July 2019 FUTURE HOSPITALIST KEY CLINICAL QUESTION IN THE LITERATURE Volume 23 No. 7 Becoming a high-value Gram-negative Complications of p10 care physician p14 bacteremia p18 midline catheters

The hospitalist-led High Value Care team at Mount Sinai Hospital, New York, won the 2019 SHM Teamwork in QI award. (Shared on Twitter by Harry Cho, MD.)

National Hospitalist Day in Pictures

he inaugural National Hospitalist Day was celebrat- practice administrators, C-suite executives, and academic ed on Thursday, March 7, 2019. Occurring the first hospitalists. Thursday in March annually, National Hospitalist In 2019, SHM also launched the first #HowWeHospitalist Day will serve to acknowledge the fastest-growing social media contest. Nearly 1,000 submissions across all so- Tspecialty in modern medicine and hospitalists’ enduring cial media platforms exuded pride and passion for hospital contributions to the evolving health care landscape. medicine. Hospitalists described the contributions they and National Hospitalist Day was approved by the National their colleagues make to improving patient care, what makes Day Calendar and was 1 of approximately 30 national days them proud to be hospitalists, and how they make a differ- to be approved for 2019 out of an applicant pool of more ence in their hospitals and in the lives of their patients. than 18,000. We have collected a selection of these images shared on a In addition to celebrating hospitalists’ contributions to variety of social media platforms. Find more by searching patient care on this date every year, the Society of Hospi- the hashtag #HowWeHospitalist. tal Medicine plans to highlight the varied career paths of Save the date for next year’s National Hospitalist Day: hospital medicine professionals, from frontline hospitalist March 5, 2020! ® physicians, nurse practitioners, and physician assistants to For more images of National Hospitalist Day, see p. 16 the-hospitalist.org

SURVEY INSIGHTS HOSPITALIST INSIGHTS Tierza Stephan, Richard Bottner, MD PA-C

Dealing with staffing The hospitalist role

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PHYSICIAN EDITOR THE SOCIETY OF HOSPITAL MEDICINE Danielle B. Scheurer, MD, SFHM, MSCR; Phone: 800-843-3360 [email protected] Fax: 267-702-2690 PEDIATRIC EDITOR Website: www.HospitalMedicine.org Weijen Chang, MD, FACP, SFHM Laurence Wellikson, MD, MHM, CEO [email protected] Vice President of Marketing & Communications COORDINATING EDITORS Lisa Zoks Dennis Chang, MD [email protected] THE FUTURE HOSPITALIST Marketing Communications Manager Jonathan Pell, MD Brett Radler KEY CLINICAL GUIDELINES [email protected] CONTRIBUTING WRITERS SHM BOARD OF DIRECTORS Rami Abdo, MD; Krystle D. Apodaca, President DNP, FHM; Bibhusan Basnet, MD; Richard Christopher Frost, MD, SFHM Bottner, PA-C; Doug Brunk; President-Elect Sarah J. Burns, MD; Krystal Chan, MD; Danielle Scheurer, MD, MSCR, SFHM Celine Goetz, MD; Jacob G. Imber, MD; Treasurer Aparna Kamath, MD, MS, SFHM; Tracy Cardin, ACNP-BC, SFHM Mary Lacy, MD; Yasmin Marcantonio, MD, Secretary MPH; Shree Menon, DO. MPH; Bianca Rachel Thompson, MD, MPH, SFHM Nogrady;Shyam Odeti, MD, MS, FAAFP, Immediate Past President FHM;Matt Pesyna; Kris Rehm, MD, SFHM; Nasim Afsar, MD, MBA, SFHM Danielle Richardson, MD, MPH; Board of Directors Poonam Sharma, MD, SFHM; Steven B. Deitelzweig, MD, MMM, SFHM Bryce Gartland, MD, FHM Amith Skandhan, MD, SFHM; Flora Kisuule, MD, MPH, SFHM Neil Stafford, MD; Tierza Stephan, MD; Kris Rehm, MD, SFHM Darlene Tad-y, MD; Adam Wachter, MD Mark W. Shen, MD, SFHM Jerome C. Siy, MD, SFHM FRONTLINE MEDICAL Chad T. Whelan, MD, MHSA, FHM COMMUNICATIONS EDITORIAL STAFF FRONTLINE MEDICAL Editor in Chief Mary Jo M. Dales COMMUNICATIONS ADVERTISING STAFF Executive Editors Denise Fulton, VP/Group Publisher; Director, Kathy Scarbeck FMC Society Partners Editor Richard Pizzi Mark Branca Creative Director Louise A. Koenig National Account Managers Director, Production/Manufacturing Valerie Bednarz, 973-206-8954 Rebecca Slebodnik cell 973-907-0230 [email protected] EDITORIAL ADVISORY BOARD Artie Krivopal, 973-206-8218 Geeta Arora, MD; Michael J. Beck, MD; cell 973-202-5402 [email protected] Harry Cho, MD; Marina S. Farah, MD, Classifi ed Sales Representative MHA; Stella Fitzgibbons, MD, FACP, FHM; Heather Gonroski, 973-290-8259 Benjamin Frizner, MD, FHM; [email protected] Nicolas Houghton, DNP, RN, ACNP-BC; Linda Wilson, 973-290-8243 James Kim, MD; Melody Msiska, MD; [email protected] Venkataraman Palabindala, MD, SFHM; Senior Director of Classifi ed Sales Raj Sehgal, MD, FHM; Rehaan Shaffi e, MD; Tim LaPella, 484-921-5001 THE ONLY Kranthi Sitammagari, MD; cell 610-506-3474 [email protected] Amith Skandhan, MD, FHM; Advertising Offi ces 7 Century Drive, HOSPITALIST-FOCUSED Lonika Sood, MD, FACP, FHM; Suite 302, Parsippany, NJ 07054-4609 Amanda T. Trask, FACHE, MBA, MHA, 973-206-3434, fax 973-206-9378 SFHM; Amit Vashist, MD, FACP; LEADERSHIP PROGRAM Jill Waldman, MD, SFHM

