibiotics. J Antimicrob Chemother. Dr. Manian are especially in comparison with Fulminant CDAD, characterized 2012 Mar;67:742-8. doi: 10.1093/jac/dkr508. hospitalists at antibiotics alone in patients with by hypotension, shock, severe ileus, Epub 2011 Dec 6. Massachusetts multiple recurrences of CDAD.13 The or megacolon, is a life-threatening 5. Chitnis AS et al. Epidemiology of commu- General Hospital Clostridium difficile IDSA/SHEA guidelines recommend medical emergency with a high mor- nity-associated infection, 2009 through 2011. JAMA Intern Med. 2013 in Boston. consideration for FMT after the sec- tality rate. Treatment should include Jul 22;173:1359-67. doi: 10.1001/jamaint- ond recurrence of CDAD. The Fecal high-dose oral vancomycin and in- ernmed.2013.7056. Dr. Manian Microbiota Transplantation Work- travenous metronidazole, with con- 6. Solomon DA et al. ID learning unit: Under- Clostrid- group has also proposed a set of sideration of rectal vancomycin in standing and interpreting testing for difficile colitis: Patterns of care and predictors ium difficile. Open Forum Infectious Diseases. guidelines for consideration of FMT patients with ileus. Immediate surgi- of mortality. Arch Surg. 2009;144:433-9. doi: 2014 Mar;1(1);ofu007. doi: 10.1093/ofid/ofu007. 10.1001/archsurg.2009.51. when available (see Table 3). cal consultation should be obtained 7. Johnson S et al. Vancomycin, metronidazole, Clostridium difficile 11. Zar FA et al. A comparison of vancomycin to weigh the benefits of colectomy. or tolevamer for infection: and metronidazole for the treatment of Clostrid- Application of data results from two multinational, randomized, ium difficile-associated diarrhea, stratified by controlled trials. Clin Infect Dis. 2014 Aug The recent IDSA/SHEA guidelines Back to our case disease severity. Clin Infect Dis. 2007;45:302-7. 1;59(3):345-54. doi: 10.1093/cid/ciu313. Epub doi: 10.1086/519265. Epub 2007 Jun 19. have revised the treatment par- Our patient was treated with a 10- 2014 May 5. 12. Bakken JS et al. Treating Clostridium difficile adigm for CDAD. Most notably, day course of vancomycin because 8. https://m.goodrx.com/fidaxomicin. Accessed infection with fecal microbiota transplantation. metronidazole is no longer recom- this was uncomplicated CDAD and June 24, 2018. Clin Gastroenterol Hepatol. 2011;9:1044-9. doi: mended for treatment of either ini- was her initial episode. Were she to 9. Van Hise NW et al. Efficacy of oral vancomycin 10.1016/j.cgh.2011.08.014. Epub 2011 Aug 24. Clostridium difficile in preventing recurrent infec- 13. Crow JR et al. Probiotics and fecal microbiota tial or subsequent episodes of mild develop a recurrence, she could be tion in patients treated with systemic antimicro- to severe CDAD, except when the treated with a pulsed, tapered van- transplant for primary and secondary preven- bial agents. Clin Infect Dis. 2016 Sep 1;63:651-3. tion of Clostridium difficile infection. Pharma- cost of treatment may preclude the comycin regimen or fidaxomicin. doi: 10.1093/cid/ciw401. Epub 2016 Jun 17. cotherapy. 2015 Nov;35:1016-25. doi: 10.1002/ use of more effective therapies. 10. Sailhamer EA et al. Fulminant Clostridium phar.1644. Epub 2015 Nov 2. Initial episodes of mild to severe Bottom line infection should be treated with Vancomycin and fidaxomicin are either oral vancomycin or fidaxo- recommended for the initial episode micin. Recurrent episodes of CDAD as well as recurrent CDAD. FMT should be treated with an agent dif- should be considered for patients Working continuously to balance the ferent from that used for the initial with multiple episodes of CDAD or episode, or with a pulsed, tapered treatment failures. SCALES OF JUSTICE. regimen of oral vancomycin. FMT, where available, should be consid- References We’re taking the mal out of malpractice insurance. ered with multiple recurrences, or 1. Louie TJ et al. Fidaxomicin versus vancomy- As a relentless champion for the practice of good medicine, with moderate to severe infection cin for Clostridium difficile infection. N Engl we continually track, review, and influence federal and state bills on your behalf. All for one reason: when you can tip the scales Quiz in favor of the practice of good medicine, you get malpractice insurance without the mal. Find out more at thedoctors.com The recent IDSA/SHEA guidelines no longer recommend metronidazole in the treatment of CDAD, except for which of the following scenarios (best The nation’s largest physician-owned insurer answer)? is now expanding in New York. A. Treatment of a first episode of nonfulminant CDAD. B. Treatment of recurrent CDAD following an initial course of oral vancomycin. C. Treatment of fulminant infection with IV metronidazole in addition to oral or rectal vancomycin. D. For prophylaxis following fecal microbiota transplant.

Answer: C. In fulminant infection, concurrent ileus may interfere with appropriate delivery of oral vancomycin to the colon. Adding intravenous metronidazole can allow this antibiotic to reach the bowel. Adding intravenous metronidazole to oral vancomycin is also recommended by IDSA/ SHEA guidelines in cases of fulminant CDAD. Evidence from high-quality randomized controlled trials has shown that vancomycin is superior to oral metronidazole for treatment of initial and recurrent episodes of CDAD. There is no evidence to support the use of metronidazole for recurrent CDAD following an initial course of oral vancomycin or for prophylaxis following FMT. the-hospitalist.org | 17 | October 2018 CLINICAL In the Literature Clinician reviews of HM-centric research By Joshua Marr, MD, MPH; Nathan Wanner, MD; Stephen Jenkins, MD; Claire Ciarkowski, MD; Amanda Breviu, MD; Joshua LaBrin, MD, FACP, SFHM University of Utah School of Medicine, Salt Lake City

IN THIS ISSUE tions with age and disease-specific travenous opioids may be excessive, mortality. considering that oral opioids may 1. VTE prophylaxis often overused in low-risk patients STUDY DESIGN: Prospective, popu- provide more con- 2. Lower grip strength associated with worse health outcomes lation-based study. sistent pain con- 3. Prioritize oral route for inpatient opioids, with subcutaneous route as SETTING: Large population cohort in trol with less risk alternative the United Kingdom (UK Biobank). of adverse effects. 4. Metformin associated with acidosis only in patients with eGFR SYNOPSIS: The UK Biobank popu- If oral treatment less than 30 mL/min per 1.73 m2 lation included 502,293 individuals, is not possible, 5. Intramuscular midazolam superior in sedating acutely agitated adults aged 40-69 years, recruited during subcutaneous 6. CTPA may not rule out VTE in high-risk patients April 2007–December 2010, with administration of 7. Increasing inpatient attending supervision does not decrease medical grip strength data available. Mean opioids is an ef- errors follow-up was 7.1 years for all-cause Dr. Wanner fective and possi- 8. Copeptin enhances risk stratification tools in normotensive patients and disease-specific mortality. Cox bly less addictive with PE proportional hazard models were alternative to the intravenous route. 9. Mortality risk remains high for survivors of opioid overdose used to report hazard ratios (HR) per STUDY DESIGN: Historical control 10. Tamsulosin not effective in promoting stone expulsion in symptomatic 5-kg decrease in grip strength and pilot study. patients were controlled for multiple socio- SETTING: Single adult general medi- demographic and lifestyle factors. cine unit in an urban academic med- A lower grip strength was found to ical center. By Joshua Marr, MD, MPH (25,369 patients) received excessive correlate with all-cause mortality SYNOPSIS: A 6-month historical pe- VTE prophylaxis often VTE prophylaxis. Overtreatment (HR, 1.16 in women; HR, 1.20 in men) riod with 287 patients was compared 1 overused in low-risk patients also was present in high-risk pa- as well as incidence of and mortality with a 3-month intervention period tients with and without a contrain- from cardiovascular disease, respi- with 127 patients. The intervention CLINICAL QUESTION: Is venous dication to VTE prophylaxis (26.9% ratory disease, and cancer. Hazard consisted of a clinical practice stan- thromboembolism (VTE) prophylax- and 32.3%, respec- ratios were higher among younger dard that was presented to medical is being appropriately prescribed in tively). Underuse age groups with similar lower grip and nursing staff via didactic ses- hospitalized patients? of VTE prophy- strength. The use of grip strength sions and email. The standard rec- BACKGROUND: Per Chest guide- laxis occurred in also improved the prediction of an ommended the oral route for opioids lines, VTE prophylaxis is recom- 2,693 high-risk office-based mortality risk score in patients tolerating oral intake and mended for hospitalized patients patients (22%). from cardiovascular disease. endorsed subcutaneous over intra- at increased risk for VTE but is not BOTTOM LINE: BOTTOM LINE: Grip strength is a venous administration. recommended for low-risk patients. Patients who are useful and easy-to-obtain measure- Intravenous doses decreased by Risk stratification can be guided by at low risk for ment that is associated with all- 84% (0.06 vs. 0.39 doses/patient-day; the Padua Prediction Score to cate- Dr. Marr VTE by Padua cause and disease-specific morbidity P less than .001), the daily rate of gorize patients. Prediction Score and can be used to improve the pre- patients receiving any parenteral STUDY DESIGN: Multicenter obser- often are prescribed pharmacologic diction of an office-based risk score. opioid decreased by 57% (6% vs. vational study. or mechanical prophylaxis that may CITATION: Celis-Morales CA et al. Continued on page 20 SETTING: A total of 52 U.S. hospitals be unnecessary. Overuse of VTE pro- Associations of grip strength with (Michigan Hospital Medicine Safety phylaxis was more common than is cardiovascular, respiratory, and can- Short Takes Consortium database). underuse. cer outcomes and all-cause mortali- SYNOPSIS: Patients admitted CITATION: Grant PJ et al. Use of ty: Prospective cohort study of half A second medical emergency during Jan. 1, 2015–Dec. 21, 2016, to venous thromboembolism prophy- a million UK Biobank participants. team (MET) activation more 52 non–intensive care medical units laxis in hospitalized patients. JAMA BMJ. 2018;361:k1651. likely in patients with recent for 2 or more days were analyzed Intern Med. 2018 Aug 1;178(8):1122-4. Dr. Marr is assistant professor of med- MET activation and stratified as high or low risk Published online May 21, 2018. icine and an academic hospitalist, A prospective cohort study for VTE using the Padua Prediction University of Utah, Salt Lake City. examined 471 MET activations Score. Excessive VTE prophylaxis Lower grip strength where the patient was not trans- was defined as low-risk patients 2 associated with worse By Nathan Wanner, MD ferred to a higher level of care prescribed pharmacologic or me- health outcomes Prioritize oral route for found that 18% had a second chanical prophylaxis, high-risk 3 inpatient opioids with MET event. These second events patients receiving therapy despite a CLINICAL QUESTION: Does mea- subcutaneous route as were more likely to occur in the contraindication to prophylaxis, or surement of patient grip strength alternative first 8-12 hours and to occur in any patient who received both me- enhance prediction of all-cause and patients recently discharged from chanical and pharmacologic ther- disease-specific morbidity and mor- CLINICAL QUESTION: Can adoption the ICU. apy. Underuse of VTE prophylaxis tality? of a local opioid standard of practice CITATION: Still MD et al. Predic- included high-risk patients who did BACKGROUND: Previous studies for hospitalized patients reduce tors of second medical emer- not receive pharmacologic or me- have shown that lower muscle func- intravenous and overall opioid expo- gency team activation within 24 chanical prophylaxis. Of the 44,775 tion is associated with increased sure while providing effective pain hours of index event. J Nurs Care patients included in the study, mortality; however, studies have not control? Qual. 2018;33(2):157-65. 32,549 were low risk, and 77.9% been able to fully examine associa- BACKGROUND: Inpatient use of in- October 2018 | 18 | The Hospitalist Because your next step could be the biggest.

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HOSP_19.indd 1 9/12/2018 7:23:52 PM CLINICAL | In the Literature

Continued from page 18 not been clearly defined. psychotics, are used, there is no con- thromboembolism (VTE)? 14%; P less than .001), and the mean STUDY DESIGN: Retrospective com- sensus regarding which medications BACKGROUND: Computed to- daily overall morphine-milligram munity-based cohort study. are most effective and safe for acute mography pulmonary angiography equivalents decreased by 31% SETTING: Geisinger Health System agitation. (CTPA) is the most common diag- (6.30 vs. 9.11). Pain scores were un- in Pennsylvania. STUDY DESIGN: Prospective obser- nostic modality used to diagnose changed for hospital days 1 through SYNOPSIS: A total of 75,413 patients vational study. pulmonary embolism (PE) and has 3 but were significantly improved were identified with diagnostic SETTING: Emergency department of a high negative predictive value in on day 4 (P = .004) and day 5 (P = codes or medication prescriptions an inner-city Level 1 adult and pedi- patients with a low 3-month risk of .009). indicating DM. Forty-five percent of atric trauma center. VTE. In patients with higher pretest Limitations of this study include patients were taking metformin at SYNOPSIS: This study enrolled 737 probability of PE, it is unknown the small number of patients on enrollment, increasing by 18% over adults in the ED who presented whether CTPA is sufficient to rule one unit, in one institution, with the 5.7 years of median follow-up. with acute agitation and treated out VTE. one clinician group. Attractive fea- The primary outcome was inpatient them with either STUDY DESIGN: Meta-analysis. tures of the intervention include acidosis, defined by an ICD-9-CM haloperidol 5 mg, SETTING: Published prospective its scalability and potential for aug- code capturing multiple forms of ziprasidone 20 outcome studies of patients with mentation via additional processes acidosis but excluding diabetic keto- mg, olanzapine 10 suspected PE using CTPA as a diag- such as EHR changes, prescribing acidosis. mg, midazolam 5 nostic strategy. restrictions, and pharmacy moni- When metformin users and mg, or haloperidol SYNOPSIS: The authors reviewed toring. nonusers were compared, risk of 10 mg intramus- 3,143 publications from MEDLINE, BOTTOM LINE: A standard of acidosis was similar for the entire cularly, based on EMBASE, and the Cochrane Library practice intervention with peer-to- cohort and for subgroups of pa- predetermined and identified 22 prospective out- peer education was associated with tients with an estimated glomer- Dr. Jenkins 3-week blocks. come studies to include in their decreased intravenous opioid expo- ular filtration rate (eGFR) greater The main out- meta-analysis. A VTE was diagnosed sure, decreased total opioid expo- than 90, 60-89, 45-59, and 30-44. come was the proportion of patients in 3,923 out of 11,872 participants sure, and effective pain control. Conversely, metformin use was adequately sedated at 15 minutes, (33%) using CTPA. Of the 7,863 pa- CITATION: Ackerman AL et al. associated with a higher risk of based on Altered Mental Status tients with a negative CTPA, 148 pa- Association of an opioid standard acidosis in patients with eGFR less Scale score less than 1. A total of 650 tients had an acute VTE confirmed of practice intervention with in- than 30 (adjusted hazard ratio, 2.07; patients (88%) were agitated from by venous ultrasound, ventilation/ travenous opioid exposure in hos- 95% confidence interval, 1.33-3.22). alcohol intoxication. perfusion scan, or angiography, and pitalized patients. JAMA Int Med. Metformin not increasing the risk Midazolam resulted in a statisti- 74 patients experienced VTE during 2018;178(6):759-63. of acidosis at eGFR greater than cally higher proportion of patients a 3-month follow-up period, yield- 30 also was noted in an additional adequately sedated, compared with ing an overall proportion of 2.4% of Metformin associated with analysis using sulfonylurea med- ziprasidone (difference, 18%; 95% patients (95% confidence interval, 4 acidosis only in patients with ications as an active comparator confidence interval, 6%-29%), halo- 1.3%-3.8%). eGFR 30 mL/min per 1.73 m2 and was replicated in a separate peridol 5 mg (difference, 30%; 95% Subgroup analysis showed that database with 82,000 patients from CI, 19%-41%), and haloperidol 10 mg cumulative occurrence of VTE was CLINICAL QUESTION: Does met- 350 private health systems. As (difference, 28%; 95% CI,17%-39%). related to pretest prevalence. In the formin increase the risk of lactic with all observational studies, this Midazolam resulted in a higher subgroup of patients with a VTE acidosis in chronic kidney disease study is limited by the potential proportion of patients adequately prevalence greater than 40%, VTE (CKD)? for residual confounding. sedated, compared with olanzapine was observed in 8.1% of patients BACKGROUND: Metformin is first- BOTTOM LINE: Metformin appears (difference 9%), but this difference with a negative CTPA (95% CI, 3.4%- line therapy for type 2 diabetes mel- to be safe in CKD patients with was not statistically significant 14.5%). litus (DM) because of its low cost, eGFR above 30 mL/min per 1.73 m2. because the confidence interval BOTTOM LINE: CTPA may be insuf- safety, and potential cardiovascular CITATION: Lazarus B et al. Associ- crossed 1 (95% CI, –1%-20%). Olan- ficient to rule out VTE in patients benefit, but fear of lactic acidosis ation of metformin use with risk zapine resulted in a statistically with a high pretest probability of PE. has limited its use in CKD. The risk of lactic acidosis across the range higher proportion of patients ad- CITATION: Belzile D et al. Outcomes of acidosis in CKD patients with of kidney function: A community- equately sedated, compared with following a negative computed to- varying levels of renal function has based cohort study. JAMA Int Med. haloperidol 5 mg (difference 20%; mography pulmonary angiography 2018;178(7):903-10. 95% CI, 10%-31%) and 10 mg (differ- according to pulmonary embolism Short Takes Dr. Wanner is director, hospital med- ence 18%; 95% CI, 7%-29%). Adverse prevalence: a meta-analysis icine section, and associate chief, effects were rare. of the management outcome Risk of CV events in patients division of general internal medicine, BOTTOM LINE: Intramuscular studies. J Thromb Haemost. 2018 with TIA or minor stroke University of Utah, Salt Lake City. midazolam is safe and may be more Jun;16(6):1107-20. decreases significantly after effective for treating acute agitation Dr. Jenkins is assistant professor of first year By Stephen Jenkins, MD in the emergency department than medicine and an academic hospital- A prospective cohort study Intramuscular midazolam standard antipsychotics. ist, University of Utah, Salt Lake City. following TIA or minor stroke 5 superior in sedating acutely CITATION: Klein LR et al. Intra- patients from the TIAregistry. agitated adults muscular midazolam, olanzapine, By Claire Ciarkowski, MD org project shows that the risk ziprasidone, or haloperidol for treat- Increasing inpatient of additional events (death from CLINICAL QUESTION: How effective ing acute agitation in the emergency 7 attending supervision does cardiovascular cause, nonfatal are intramuscular midazolam, olan- department. Ann Emerg Med. 2018 not decrease medical errors stroke, or nonfatal acute coro- zapine, ziprasidone, and haloperidol at Jun 6. doi: https://doi.org/10.1016/j. nary syndrome) in the following 5 sedating acutely agitated adults in the annemergmed.2018.04.027. CLINICAL QUESTION: What is the years is 12.9%, with half of those emergency department? effect of increasing attending phy- events occurring in the first year. BACKGROUND: Acute agitation CTPA may not rule out VTE sician supervision on a resident in- CITATION: Amarenco P et al. is commonly seen in the ED and 6 in high-risk patients patient team for both patient safety Five-year risk of stroke after TIA sometimes requires parenteral med- and education? or minor ischemic stroke. N Engl ications to keep patients and staff CLINICAL QUESTION: Does a nega- BACKGROUND: Residents need J Med. 2018;378:2182-90. safe. Although many medications, tive computed tomography pulmo- autonomy to help develop their including benzodiazepines and anti- nary angiography rule out venous clinical skills and to gain compe- October 2018 | 20 | The Hospitalist CLINICAL | In the Literature tence to practice independently; fication tool to help influence treat- SETTING: U.S. national cohort of gesting that this treatment is more however, there is rising concern that ment decisions for patients with Medicaid beneficiaries, aged 18-64 