THE HOSPITALIST is the official newspaper of the THE HOSPITALIST (ISSN 1553-085X) is published VISIT SHMLEADERSHIPACADEMY.ORG Society of Hospital Medicine, reporting on issues monthly for the Society of Hospital Medicine by and trends in hospital medicine. THE HOSPITALIST Frontline Medical Communications Inc., 7 Century reaches more than 35,000 hospitalists, physician Drive, Suite 302, Parsippany, NJ 07054-4609. Print assistants, nurse practitioners, medical residents, and subscriptions are free for Society of Hospital Medi- health care administrators interested in the practice cine members. Annual paid subscriptions are avail- and business of hospital medicine. Content for able to all others for the following rates: THE HOSPITALIST is provided by Frontline Medical Domestic Communications. Content for the Society Pages is Individual: – $184 (One Year), provided by the Society of Hospital Medicine. $343 (Two Years), $495 (Three Years), Canada/Mexico – $271 (One Year), $489 (Two Years), Copyright 2019 Society of Hospital Medicine. All $753 (Three Years), Other Nations-Surface – $335 rights reserved. No part of this publication may be (One Year), $646 (Two Years), $946 (Three Years), reproduced, stored, or transmitted in any form or by Other Nations - Air – $431 (One Year), any means and without the prior permission in writing $835 (Two Years), $1,264 (Three Years) from the copyright holder. The ideas and opinions expressed in The Hospitalist do not necessarily Institution: United States – $382; reflect those of the Society or the Publisher. The Canada/Mexico – $463 All Other Nations – $537 Society of Hospital Medicine and Frontline Medical Student/Resident: $51 Communications will not assume responsibility for damages, loss, or claims of any kind arising from Single Issue: Current – $35 (US), $47 (Canada/ or related to the information contained in this Mexico), $59 (All Other Nations) Back Issue – $47 publication, including any claims related to the (US), $59 (Canada/Mexico), $71 (All Other Nations) products, drugs, or services mentioned herein. POSTMASTER: Send changes of address (with old Letters to the Editor: [email protected] mailing label) to THE HOSPITALIST, Subscription Services, P.O. Box 3000, Denville, NJ 07834-3000. The Society of Hospital Medicine’s headquarters is located at 1500 Spring Garden, Suite 501, RECIPIENT: To subscribe, change your address, Philadelphia, PA 19130. purchase a single issue, file a missing issue claim, ¨ or have any questions or changes related to your Editorial Offices: 2275 Research Blvd, Suite 400, subscription, call Subscription Services at 1-833-836- Rockville, MD 20850, 240-221-2400, fax 240-221-2548 2705 or e-mail [email protected].