effective for larger stones (5-10 increased supervision is needed for pulmonary embolism (PE). Patients years, during 2001-2007. mm). However, other prospective patient safety. who are normotensive, however, are SYNOPSIS: This cohort included trials have called these guidelines STUDY DESIGN: Randomized, cross- often difficult to risk stratify. Co- 76,325 adults with nonfatal opioid into question. over clinical trial. peptin is a surrogate marker for va- overdose with 66,736 person-years of STUDY DESIGN: Double-blind, pla- SETTING: 1,100-bed academic medi- sopressin, which is released during follow-up. In the cebo-controlled study. cal center at Massachusetts General stress and hypotension and may first year after SETTING: Six emergency depart- Hospital, Boston. help identify patients at higher risk overdose, there ments at U.S. tertiary-care hospitals. SYNOPSIS: Twenty-two attend- of adverse clinical outcomes. were 5,194 deaths, SYNOPSIS: 512 participants with ing physicians participated in the STUDY DESIGN: Post hoc analysis and the crude symptomatic ureteral stones were study over 44 2-week teaching of prospective multicenter study. death rate was randomized to either tamsulosin blocks with a total of 1,259 patient SETTING: Three European cohorts, 778.3 per 10,000 or placebo. At the end of a 28-day hospitalizations including 12 sites. person-years. treatment period, the rate of uri- on the general SYNOPSIS: A total of 843 normo- Compared with a nary stone passage was 49.6% in medicine teach- tensive patients with symptomatic Dr. Breviu demographically the tamsulosin group vs. 47.3% in ing service. In the PE were included, and the 2014 ESC matched general the placebo group (95.8% confi- intervention arm, algorithm was used to identify low- population, the standardized mor- dence interval, 0.87-1.27; P = .60). attendings were risk patients, with intermediate-risk tality rate ratios (SMRs) for this The time to stone passage also was present during patients further stratified using cohort were 24.2 times higher for not different between treatment work rounds; a copeptin level cut off of greater all-cause mortality and 132.1 times groups (P = .92). A second phase in the control than 24 pmol-L–1. Elevated copeptin higher for drug use–associated dis- of the trial also evaluated stone Dr. Ciarkowski arm, attendings levels were associated with a 12.9% ease. The SMRs also were elevated passage by CT scan at 28 days, with discussed estab- rate of adverse outcome (95% confi- for conditions including HIV (45.9), stone passage rates of 83.6% in the lished patients with the resident dence interval, 6.6-22.0) and an 8.2% chronic respiratory disease (41.1), tamsulosin group and 77.6% in the via card flip. New patients were risk of PE-related death (95% CI, 3.4- viral hepatitis (30.6), and suicide placebo group (95% CI, 0.95-1.22; P discussed at the bedside in both 16.2), compared with only a 5.6% rate (25.9). Though limited to billing data = .24). This study is the largest of arms. There was no statistically sig- of adverse outcome when using the from Medicaid beneficiaries during its kind in the United States, with nificant difference in the number ESC algorithm alone. The use of co- 2001-2007, this study is important in findings similar to those of two re- of medical errors or patient safety peptin helped identify patients with identifying a relatively young pop- cent international multisite trials, events between the two groups. increased risk of adverse events ulation at high risk of preventable increasing the evidence that tam- Residents in the intervention and death, but implementation of death and suggests that additional sulosin is not beneficial for larger group, however, felt less efficient copeptin-based assessments may resources and interventions may be stone passage. and autonomous and were less able be limited by laboratory access and important in this population. BOTTOM LINE: For patients pre- to make independent decisions. may not be a cost-effective tool in BOTTOM LINE: Adults surviving senting to the ED for renal colic Limitations include this being a sin- many hospitals. opioid overdose remain at high risk from ureteral stones smaller than 9 gle-center study at a program em- BOTTOM LINE: Risk stratification of death over the following year and mm, tamsulosin does not appear to phasizing resident autonomy and of normotensive PE patients with may benefit from multidisciplinary promote stone passage. therefore may limit generalizability. intermediate risk can be optimized interventions targeted at coordinat- CITATION: Meltzer AC et al. Effect Current literature on supervision by the use of copeptin in addition to ing medical care and treatment of of tamsulosin on passage of symp- and patient safety has variable the 2014 ESC algorithm. mental health and substance use tomatic ureteral stones: A random- results. This study suggests that CITATION: Hellenkamp K et al. disorders following hospitalization ized clinical trial. JAMA Intern Med. increasing attending supervision Prognostic impact of copeptin in and emergency department presen- 2018;178(8):1051-7. Published online may not increase patient safety, but pulmonary embolism: a multicenter tations. June 18, 2018. may negatively affect resident edu- validation study. Eur Respir J. CITATION: Olfson M et al. Causes Dr. Breviu is assistant professor of cation and autonomy. 2018;51(4): 2017-37. of death after nonfatal opioid over- medicine and an academic hospitalist, BOTTOM LINE: Attending physician Dr. Ciarkowski is clinical instructor of dose. JAMA Psychiatry. 2018 Aug University of Utah, Salt Lake City. presence on work rounds does not medicine and an academic hospital- 1;75(8):820-7. Published online June improve patient safety and may ist, University of Utah, Salt Lake City. 20, 2018. Short Takes have deleterious effects on resident education. By Amanda Breviu, MD Tamsulosin not effective Maintenance of certification CITATION: Finn KM et al. Effect Mortality risk remains high 10 in promoting stone associated with better of increased inpatient attending 9 for survivors of opioid expulsion in symptomatic physician performance scores physician supervision on medical overdose patients Physicians who still participated errors, patient safety, and resident in Maintenance of Certification education. JAMA Intern Med. CLINICAL QUESTION: What are CLINICAL QUESTION: Does tam- (MOC) programs 20 years after 2018;178(7):925-59 the causes and risks of mortality in sulosin provide benefit in ureteral their initial certification scored the first year after nonfatal opioid stone expulsion for patients who higher on a variety of physician Copeptin enhances risk overdose? present with a symptomatic stone performance scores on Medicare 8 stratification tools in BACKGROUND: The current opioid less than 9 mm? patients. normotensive patients with PE epidemic has led to increasing hos- BACKGROUND: Treatment of CITATION: Gray BG et al. Associ- pitalizations and ED presentations urinary stone disease often in- ations between American Board CLINICAL QUESTION: Does the use for nonfatal opioid overdose. Despite cludes the use of alpha-blockers of Internal Medicine Mainte- of copeptin, either alone or with this, little is known about the sub- such as tamsulosin to promote nance of Certificate status and stratification tools, help identify sequent causes of mortality in these stone passage, and between 15% performance on a set of health- high-risk patients with pulmonary patients. Additional information and 55% of patients presenting to care effectiveness data and embolism? could suggest potential interventions EDs for renal colic are prescribed information set (HEDIS) process BACKGROUND: The 2014 guide- to decrease subsequent risk of death. alpha-blockers. Current treatment measures. Ann Intern Med. lines from the European Society of STUDY DESIGN: Retrospective co- guidelines support the use of tam- 2018;169(2):97-105. Cardiology (ESC) offers a risk strati- hort study. sulosin, with recent evidence sug- the-hospitalist.org | 21 | October 2018 NEWS A new, simple, inexpensive DVT diagnostic aid By Bruce Jancin DVT diagnosis showdown: CBC vs. D-dimer or higher, a positive PLR was a ratio MDedge News of 230 or more, and a positive D-di- Sensitivity Specificity Positive Negative mer level was 500 ng/mL or greater. predictive value predictive value FROM ACP INTERNAL MEDICINE / The NLR and PLR collectively out- NEW ORLEANS / Both the neutro- NLR 90.2% 80.4% 82.1% 89.1% performed the D-dimer test in terms phil-to-lymphocyte ratio (NLR) and PLR 62.7% 89% 97% 72.5% of sensitivity, specificity, positive

the platelet-to-lymphocyte ratio Double-ratio 88.6% 100% 100% 90.9% ews predictive value, and negative pre- positive

(PLR) proved to be better predictors ge N dictive value. of the presence or absence of deep D-dimer 88.2% 35.3% 57.7% 75% In addition, 89% of the DVT group vein thrombosis than the ubiqui- MD e D were classified as “double-positive,” tous D-dimer test in a retrospective Notes: Based on data from a single-center retrospective study involving 102 patients. Positive meaning they were both NLR and study, Jason Mouabbi, MD, reported NLR = 3.4 or higher, positive PLR = 230 or more, positive D-dimer = 500 ng/mL or greater. PLR positive. That combination pro- at the annual meeting of the Ameri- Source: Dr. Mouabbi vided the best diagnostic value of can College of Physicians. all, since none of the controls were What’s more, both the NLR and clinicians to help them in the diag- derwent a lower extremity Doppler double-positive and only 2% were the PLR can be readily calculated nosis of DVT,” he said. “The NLR can ultrasound evaluation. In 51 patients, PLR positive. from the readout of a complete blood be useful to rule out DVT when it’s the ultrasound revealed the presence While the results are encouraging, count with differential. A CBC costs negative, whereas PLR can be useful of DVT and anticoagulation was before NLR and PLR can supplant an average of $16, and everybody that in ruling DVT when positive.” started. In the other 51 patients, the D-dimer in patients with suspected comes through a hospital emergency Investigators in a variety of fields ultrasound exam was negative, and DVT in clinical practice a confirma- department gets one. In contrast, the are looking at the NLR and PLR as they weren’t anticoagulated. Since tory prospective study should be average charge for a D-dimer test is emerging practical, easily obtainable the study purpose was to assess the carried out, Dr. Mouabbi said. Ide- about $231 nationwide, and depend- biomarkers for systemic inflamma- implications of a primary elevation ally it should include the use of the ing upon the specific test used the re- tion. And DVT is thought to be an of NLR and/or PLR, patients with Wells score, which is part of most sults can take up to a couple of hours inflammatory process, he explained. rheumatic diseases, inflammatory diagnostic algorithms as a prelim- to come back, noted Dr. Mouabbi of Dr. Mouabbi presented a single- bowel disease, recent surgery, chron- inary means of categorizing DVT St. John Hospital and Medical Center center retrospective study of 102 ic renal or liver disease, inherited probability as low, moderate, or high. in Detroit. matched patients who presented thrombophilia, infection, or other However, the popularity of the Wells “The NLR and PLR ratios offer a with lower extremity swelling and possible secondary causes of altered score has fallen off in the face of re- new, powerful, affordable, simple, and had a CBC drawn, as well as a D-di- ratios were excluded from the study. ports that the results are subjective readily available tool in the hands of mer test, on the same day they un- A positive NLR was considered 3.4 and variable.

More than a conference, it’s a movement. HM19 is the largest national gathering of hospitalists in the United States, and offers a comprehensive array of educational and networking opportunities designed specifically for the hospital medicine professional.

New to SHM? Get one year of FREE membership shmannualconference.org with registration.

October 2018 | 22 | The Hospitalist MEMBER SPOTLIGHT

Q&A Hospital medicine and palliative care: Wearing both hats Dr. Barbara Egan leads SHM’s Palliative Care Work Group

By Felicia Steele malignancy. As such, early in my career, I had to develop a broad base Editor’s note: Each month, the So- of palliative medical skills, such as ciety of Hospitalist Medicine puts pain and symptom management the spotlight on some of our most and communication skills. I find this active members who are making work extremely rewarding, albeit substantial contributions to hospital emotionally taxing. I have learned medicine. Visit www.hospitalmed- to redefine what clinical “success” icine.org for more information on looks like – my patients often have how you can lend your expertise to unfixable medical problems, but I help improve the care of hospitalized can always strive to improve their patients. lives in some way, even if that This month, The Hospitalist spot- means helping to provide them with lights Barbara Egan, MD, FACP, a painless, dignified death as op- SFHM, chief of the hospital medicine posed to curing them. service in the department of med- When the American Board of Med- icine at Memorial Sloan Kettering ical Specialties established a board Cancer Center in New York. Barbara certification in Hospice and Pallia- has been a member of SHM since tive Medicine, there briefly existed 2005, is dual certified in hospital a pathway to be “grandfathered” in; medicine and palliative care, and is i.e., to qualify for board certifica- the chair of SHM’s Palliative Care tion through an examination and Work Group. Dr. Barbara Egan clinical experience, as opposed to a fellowship. I jumped at the chance When did you first hear about University of California, San Fran- currently focusing on? to formalize my palliative care skills SHM, and why did you decide cisco. Wendy is a visionary leader The primary focus of SHM’s Pal- and experience, and I attained board to become a member? who practices and researches at the liative Care Work Group is educa- certification in 2012. This allowed I first learned about SHM when I intersection of palliative care and tional. That is, we aim to assess and me to further diversify my clinical was an internal medicine resident at hospital medicine. She and I met help meet the educational needs practice here at MSKCC. Brigham and Women’s Hospital, Bos- during 2015, when we were both in- of hospitalists, thereby helping to Hospital medicine is still my first ton, in the early 2000s. BWH had an vited to join a collaboration between empower them to be outstanding love, and I spend most of my time extremely strong hospitalist group; SHM and the Hastings Center in providers of primary palliative care practicing as a hospitalist on our the staff I worked with served as Garrison, N.Y., which was aimed at to seriously ill, hospitalized patients. solid tumor services. But now I also powerful role models for me and improving hospitalists’ ability to To that end, we were very proud to spend several weeks each year at- inspired my interest in becoming a provide outstanding care to hospi- orchestrate a palliative care mini- tending as a consultant on our inpa- hospitalist. One of my attendings talized patients with life-limiting track for the first time at HM18. To tient supportive care service. In that suggested that I join SHM, which illnesses. That collaboration resulted our group’s delight, the attendance role, I am able to collaborate with I did right after I graduated from in the Improving Communication and reviews of that track were a fantastic multidisciplinary team residency. I attended my first SHM about Serious Illness–Implementa- great. Thus, we were invited to fur- consisting of MDs, NPs, a chaplain, Annual Conference in 2005. By then, tion Guide, a compilation of resourc- ther expand the palliative care offer- a pharmacist, a social worker, and I was working as a hospitalist at es and best practices. ings at HM19. We are busy planning integrative medicine practitioners. Memorial Sloan Kettering Cancer Wendy was chairing the SHM Pal- for HM19: a full-day pre-course in I also love the opportunity to teach Center. SHM and the field of hospi- liative Care Work Group and invited palliative medicine; several podium and mentor our palliative medicine tal medicine have exploded since my me to join, which I did with great presentations which will touch on fellows. career first began, and I am happy enthusiasm. This group consists ethical challenges, symptom man- To me, the opportunity to marry to have grown alongside them. Sim- of several passionate and brilliant agement, prognostication, and other hospital medicine and palliative ilarly, our hospital medicine group hospitalists whose practices, in a va- important topics; and a workshop in medicine in my career was a nat- here at MSKCC has dramatically riety of ways, involve both hospital communication skills. ural fit. Hospitalists, particularly grown, from 1 hospitalist (me) to medicine and palliative medicine. I those caring exclusively for cancer more than 30! was so honored when Wendy passed What led to your dual patients like I do, need to provide the baton to me last spring and in- certification and how do your excellent palliative care to our pa- How did you get involved with vited me to chair the Work Group. two specialties overlap? tients every day. The opportunity to SHM’s Palliative Care Work I am lucky to have the opportunity I am board certified in internal further my training and to obtain Group, and what has the work to collaborate with this group of dy- medicine with Focused Practice in board certification was a golden one, group accomplished since you namic individuals, and we are well Hospital Medicine by virtue of my and I love being able to wear both joined? supported by an outstanding SHM clinical training and my primary hats here at MSKCC. I was honored to be invited to join staff member, Nick Marzano. clinical practice as a hospitalist. As SHM’s Palliative Care Work Group a hospitalist in a cancer center, I Ms. Steele is a marketing in 2017 by Wendy Anderson, MD, a Are there any new projects spend most of my time caring for communications specialist at the colleague and now a friend from that the work group is patients with late- and end-stage Society of Hospital Medicine. the-hospitalist.org | 23 | October 2018 Make your next smart move. Visit shmcareercenter.org.