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To learn more about SHM’s relationship with industry partners, visit www.hospitalmedicine.com/industry. July 2019 | 2 | The Hospitalist HOSP_7.indd 1 6/17/2019 4:31:12 PM FROM THE SOCIETY July: An important month for pediatric hospital medicine National conferences and grassroots initiatives

By Kris Rehm, MD, SFHM are also navigating the road ahead. in all who care for patients in the During 2019, the Pediatric Hospi- hospital; we have an active group ach July, the largest gather- talist Special Interest Group (SIG) of advanced-practice providers, ing of pediatric hospitalists of SHM has been working tirelessly practice administrators, residents, occurs, and 2019 is no differ- on several initiatives, including a students, and academic hospital- ent! This year, hospitalists revision of the Pediatric Hospital ists, and the list goes on and on. Ewho care for children will gather at Medicine Core Competencies as We collaborate with a number of Pediatric Hospital Medicine (PHM) well as additional work to develop spectacular societies dedicated to in Seattle from July 25 to 28, with Choosing Wisely 2.0 recommenda- medical specialties, and we are al- the goal of enhancing participants’ tions. These will help us ensure we ways open to new ways of improv- knowledge and competence in the are developing the best curricula ing the methods of delivering care areas of innovation, clinical med- for the next generation of pediatric to patients, in hospitals, post-acute icine, education, health services, hospitalists, while cutting back on care facilities, homes – you name practice management, quality im- unnecessary tests and procedures it! As health care delivery models provement, and research. for those practicing today. Each of continue to evolve, I believe we are well positioned to be leaders in the Having an opportunity to sit on the board of SHM has delivery of acute care medicine in the hospital and beyond. allowed me a chance to really appreciate the efforts I have also learned of happenings Dr. Rehm is associate professor, that this organization invests in all who care for at the grassroots level by attend- pediatrics, and director, division patients in the hospital. ing SHM chapter meetings across of pediatric outreach medicine at the United States. For example, Vanderbilt University and Mon- the Hampton Roads Chapter led roe Carell Jr. Children’s Hospital But what makes this year partic- these initiatives, as well as the July a great Point-of-Care Ultrasound at Vanderbilt, both in Nashville, ularly special is the launch of the conference, highlights the opportu- (POCUS) workshop, and influenced Tenn. She is also a member of the subspecialty exam for certification nities that we have within SHM to by that, I shared an idea at home in SHM board of directors. in pediatric hospital medicine work with other like-minded pro- Nashville – borrowing my son as a coming later this fall, solidifying viders who care for children. While model to demonstrate ultrasound its growth and importance within we partner with all professionals techniques that hospitalists can use provide education and networking hospital medicine and the entire across many organizations, like the to assist in clinical care. I hope you, closer to home. health care landscape. The Amer- American Academy of Pediatrics as pediatric hospitalists, will see if If you can’t attend PHM in Seattle ican Board of Pediatrics (ABP) and the Academic Pediatric Asso- you have a local chapter and attend this year, I hope you will make every has approved PHM as the newest ciation to name a few, I wanted to a meeting; whether you are a mem- effort to be at PHM 2020, where our board subspecialty with a 2-year share my reflections on SHM and ber of SHM or not, you can mingle own SIG leader, Jeffrey Grill, MD, fellowship accredited by the Ac- my appreciation for the “big tent” with those who provide acute care from Louisville, Ky., will be chairing creditation Council for Graduate philosophy that has served us so treatments to all your communities the next rendition of this amazing Medical Education (ACGME). This well thus far. and share best practices. If you conference. The SHM Meetings conference will be a great opportu- Having an opportunity to sit on don’t see an SHM chapter close by, team led by Michelle Kann will be nity to join with others to review the board of SHM has allowed me a let’s get one going! SHM is here to working tirelessly to make it a great competencies for board review, as chance to really appreciate the ef- help launch a chapter that can help event with continued growth in con- well as to network with those who forts that this organization invests bring your community together and tent and attendance.