Maximize your Career with Emory’s Premier Academic Hospital Medicine Division

The Division of Hospital Medicine at the Emory University School of Medicine and Emory Healthcare is currently seeking exceptional individuals to join our highly respected team of physicians and medical directors. Ideal candidates will be BC/BE internists who possess outstanding clinical and interpersonal skills and who envision a fulfilling career in academic hospital medicine. Emory hospitalists have opportunities to be involved in teaching, quality improvement, patient safety, health services research, and Our Programs: other professional activities. Our hospitalists have access to faculty development programs within the Emory University Hospital Division and work with leaders focused on mentoring, medical education, and fostering research. Emory University Hospital Midtown Emory University Orthopaedics & Spine Hospital Emory Saint Joseph’s Hospital We are recruiting now for both Nocturnist and Daytime positions, so apply today. Applications will be Emory Johns Creek Hospital considered as soon as they are received. Emory University is an Equal Opportunity Employer. Emory Decatur Hospital Emory Hillandale Hospital Grady Memorial Hospital A career ith Emory includes: Apply for immediate openings! Veterans Affairs Medical Center, Atlanta • Generous salary, benefits, and incentives Email your cover letter and C to: • Faculty appointments commensurate with experience Dr. Dan Hunt, Director • Broad range of clinical, academic, and research c/o Danielle Moses, Physician Services experiences Coordinator/Recruiter for Medicine • On-site medical directors Phone: 404-778-7726 • Flexible scheduling options [email protected] • Full malpractice and tail coverage

medicine.emory.edu/hospital-medicine | emoryhealthcare.org/hospital-medicine

Hospitalist Opportunities in Eastern PA – Starting Bonus and Loan Repayment –

We have day positions at our Miners Campus in beautiful Schuylkill County and at our newest hospital in Monroe County set in the Pocono Mountains. Both campuses offer you an opportunity to make a difference in a Rural Health Community yet live in your choice of family friendly, thriving suburban areas. In addition, you’ll have access to our network’s state of the art technology and Network Specialty Support Resources. We also have opportunities at our Quakertown campus, where a replacement hospital will open in 2019.

We offer: • Starting bonus and up to $100,000 in loan repayment • 7 on/7 off schedules • Additional stipend for nights • Attractive base compensation with incentive • Excellent benefits, including malpractice, moving expenses, CME • Moonlighting Opportunities within the Network

SLUHN is a non-profit network comprised of physicians and 10 hospitals, providing care in eastern Pennsylvania and western NJ. We employ more than 800 physician and 200 advanced practitioners. St. Luke’s currently has more than 220 physicians enrolled in internship, residency and fellowship programs and is a regional campus for the Temple/St. Luke’s School of Medicine. Visit www.slhn.org. Our campuses offer easy access to major cities like NYC and Philadelphia. Cost of living is low coupled with minimal congestion; choose among a variety of charming urban, semi-urban and rural communities your family will enjoy calling home. For more information visit www.discoverlehighvalley.com Please email your CV to Drea Rosko at [email protected]

October 2018 | 24 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

HM + EM One Group. All Owners. Focused On One Goal: Outstanding Patient Care.

At US Acute Care Solutions, uniting HM and EM under a single team has led to unquestionable improvement for our patients, our hospital partners, and our clinicians. By integrating the patient journey, our physicians are able work together not just as colleagues, but as co-owners in the same group, to focus on providing the best possible patient care throughout the acute care episode, and beyond. No silos. No turf wars. Just one team, accountable for care and driven toward continual improvement.

FEATURED OPPORTUNITIES DISCOVER THE BENEFITS

• Highly competitive financial/benefits package including Union Hospital – Elkton, MD sign-on bonus Positions available Hospitalists and a Medical Director • Physician equity ownership for all full-time docs • Industry-leading and company funded 401(k) Sharon Regional • Yearly CME/BEA (Business Expense Account) Medical Center – Sharon, PA • Student loan refinancing as low as 2.99% Positions available Pulmonary/Critical Care • Groundbreaking Paid Parental Leave Intensivists and Hospitalists • Pioneering Paid Military Leave Warren General Hospital – Warren, PA • Short- and long-term disability Positions available Hospitalists • Comprehensive medical, dental, vision and Rx coverage • The best medical malpractice including tail coverage • Professional development programs • Location flexibility & career stability of a national group • Procedural autonomy with back up support as needed

800-828-0898 [email protected]

the-hospitalist.org | 25 | October 2018 Make your next smart move. Visit shmcareercenter.org.

M assachusetts – hospitalist p ositions a vailable YOU Location, Location, Location belong at the TOP!

Concord :30 Boston

Come join our well established hospitalist team of dedicated Emerson Hospital provides advanced medical services hospitalist at Emerson Hospital located in historic Concord, to more than 300,000 people in over 25 towns. We are a Palo Duro Massachusetts. Enjoy living in the suburbs with convenient 179 bed hospital with more than 300 primary care doctors State Park access to metropolitan areas such as Boston, New York and and specialists. Our core mission has always been to make Providence as well as the mountains, lakes and coastal areas. high-quality health care accessible to those that live and work Opportunities available for hospitalist and nocturnists; full in our community. While we provide most of the services time, part time, per diem and moonlighting positions, just that patients will ever need, the hospitals strong clinical 25 minutes from Boston. A great opportunity to join a well collaborations with Boston’s academic medical centers established program. ensures our patients have access to world-class resources • Manageable daily census for more advanced care. For more information please 2 • Flexible scheduling to ensure work life balance contact: Diane M Forte, Director of Physician Recruitment 0 and Relations 978-287-3002, [email protected] 1 • Dedicated nocturnist program 7 • Intensivists coverage of critical care unit Not a J-1 of H1B opportunity • Competitive compensation and bonus structure • Comprehensive benefit package including CME allowance BSA Health System ranks • Access to top specialty care eMersonhospital.org among the nation’s best for clinical excellence, employee culture and Day Hospitalists patient experience. Greater St. Louis Area Mercy Clinic South seeks Adult Hospitalists for Mercy Seeking board certified/ Hospital Jeff erson, a 251-bed facility located in the greater St. Louis area. eligible physicians. Positions Off er: • Competitive base salary, quarterly bonus and incentives Amarillo enjoys some of the Southwest’s • Attractive 7 on /7 off block schedule • Closed ICU/ No procedures To advertise in finest medical facilities, schools and • Clinical services at one hospital location cultural centers. BSA’s Hospitalist • In-house night coverage provided by Mercy Noturnists The Hospitalist or the • System-wide Epic EMR Program offers a strong compensation • Comprehensive beneﬁ ts including health, dental, vacation Journal of Hospital Medicine and CME package and excellent benefits. • Relocation assistance and professional liability coverage Texas does not have a state income tax. • Eligibility for sponsorship of H1B Visas Contact: Mercy is a physician-led, professionally managed health care system and the ﬁ fth largest Catholic health care system in the U.S. with 44 Heather Gonroski hospitals, 45,000 co-workers and over 2,500 integrated physicians. 973.290.8259 For more information, please contact: Joan Humphries [email protected] Director, Physician Recruitment p 314.364.3821 | f 314.364.2597 or [email protected] Linda Wilson AA/EEO/Minorities/Females/Disabled/Veterans 973.290.8243 [email protected] To apply or for more information: Contact Eileen Harpole 806-212-6965 Your life is our life’s work. [email protected]

October 2018 | 26 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

ENVISION PHYSICIAN SERVICES OFFERS ... THE SUPPORT I NEED TO GROW AS A icia a d leade .

BEATA SUMMER-BRASON, DO HOSPITAL MEDICINE

JOIN OUR HOSPITALIST TEAM:

■ Ft. Walton Beach Medical Center Ft. Walton Beach, FL ■ Gulf Coast Medical Center Panama City, FL

■ Lawnwood Medical Center Ft. Pierce, FL

■ North Knoxville Medical Center Hospitalist and Critical Care Physician openings Powell, TN

■ Tennova Healthcare Lebanon Lebanon, TN

877.265.6869 [email protected]

the-hospitalist.org | 27 | October 2018 Make your next smart move. Visit shmcareercenter.org.

ACADEMIC NOCTURNIST HOSPITALIST Opportunities for Internal Medicine Physicians in the Southwest San Juan Regional Medical Center in Farmington, New The Division of General Internal Medicine at Penn State Health Milton S. Hershey Medical Center, Mexico, is recruiting for Internal Medicine Physicians to join a hospital-owned practice. Penn State College of Medicine (Hershey, PA) is seeking a BC/BE Internal Medicine NOCTURNIST HOSPITALIST to join our highly regarded team. Successful candidates will hold a faculty appointment You can look forward to: • Compensation of $240,000-$250,000 base salary to Penn State College of Medicine and will be responsible for the care in patients at Hershey Medical • Productivity bonus incentive with no cap Center. Individuals should have experience in hospital medicine and be comfortable managing patients • General Internal Medicine-Primary Care out-patient practice in a sub-acute care setting. • No call, no weekends, no holidays • Lucrative benefit package, including retirement Our Nocturnists are a part of the Hospital Medicine program and will work in collaboration with • Sign on and relocation advanced practice clinicians and residents. Primary focus will be on overnight hospital admission for • Student loan repayment patients to the Internal Medicine service. Supervisory responsibilities also exist for bedside procedures, • Quality work/life balance and proficiency in central line placement, paracentesis, arthrocentesis, and lumbar puncture is Great Opportunity for a Hospitalist in the Southwest required. The position also supervises overnight Code Blue and Adult Rapid Response Team calls. This San Juan Regional Medical Center is recruiting Hospitalists to join position directly supervises medical residents and provides for teaching opportunity as well. a team dedicated to providing personalized, compassionate care. Competitive salary and benefits among highly qualified, friendly colleagues foster networking You can look forward to: opportunities. Excellent schools, affordable cost of living, great family-oriented lifestyle with a • $275,000-$295,000 base salary plus productivity and quality bonuses • 100% Hospitalist work multitude of outdoor activities year-round. Relocation assistance, CME funds, Penn State University • Wide variety of critical care tuition discount for employees and dependents, LTD and Life insurance, and so much more! • Lucrative benefit package, including retirement Appropriate candidates must possess an MD, DO, or foreign equivalent; be Board Certified in Internal • Sign on and relocation • Student loan repayment Medicine and have or be able to acquire a license to practice in the Commonwealth of Pennsylvania. • Quality work/life balance Qualified applicants should upload a letter of interest and CV at: San Juan Regional Medical Center is a non-profit and community http://tinyurl.com/j29p3fz Ref Job ID#4524 governed facility. Farmington offers a temperate four-season cli- For additional information, please contact: mate near the Rocky Mountains with world-class snow skiing, fly fishing, golf, hiking and water sports. Easy access to world renowned Brian Mc Gillen, MD — Director, Hospitalist Medicine Santa Fe Opera, cultural sites, National Parks and monuments. c/o Heather Peffley, PHR FASPR — Physician Recruiter Farmington’s strong sense of community and vibrant Southwest Penn State Health Penn State Health is committed to affirmative action, equal culture make it a great place to pursue a work-life balance. [email protected] opportunity and the diversity of its workforce. Equal Opportunity Contact Terri Smith | 888.282.6591 or 505.609.6011 (phone) | Employer – Minorities/Women/Protected Veterans/Disabled. [email protected] (email) | sanjuanregional.com or sjrmcdocs.com

Med/Peds Hospitalist Opportuniti es Available Join the Healthcare Team at ACHIEVE Berkshire Health Systems Berkshire Health Systems is currently seeking BC/BE Med/Peds extraordinary outcomes physicians to join our comprehensive Hospitalist Department • Day and Nocturnist positions When you're part of Mercy Medical Group, a service of Dignity • Previous Med/Peds Hospitalist experience is preferred Health Medical Foundation, you'll be able to do more than just • Leadership opportunities available care for your patients. You’ll have the opportunity to develop and Find your Located in Western Massachusetts Berkshire Medical Center is the participate in health, education and wellness programs that will region’s leading provider of comprehensive health care services help improve the lives of people throughout your community… • Comprehensive care for all newborns and pediatric inpatients including: and beyond. If you want to achieve extraordinary outcomes, join next job today! o Level Ib nursery us today. o 7 bed pediatrics unit visit SHMCAREERCENTER.ORG o Care for pediatric patients admitted to the hospital HOSPITALISTS - Sacramento, CA • Comprehensive adult medicine service including: o 302-bed community teaching hospital with residency programs Full-time openings are available, as are opportunities for o Geographic rounding model Nocturnists. At our large multi-specialty practice with o A closed ICU/CCU approximately 450 providers, we strive to offer our patients a o A full spectrum of Specialties to support the team full scope of healthcare services throughout the Sacramento o A major teaching afﬁ liate of the University of Massachusetts Medical area. Our award-winning Hospitalist program has around School and University of New England College of Osteopathic Medicine 70 providers and currently serves 4 major hospitals in the area. • 7 on/7 off 12 hour shift schedule Sacramento offers a wide variety of activities to enjoy, including We understand the importance of balancing work with a healthy fine dining, shopping, biking, boating, river rafting, skiing and personal lifestyle cultural events. • Located just 2½ hours from Boston and New York City • Small town New England charm Our physicians utilize leading edge technology, including EMR, • Excellent public and private schools and enjoy a comprehensive, excellent compensation and benefits • World renowned music, art, theater, and museums package in a collegial, supportive environment. • Year round recreational activities from skiing to kayaking, this is an ideal family location. For more information, please contact: Physician Recruitment Berkshire Health Systems offers a competitive salary and beneﬁ ts package, including relocation. Phone: 888-599-7787 | Email: [email protected] www.mymercymedgroup.org Interested candidates are invited to contact: www.dignityphysiciancareers.org Liz Mahan, Physician Recruitment Specialist, Berkshire Health Systems 725 North St. • Pittsfield, MA 01201 • (413) 395-7866. These are not J1 opportunities. Applications accepted online at www.berkshirehealthsystems.org October 2018 | 28 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

BECOME PART OF BETTER MEDICINE

Join the thriving hospitalist team at Northwestern Medicine Lake Forest Hospital, now located in a new state-of-the-art facility as of March 2018. We are seeking a physician who is dedicated to exceptional clinical care, quality improvement and medical education. Here, you will be an integral part of our community hospital team.

Lake Forest Hospital is located about 30 miles north of downtown Chicago. Care is provided through the main hospital campus in suburban Lake Forest and an outpatient facility in Grayslake, Illinois, which also includes a free-standing emergency room. Lake Forest Hospital is served by a medical staff of more than 700 employed and affiliated physicians. The hospital also received American Nurses Credentialing Center Magnet® re-designation in 2015, the gold standard for nursing excellence and quality care.

If you are interested in advancing your career as a Northwestern Medical Group hospitalist, please email your CV and cover letter to [email protected]. Visit nm.org to learn more.

BETTER

the-hospitalist.org | 29 | October 2018 Make your next smart move. Visit shmcareercenter.org.

HOSPITALISTS/ NOCTURNISTS Joy. NEEDED IN SOUTHEAST LOUISIANA Make it part of your career.

Vituity provides the support and resources OchsnerOchsner Health System is seeking physicians to join our you need to focus on the joy of healing.

hospitalist team. BC/BE Internal Medicine and Family Medicine We currently have opportunities for hospitalists and intensivists at hospitals and skilled nursing practices across physicians are welcomed to apply. Highlights of our opportunities are: the country. Some with sign-on bonuses up to $100,000!  Hospital Medicine was established at Ochsner in 1992. We have a stable 50+ member group  7 on 7 off block schedule with flexibility  Dedicated nocturnists cover nights  Base plus up to 45K 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  Community based academic appointment  The only Louisiana Hospital recognized by US News and World Report Distinguished Hospital for Clinical Excellence award in 4 medical specialties  Co-hosts of the annual Southern Hospital Medicine Conference  We are a medical school in partnership with the University of Queensland providing clinical training to third and fourth year students  Leadership support focused on professional development, quality improvement, and

 Opportunities for leadership development, research, resident and medical student teaching  Skilled nursing and long term acute care facilities seeking hospitalists and mid-levels with an interest in geriatrics  Paid malpractice coverage and a favorable malpractice environment in Louisiana  Generous compensation and benefits package Ochsner Health System is Louisiana’s largest non-profit, academic, healthcare system. California Driven by a mission to Serve, Heal, Lead, Educate and Innovate, coordinated clinical and • Fresno • Sacramento hospital patient care is provided across the region by Ochsner’s 29 owned, managed and • Modesto • San Francisco affiliated hospitals and more than 80 health centers and urgent care centers. Ochsner is • Redding • San Jose orld Report as a “Best Hospital” Maryland Missouri across four specialty categories caring for patients from all 50 states and more than 80 Illinois • Belleville • Baltimore • St. Louis countries worldwide each year. Ochsner employs more than 18,000 employees and over • Chicago 1,100 physicians in over 90 medical specialties and subspecialties, and conducts more than • Greenville 600 clinical research studies. For more information, please visit ochsner.org and follow us on Twitter and Facebook. Interested in travel? Interested physicians should email their CV to [email protected] Check out our Reserves Program. or call 800-488-2240 for more information. Future leader? Reference # SHM2017. Apply for our Administrative Fellowship.

Sorry, no opportunities for J1 applications. We proudly sponsor visa candidates!

Ochsner is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, disability For more information, please contact us at status, protected veteran status, or any other characteristic protected by law [email protected].

To learn more, visit www.the-hospitalist.org and click “Advertise” or contact Heather Gonroski • 973-290-8259 • [email protected] or Linda Wilson • 973-290-8243 • [email protected]

October 2018 | 30 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

Hospital Medicine TOGETHER, Post-Acute Services WE IMPACT CARE Advisory Services

As a physician-owned and managed healthcare practice, Adfinitas Health develops and delivers team-supported programs that are customized to the individual needs of our partners.