Hospitalist Movers and Shakers By Matt Pesyna Kai Mebust, MD, was recently named the new as- Pa.). Dr. Bhimani moves over from Suburban sociate chief of medicine at Bassett Hospital (Coo- Community Hospital (Norristown, Pa.), where Christopher Moriates, MD, has been named perstown, N.Y.), where he has worked the past 15 he served as an academic hospitalist the past 2 executive director of the nonprofit health care years as a hospitalist and internist, serving as years. organization Costs of Care (Boston). He replaces chief of hospitalists for the last decade. Dr. Me- Previously, Dr. Bhimani was medical director of Neel Shah, MD, who was tabbed chairperson of bust also completed his internship and residency Kindred/Avalon Hospice and a core faculty mem- the board. at Bassett, and he is a fellow with the Society of ber in the internal medicine program for resi- Dr. Moriates serves a number of roles at the Hospital Medicine. dents at Suburban Community. University of Texas at Austin. He is the assistant Dr. Mebust will work closely with Charles Hy- dean for health care value; associate chair for man, MD, the center’s physician in chief, who is Danielle Prince, MD, was re- quality, safety and value; and associate professor leaving the role at the end of the calendar year. cently named associate medical of internal medicine. Dr. Mebust will oversee inpatient services and be director at St. Luke’s Siouxland In his role at Costs of Care, Dr. Moriates will part of the transition process when Dr. Hyman PACE (Sioux City, Iowa), an direct an organization that uses feedback and departs. affiliate of UnityPoint Health. stories from frontline physicians to help health Dr. Prince is a practicing hospi- systems provide high-quality care at lower Ronak Bhimani, MD, has been appointed chief talist at UnityPoint Health St. costs. medical officer at Lower Bucks Hospital (Bristol, Luke’s and served previously in Dr. Prince July 2019 | 8 | The Hospitalist FROM THE SOCIETY

Survey Insights Dealing with staffing shortfalls Five options for covering unfilled positions

By Tierza Stephan, MD members voluntarily work extra ens is likely because of the willing- shifts, with 91.1% of groups with 30 ness and/or ability of the respective eing in stressful situations or more full-time equivalent posi- groups to afford this option because is part of being a hospitalist. tions employing this tactic. it is generally the most expensive During a hospitalist’s work For HMGs that cover adults only option of those surveyed. shift, one of the key determi- and those that cover children only, Requiring that members of the Bnants of stress is adequate staffing. the second most common tactic is to group work extra shifts is the least With use of survey data from 569 use moonlighters (57.4% and 53.3%, popular staffing method among hospital medicine groups (HMGs) adults-only HMGs (10.0%) across the nation, one of the topics and HMGs serving both chil- examined in the 2018 State of Hos- dren and adults (7.7%). This pital Medicine Report is how HMGs strategy is unpopular, espe- cope with unfilled hospitalist physi- cially when there is little ad- cian positions. vance warning. Surprisingly, The survey presented five options 40.0% of HMGs that see chil- for covering unfilled hospitalist phy- dren only require members sician positions: using locum tenens, to work extra shifts to cover Dr. Stephan is a hospitalist at Alli- use of moonlighters, having the I work with a large HMG that unfilled slots. This could be na Health’s Abbott Northwestern HMG’s existing hospitalists volun- has more than 70 members, because pediatric HMGs are Hospital in Minneapolis and is teer for extra shifts, requiring extra often smaller, and it would a member of the SHM Practice shifts, and leaving some shifts un- and when it has been short- be more difficult to absorb Analysis Committee. covered. Recipients were instructed staffed, it tries to ensure a full the work if the shift is left to select all options that applied, so uncovered. In fact, many totals exceeded 100%. The data are complement of evening and pediatric HMGs staff with ing model of going short-staffed for organized according to HMGs that night staff as the top priority only one clinician at a time, at least some shifts. HMGs serving serve adults only, children only, and so there may be no option children only are much less likely to both adults and children. because these shifts are besides requiring someone go short-staffed (20.0%). For all three types of HMGs, the typically more stressful. else in the group to come in I work with a large HMG that most common tactic to fill coverage and work. has more than 70 members, and gaps is through voluntary extra Of the options surveyed, when it has been short-staffed, it shifts by existing clinicians, report- respectively), while use of moon- perhaps the most uncomfortable for tries to ensure a full complement edly used by 70.3% of HMGs that lighters is the third most commonly those hospitalist physicians on duty of evening and night staff as the cover adults only, 66.7% by those employed surveyed tactic for HMGs is to leave some shifts uncovered. top priority because these shifts that cover children only, and 76.9% that cover both adults and children The rapid growth and development are typically more stressful. Since by those that cover both adults (53.8%). of the specialty of hospital medicine we have more hospitalist capacity and children. Data for adults-only HMGs that serve both adults and has made it difficult for HMGs to during the day to absorb the loss HMGs were further broken down by children were much more likely continuously hire qualified hospi- of a physician, we pull staff from geographic region, academic status, to utilize locum tenens to cover talists fast enough to meet demand. their daytime rounding schedules teaching status, group size, and em- unfilled positions (69.2%) than The survey found 46.2% of HMGs to execute this strategy. While go- ployment model. Among adults-only were groups that serve adults only that serve both adults and children ing short-staffed is not ideal, this HMGs, there is a direct correlation (44.0%) or children only (26.7%). The and 31.4% of groups that serve option has worked for many groups between group size and having variability in the use of locum ten- adults only have employed the staff- out of sheer necessity.