Growing nationally, we now partner with more than 60 hospitals and post-acute facilities to elevate care and drive quality.

www.AdfinitasHealth.com Elevating Care | Driving Quality | Building Partnerships

the-hospitalist.org | 31 | October 2018 Make your next smart move. Visit shmcareercenter.org. Live a Balanced Life Focus on caring for your patients, while enjoying the best that life has to offer with the help of our loan forgiveness program for hospitalists.

Loan Forgiveness Program

For more information please visit, www.flhealth.org/careers or call (315) 787-4056.

Employment Opportunity in the Beautiful Adirondack Mountains of Northern New York

Current Opening for a full-time, HOSPITALIST POSITION Hospital Employed Hospitalist. This opportunity provides a comfortable 7 on/7 off schedule, Great Lakes Medicine, PLC., invites you to consider allowing ample time to enjoy all that the an excellent Hospitalist opportunity in and around the Adirondacks have to offer! suburbs of Detroit, Michigan. We are currently seeking a hard-working Board Eligible/Board Certified Come live where others vacation! Internist to join our dedicated group. • Convenient schedules • Salary starting at $200,000 for full time • Competitive salary & benefits • Great medical benefits • Unparalleled quality of life • 401k and Profit Sharing at signing • Family friendly community • Partnership opportunity available • Excellent schools • Quarterly bonuses, based on productivity • Nearby Whiteface • 12 weeks’ vacation/ one week per month for To advertise in Mountain ski resort full-time hospitalists • Home of the 1932 & 1980 The Hospitalist or the Winter Olympics and current Job requirements: Olympic Training Center • Michigan license Journal of Hospital Medicine • Annual lronman Competition • Current CV • World Cup Bobsled and • Board certification or board eligibility Ski Events • Abundant arts community Job description: • No 24-hour in-house call CONTACT: Hike, fish, ski, golf, boat or simply relax • Share on-call duties Heather Gonroski and take in the beauty and serenity of • Rounding and reporting and simple procedures the Adirondack Mountains 973.290.8259 Great Lakes Medicine, PLC was established in 2005. [email protected] Contact: Joanne Johnson The group is made up of very motivated, dedicated, energetic 518-897-2706 physicians. We are a hospital group, dedicated to our or [email protected] patients, their families and the primary care physicians Linda Wilson www.adirondackhealth.org whom we represent. 973.290.8243 For more info, please call 586-731-8400 or email us at [email protected] [email protected] Visit www.g-l-medicine.com October 2018 | 32 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

Hospitalist Regional Medical Director Opportunities in Eastern PA – Starting Bonus and Loan Repayment –

St. Luke’s University Health Network (SLUHN) is interviewing for Hospitalist Regional Medical Director Candidates for our growing 10-hospital network. This is an opportunity to lead a dynamic group of physicians at several campuses, engage them as a team and work to assure consistent high quality. All campuses have a closed ICU, strong advanced practitioner assistance and all specialty back up, Central Vermont Medical Center, a partner in in addition to an opportunity for upward mobility the University of Vermont Health Network, We offer: within the Network. is recruiting for a full-time BC/BE IM or • Starting bonus and up to FM physician for our Hospitalist service. SLUHN is a non-profit network comprised of $100,000 in loan repayment Located in the heart of the Green Mountain physicians and 10 hospitals, providing care in eastern state, CVMC has a reputation of clinical • 7 on/7 off schedules Pennsylvania and western NJ. We employ more excellence with a staff that is deeply rooted • in our community. We have attracted and than 800 physician and 200 advanced practitioners. Additional stipend for nights retained a very talented staff due to our St. Luke’s currently has more than 220 physicians • Attractive base compensation focus on lifestyle and professional growth. enrolled in internship, residency and fellowship Our Hospitalist admit and care for patients with incentive programs and is a regional campus for the Temple/ from our 9 primary care practices on our • Excellent benefits, including med/surg floors and ICU. Very competitive St. Luke’s School of Medicine. Visit www.slhn.org. salary and loan repayment! malpractice, moving Our campuses offer easy access to major cities like expenses, CME Interested? Contact Sarah Child, Manager of NYC and Philadelphia. Cost of living is low coupled • Physician Services. with minimal congestion; choose among a variety of Moonlighting Opportunities (802) 225-1739 | [email protected] charming urban, semi-urban and rural communities within the Network your family will enjoy calling home. For more information visit www.discoverlehighvalley.com Please email your CV to Drea Rosko at [email protected]

The Ohio State University Hospitalist Opportunity Available Join the Healthcare Team at Wexner Me dical Center Berkshire Health Systems!

Berkshire Health Systems is currently seeking BC/BE Internal Medicine physicians to join our Join a Leader in Hospital Medicine comprehensive Hospitalist Department As one of the nation’s largest academic hospitalist programs, we offer a • Day, Evening and Nocturnist positions • Previous Hospitalist experience is preferred variety of teaching and non-teaching inpatient and consultative services. Located in Western Massachusetts Berkshire OSUWMC Division of Hospital Medicine is dedicated to the health and well- Medical Center is the region’s leading provider of Our faculty enjoy: being of our patients, team members, and the OSUWMC community. We are  comprehensive health care services currently seeking exceptional individuals to join our highly regarded team. Manageable clinical workload  • 302-bed community teaching hospital with We focus on improving the lives of our patients and faculty by providing Flexible scheduling options residency programs personalized, patient-centered, evidence-based medical care of the highest  Competitive salary & bonus • A major teaching affiliate of the University of  Massachusetts Medical School and UNECOM quality. Our clinical practice meets rigorous standards of scholarship, and Comprehensive benefit package • Geographic rounding model we are devoted to serving as expert educators and mentors to the next gen-  Faculty appointment commensurate eration of physicians. with experience • A closed ICU/CCU  • A full spectrum of Specialties to support the team Research & teaching opportunities Preferred candidates are BC/BE in Internal Medicine or Internal Medicine- • 7 on/7 off 10 hour shift schedule  Ongoing education and development Pediatrics, have work experience or residency training at an academic med- programs We understand the importance of balancing work with a ical center, and possess excellent inpatient, teamwork, and clinical skills.  Occurrence-based malpractice healthy personal lifestyle We are an Equal Opportunity/Affirmative Action Employer, Qualified women, minorities, Vietnam-era and  • Located just 2½ hours from Boston and New York City Relocation allowance disabled Veterans, and individuals with disabilities are encouraged to apply. This is not a J-1 opportunity. • Small town New England charm • Excellent public and private schools • World renowned music, art, theater, and museums • Year round recreational activities from skiing to kayaking, Practice Locations: We are interviewing competitive applicants! this is an ideal family location.  University Hospital ● University Hospital East Forward your letter of interest and CV: Berkshire Health Systems offers a competitive salary and benefits  James Cancer Hospital & Solove Research package, including relocation. Institute Natasha Durham, DASPR  Richard M. Ross Heart Hospital http://go.osu.edu/hospitalmedicine  Dodd Rehabilitation Hospital Interested candidates are invited to contact: [email protected] Liz Mahan, Physician Recruitment Specialist, Berkshire Health Systems  OSU Harding Hospital 725 North St. • Pittsfield, MA 01201 • (413) 395-7866.  Nationwide Children’s Hospital (Med-Peds) 614/366-2360 Applications accepted online at www.berkshirehealthsystems.org

the-hospitalist.org | 33 | October 2018 Make your next smart move. Visit shmcareercenter.org.

Sweet Hospitalist Opportunity with Penn State Health Th e Practice You’ve Always

Penn State Health is a multi-hospital health system serving patients across central Pennsylvania seeking Wanted in the exceptional physicians to join our Penn State Health family to provide patient care as a Hospitalist. Hometown  What we’re offering: You’ve Always Physician owned and managed

• Faculty positions as well as non-teaching hospitalist positions within our multi-hospital system as well as our outpatient Dreamed About  Enjoy an outstanding practices; employment package

• Network with experienced hospitalist colleagues and  Bask in the beauty of a mild collaborative leadership; climate, stunning lakes and • Ability to develop quality improvement projects in transition Hospitalist positions pristine national forests are now available. of care and other scholarly pursuits of interest; NOW RECRUITING new • Commitment to patient safety in a team approach model; Learn more at team members who share our • Potential for growth into leadership roles; NAzHospitalists.com passion for hospital medicine. • Competitive salary, comprehensive benefit package, Sandy: [email protected] Talk to us about becoming part relocation, and so much more! (928) 771-5487 of the NAzH team. What we’re seeking: • Collaborative individual to work with diverse population and staff; NORTHERN • Medical degree - MD, DO, or foreign equivalent; ARIZONA NAzH HOSPITALISTS • Completion of an accredited Internal Medicine or  Family Medicine program; NazHospitalists.com Prescott, Arizona • BC/BE in Internal or Family Medicine; • Must have or be able to acquire a license to practice in the Commonwealth of Pennsylvania; • No J1 visa waiver sponsorships available. Join our Team on Florida’s What the area offers: Located in a safe family-friendly setting in central Pennsylvania, our local neighborhoods boast a reasonable cost of living whether Gulf Coast! you prefer a more suburban setting or thriving city rich in theater, arts, and culture. Our communities are rich in history and offers an abundant range of outdoor activities, arts, and diverse experiences. We’re conveniently located within a short distance to major cities such as Philadelphia, Pittsburgh, NYC, Baltimore, and Washington DC. FT/PT Hospitalists For more information please contact: Heather Peffley, Physician Recruiter at: [email protected] FT/PT Transitional Care