as a family physician while working as chief med- Dr. Rankin came to UNMH after working for Alteon Health (Germantown, Md.) has become ical informatics officer at Mercy Medical Center hospitals in Colorado and Nebraska and is a the manager of hospitalist services for three fa- (Sioux City). founding member of the UNMH patient flow cilities in Maryland and Ohio, including Carroll At Siouxland PACE, Dr. Prince will assist in committee, striving to improve patient care pro- Hospital (Westminster, Md.), Washington Adven- managing the full-service care of elderly patients, cesses throughout the institution. tist Hospital (Takoma Park, Md.), and University including home health, specialty care, medica- Hospitals Cleveland Medical Center. tions, transportation, and other therapies. Tom Guirkin, MD, has been appointed vice pres- At Carroll, Alteon physicians will provide criti- ident of medical affairs for Virginia Common- cal care services in addition to hospitalist duties. Alex Rankin, MD, has been named the new asso- wealth University Community Memorial Hospital Alteon has been Carroll’s emergency medicine ciate chief medical officer for (South Hill, Va.). Dr. Guirkin, a Virginia native, provider for more than two decades. the University of New Mexico returns to his home state after most recently At Washington Adventist, Alteon will take over Health Transfer Center and overseeing the hospitalist group at Saint Francis the hospitalist program, adding to the emergency Patient Throughput in Albu- Health System (Tulsa, Okla.). medicine services it has provided since 1991 and querque. A hospitalist with Dr. Guirkin will have the opportunity to contin- critical care services it has managed since 1996. UNMH’s Family and Commu- ue practicing medicine at CMH while helping to At UH Cleveland, Alteon will assume hospital- nity Medicine department, Dr. manage the quality management side of the busi- ist management at its third University Hospitals Rankin was previously the ness. He received his MBA from Virginia Com- facility. Alteon controls emergency medicine at 14 medical director at the system’s monwealth, working for James River Hospitalist UH locations as well. UH Cleveland is an affiliate 3 North facility since 2014. Dr. Rankin Group in Richmond at the same time. of Case Western Reserve University. the-hospitalist.org | 9 | July 2019 COMMENTARY

The Future Hospitalist Becoming a high-value care physician ‘Culture shift’ comes from collective efforts