Penn State Health is committed to affirmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.

www.theMHG.com Physician-Led Medicine in Montana Send CV : Internal Medicine/Family Medicine [email protected] 440Ͳ542Ͳ5000 Hospitalist Chicago—Vibrant City, Family Friendly Suburbs IMMEDIATE OPENINGS-Advocate Medical Generous loan repayment Group (AMG), a part of Advocate Health Seeking a BE/BC Hospitalist and a Nocturnist to join our Care, is actively recruiting HOSPITALISTS for group in Montana’s premier, state-of-the-art medical growing teams across metro Chicago. center, which serves as the region’s tertiary referral • Flexible 7 on7 off scheduling center. Our seasoned team values work-life balance • Manageable daily census and collegiality. • Extremely flexible • Established, stable program with Find your scheduling 90+ providers • Shifts reduced for Nocturnist Billings Clinic is nationally • First-rate specialist support next job today! • Generous salary with recognized for clinical yearly bonus excellence and is a proud • Comprehensive benefits, relocation & visit WWW.SHMCAREERS.ORG member of the Mayo Clinic • Signing bonus CME allowance • No procedures required Care Network. Located in Billings, Montana – this • J-1 waivers accepted friendly college community is Advocate Medical Group is part of • “Top 10 Fittest Cities in a great place to raise a family America 2017” – Fitbit near the majestic Rocky Advocate Aurora Health – the 10th largest • “America’s Mountains. Best Town Exciting not-for-profit health system in the nation. of 2016” outdoor Contact: Rochelle Woods recreation Submit CV & cover letter to 1-888-554-5922 close to physicianrecruiter@ home. 300 [email protected] billingsclinic.org days of Tomorrow starts today. billingsclinic.com sunshine! #1 in Montana October 2018 | 34 | The Hospitalist Legacies NAIP to SHM: The importance of a name Defining the hospitalist ‘brand’

By Jeffrey R. Dichter, MD, name of our field, hospital medicine, gional hospitalists, invited feedback SFHM has now become widely recognized. from all NAIP members, and solicit- Though the term “inpatient phy- ed leadership feedback from other he National Association of sician” had focused on physicians professional organizations. All of Inpatient Physicians (NAIP) as a primary constituency, the suc- these data were taken into our fall “opened its doors” in the cessful growth of hospital medicine 2002 board meeting in St. Louis. spring of 1998, welcoming now increasingly depended upon Prior to the meeting, it was Tthe first 300 hospitalists. The term other important constituencies and agreed that making a name change “hospitalist” was first coined in Bob their understanding of the hospital would require a supermajority of Wachter’s 1996 New England Journal medicine specialty and the role of two-thirds of the 11 voting board of Medicine article,1 although hos- hospitalists. These stakeholders members (though only 10 ultimately pitalists were relatively few at that included virtually all health care attended the meeting). Also partic- time, and the term not infrequently professionals and administrators; ipating in the discussion were the Dr. Dichter is an intensivist and as- evoked controversy. government officials at the federal, nonvoting four ex-officio board sociate professor of medicine Having full-time hospital-based state, and local levels; patients; and members and the NAIP CEO. The at the University of Minnesota physicians was highly disruptive to the American public. initial discussion included presenta- Medical Center, Minneapolis. the traditional culture of medicine, tions arguing for Hospital Medicine where hospital rounds were an in- versus Hospitalist as part of the tegral part of a primary care physi- name. We then discussed and voted Of note, SHM membership currently cians’ practice, professional identity, on the primary professional com- exceeds 17,000 members and now of- and referral patterns. Additionally, It was our belief … that ponent of the name, with “Society” fers membership that includes nurse many hospital-based specialists were “ finally being chosen. After further practitioners, physician assistants, beginning to fill the hospitalist role. having a name that discussion and a series of ballots, we fellows, residents, students, and prac- The decision to include “inpatient accurately portrayed arrived at the name “Society of Hos- tice administrators, among others.12 physician” rather than “hospitalist” hospitalists and hospital pital Medicine.” In the final ballot, 7 These achievements and many in the name was carefully consid- out of 10 cast their votes in favor of more have been driven by the ered and was intended to be inclu- medicine would define this finalist, and our organization efforts of past and present SHM sive, without alienating potential our ‘brand’ in an became The Society of Hospital members and staff, and like-minded allies. Virtually any doctor working Medicine. Our abbreviation SHM professionals and organizations. The in a hospital could identify them- understandable way. was to become our logo, which was name “Society of Hospital Medicine” selves as an inpatient physician, and ” developed in advance of our 2003 is highly familiar and well regarded all who wanted to participate were annual meeting. by virtually all our stakeholders and welcomed. It also was evident early In the 15 years since, the Society is recognized for its proven lead- on that this young specialty was As NAIP leadership, it was our of Hospital Medicine has become ership in continuing to define our going to comprise many different belief and intent that having a name well known to our constituents and brand, hospital medicine. disciplines, including internal medi- that accurately portrayed hospital- stakeholders. SHM is recognized for cine, family practice, and pediatrics ists and hospital medicine would its staunch advocacy, particularly References to name a few, and reaching out to define our “brand” in an under- at the federal level, with recent es- 1. Wachter RM et al. The emerging role of all potential stakeholders was an standable way. This was especially tablishment of a Medicare specialty “hospitalists” in the American health care system. N Eng J Med. 1996 Aug 15;335(7):514-7. urgent priority. important given the breadth and code designation for hospitalists, 2. SHM’s State of Hospital Medicine Report During its first 5 years, the field of depth of the responsibilities that and support for endeavors such as 2018. Fall 2018. hospital medicine grew rapidly, with NAIP and its’ members were increas- Project Boost, which focused on 3. Satyen N et al. Core competencies in hospi- NAIP membership nearing 2,000 ingly taking on in a rapidly changing patient transitions from hospital tal medicine 2017 Revision. J Hosp Med. 2017 members. The bimonthly newsletter health care system. Additionally, it discharge to home.4-6 Hospitalists Apr;12:S1. The Hospitalist provided a vehicle was a top priority to find a name throughout the United States rou- 4. Society of Hospital Medicine website, Policy to reach out to members and other that would inspire confidence and tinely manage hospitalized patients, & Advocacy homepage. Accessed July 26, 2018. stakeholders, and the annual meet- passion among our members, stir a and now have their specialty exper- 5. CMS manual system, Oct. 28, 2016. Accessed July 26, 2018. ing gave hospitalists a forum to sense of loyalty and pride, and con- tise recognized via Focused Practice 6. Society of Hospital Medicine website, Clinical gather, learn from each other, and tinue to be inclusive. in Hospital Medicine (Internal Medi- Topics: Advancing successful care transitions to enjoy camaraderie. Early research With this in mind, the NAIP board cine and Family Practice), and future improve outcomes. Accessed July 26, 2018. efforts focused on patient safety undertook a process to search for a specialty training and certification 7. American Board of Internal Medicine website, and, just as importantly, in 2002, the new name in the spring of 2002. As for pediatric hospitalists.7,8,9 MOC requirements: Focused practice in hospital medicine. Accessed July 26, 2018. publication of the first Productivity NAIP President-Elect, stewarding The Journal of Hospital Medicine 8. American Board of Family Medicine website, and Compensation Survey (which is the name-change process was my now highlights accomplishments Designation of practice in hospital medicine. now known as SHM’s State of Hospi- responsibility. in hospital medicine research and Accessed July 26, 2018. 10 tal Medicine Report) and the initial In approaching this challenge, we knowledge. Hospitalist leaders 9. The American Board of Pediatrics website, development of The Hospitalist initially evaluated the components frequently are developed through Pediatric hospital medicine certification. Core Competencies (first published of other professional organiza- the SHM Leadership Academy,11 and Accessed July 26, 2018. in 2006, and now in its 2017 revision) tions’ names, including academy, hospitalists increasingly fill diverse 10. Journal of Hospital Medicine official website. Accessed July 26, 2018. all helped define the young special- college, and society among others, health care responsibilities in educa- 2,3 11. SHM Leadership Academy website. Accessed ty and gain acceptance. and whether the specialist name or tion, research, informatics, palliative July 26, 2018. The term hospitalist became professional field was included. We care, performance improvement, and 12. Society of Hospital Medicine website, About mainstream and accepted, and the then held focus groups among re- administration, among many others. SHM membership. Accessed July 26, 2018. the-hospitalist.org | 35 | October 2018 Intensive Caring for a Continued Recovery

When patients are discharged from a traditional hospital they often need continued care. Care that’s led by physicians and offers the extended recovery time that critically, chronically ill patients need.

Our interdisciplinary teams feature daily physician oversight, ICU/CCU-level stafﬁ ng and specially-trained caregivers striving to improve outcomes, reduce costly readmissions and help patients reach their potential.

To learn more about Kindred Hospitals and the success of our patients visit us at www.kindredhospitals.com.

Daily Physician Oversight • ICU/CCU-Level Stafﬁ ng • Reducing Readmissions Intensive Caring.

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