By Mary Lacy, MD, and Celine Other ways to avoid low-value time required to discuss treatment Goetz, MD care include following the United plans with patients – it’s much States Choosing Wisely™ campaign, faster to just order the test than t’s Monday morning, and Mrs. which has collected more than 500 to explain why it isn’t needed. Re- Jones still has abdominal pain. specialty society recommendations. search, however, shows that these Your ward team decides to order Likewise, the American College of cost conversations take 68 seconds a CT. On chart review you notice Radiology Appropriateness Criteria on average.4 Costs of Care (see Table Ishe’s had three other abdominal CTs are designed to assist providers with 2) has an excellent video series that for the same indication this year. ordering the appropriate imaging highlights how effective commu- How did this happen? What should tests (for a more extensive list see nication allows for shared decision you do? Table 2). making, which both promotes pa- High-value care has been defined tient engagement and helps avoid by the Institute of Medicine as “the Express your clinical wasteful care. best care for the patient, with the 2 reasoning Physicians’ first instincts are of- optimal result for the circumstanc- One driver of health care expendi- ten defensive when a patient asks es, delivered at the right price.”1 tures that is especially prevalent in for care we perceive as unnecessary. With an estimated $700 billion dol- academia is the pressure to demon- However, exploring what the patient lars – 30% of medical expenditures strate knowledge by recommending hopes to gain from said test or treat- – spent on wasted care, there are extensive testing. While these tests ment frequently reveals concern rising calls for a transformational may rule out obscure diagnoses, for a specific, missed diagnosis or shift.2 they often do not change manage- complication. Addressing this un- You are now asked to consider ment. derlying fear, rather than defending not just everything you can do for a You can still demonstrate a your ordering patterns, can create patient, but also the benefits, harms, mastery of your patients’ care by improved rapport and may serve to and costs associated with those expressing your thought process provide more reassurance than a choices. But where to start? We overtly. For instance, “I considered test ever could.5 recommend that trainees integrate secondary causes of the patient’s As a physician-in-training, try to these tips for high-value care into severe hypertension but felt it was observe others having these conver- their routine practice. most reasonable to first treat her sations and take every opportunity pain and restart her home medica- to practice. By focusing on this key Use evidence-based tions before pursuing a larger work- skill set, you will increase your com- 1 resources that highlight up. If the patient’s blood pressure fort with in-depth discussions on Dr. Lacy is assistant professor value remains elevated and she is hypoka- the value of care. and associate clerkship director A great place to begin is the “Six lemic, we could consider testing for at the University of New Mexico, Things Medical Students and Train- hyperaldosteronism.” If you explain Get involved in a project Albuquerque, as well as division ees Should Question,” originally why you think a diagnosis is less 4 related to high-value care director of high-value care for the published in Academic Medicine and likely and order tests accordingly, While you are developing your division of hospital medicine. Dr. created by Choosing Wisely Cana- others will be encouraged to consid- own practice patterns, you may be Goetz is assistant professor at da™. Recommendations range from er value in their own medical deci- inspired to tackle areas of overuse Rush University Medical Center, avoiding tests or treatments that sion making. and underuse at a more systemwide Chicago. They met as 2015 Co- will not change a patient’s clinical level. If your hospital does not have pello Fellows at the National Phy- course to holding off on ordering Hone your communication a committee for high-value care, per- sician Alliance. Both have been tests solely based on what you as- 3 skills haps a quality improvement leader involved in numerous high-value sume your preceptor will want (see One of the most cited reasons for can support your ideas to launch a care initiatives, curricular develop- the full list in Table 1).3 providing unnecessary care is the project or participate in an ongoing ment, and medical education at initiative. Physicians-in-training their respective institutions. Table 1 have been identified as crucial to Six Things Medical Students and Trainees Should Question these projects’ success – your front- 1. Don’t suggest ordering the most invasive test or treatment before considering line insight can highlight potential tations, and the desire to take action 6 other less invasive options. problems and the nuances of work- “just to be safe.” flow that are key to effective solu- Interestingly, fear of malpractice 2. Don’t suggest a test, treatment, or procedure that will not change the patient’s tions.6 does not seem to dissipate in areas clinical course. where tort reform has provided 3. Don’t miss the opportunity to initiate conversations with patients about whether Embrace lifelong learning stronger provider protections.7 a test, treatment or procedure is necessary. 5 and reflection Practitioners may also inaccurate- 4. Don’t hesitate to ask for clarification on tests, treatments, or procedures that you The process of becoming a physician ly assume a patient’s desire for believe are unnecessary. and of practicing high-value care is additional work-up or treatment.8 5. Don’t suggest ordering tests or performing procedures for the sole purpose of not a sprint but a marathon. Multi- Furthermore, be aware of the role of gaining personal clinical experience. ple barriers to high-value care exist, “commission bias” by which a pro- 6. Don’t suggest ordering tests or treatments pre-emptively for the sole purpose of and you may feel these pressures vider regrets not doing something anticipating what your supervisor would want. differently at various points in your that could have helped a previous career. These include malpractice patient. This regret can prove to be Published with permission of Choosing Wisely Canada™ concerns, addressing patient expec- a stronger motivator than the po- July 2019 | 10 | The Hospitalist COMMENTARY Table 2 tential harm related to unnecessary References High Value Care Resources diagnostic tests or treatments.9 1. Committee on the Learning Health Care Resource: What it offers: While these barriers cannot be System in America, Institute of Medicine. “Best Choosing Wisely™ and Highlights low value care identified by various professional removed easily, learners and provid- Care at Lower Cost: The Path to Continuously Learning Health Care in America.” Edited Choosing Wisely Canada™ societies. All recommendations are best on the best available ers can practice active reflection by by Smith M, Saunders R, Stuckhardt L, and evidence and many of them also have patient pamphlets to help examining their own fears, biases, McGinnis JM (Washington: National Acade- guide discussions with patients. and motivations before and after mies Press, 2013). http://www.ncbi.nlm.nih.gov/ American College of Radiology Evidence-based guidelines intended to assist ordering providers on books/NBK207225/. Appropriateness Criteria® the most appropriate imaging for a specific clinical scenario (i.e. they order additional testing or 2. Berwick DM, Hackbarth AD. Eliminating waste early acute pancreatitis). Also includes relative radiation level of given imaging options. treatment. in US health care. JAMA. 2012;307(14):1513-6. As a physician-in-training, you 3. Lakhani A et al. Choosing Wisely for Medi- ACP/AAIM High Value Care Six-hour curriculum with robust facilitator toolkits targeted towards Curriculum education of internal medicine residents may feel that your decisions do not cal Education: Six things medical students and have a major impact on the health trainees should question. Acad Med. 2016 Dell Medical School Interactive Three freely available interactive online learning modules designed Oct;91(10):1374-8. Learning Modules to help introduce learners to value-based health care. care system as a whole. However, (www.vbhc.dellmed.utexas.edu) the culture shift needed to “bend 4. Hunter WG et al. Patient-physician discus- sions about costs: Definitions and impact on Journal of Hospital Medicine Based on a series of talks by Dr. Leonard Feldman delivered at the the cost curve” will come from the cost conversation incidence estimates. BMC series: Choosing Wisely: Things Society of Hospital Medicine annual meetings. This series appears collective efforts of individuals like Health Serv Res. 2016;16:108. We Do for No Reason in the print issues of the Journal of Hospital Medicine and covers various low value practices. you. Practicing high-value care is 5. van Ravesteijn H et al. The reassuring value not just a matter of ordering few- of diagnostic tests: a systematic review. Patient JAMA Internal Medicine series: Trainee-written series to bring attention to harms that can result Teachable Moment from overuse and underuse based on real patient encounters. er tests – appropriate ordering of Educ Couns. 2012;86(1):3-8. 6. Moriates C, Wong BM. High-value care Healthcare Bluebook™ Resource to find price estimates for procedures or testing based on an expensive test that expedites geographic location. The Fair Price listing is the out-of-pocket programmes from the bottom-up… and the a diagnosis may be more cost ef- reasonable price you should expect your patients to pay based on top-down. BMJ Qual Saf. 2016;25(11):821-3. geographic trends, not necessarily the the price your patient will fective and enhance the quality 7. Snyder Sulmasy L, Weinberger SE. Better care pay. of care provided. Increasing your is the best defense: High-value clinical prac- The NNT This website provides a quick review of some statistics that can own awareness of both necessary tice vs. defensive medicine. Cleve Clin J Med. www.thennt.com help you make high value treatment options: Likelihood Ratios and unnecessary practices is a ma- 2014;81(8):464-7. (LRs) and Number Needed to Treat (NNT). They also review jor step toward realizing system 8. Mulley AG, Trimble C, Elwyn G. Stop the silent various articles to extract the LR or NNT of a given exam misdiagnosis: Patients’ preferences matter. maneuver, test, or treatment. change. Your efforts to resist and re- BMJ. 2012;345:e6572. Costs of Care Various resources for advocacy and education about high value form the medical culture that prop- 9. Scott IA. Cognitive challenges to minimising (www.costsofcare.org) care. Of particular use is the Value Conversations Modules where agates low-value care will encourage low value care. Intern Med J. 2017;47(9):1079- there are recommendations and examples to help you lead conversations with patients and other clinicians. your colleagues to follow suit. 83. Rivaroxaban tied to higher GI bleeding than other NOACs Real-world studies have been limited

By Doug Brunk hospitalized for GI bleeding. They used 1:1 nearest MDedge News neighbor propensity score for matching and Ka- plan-Meier survival estimates and Cox regression to REPORTING FROM DDW 2019 / SAN DIEGO / compare rates of GI bleeding. The study outcome of Patients on rivaroxaban had significantly higher interest was any clinically relevant GI bleeding. rates of GI bleeding, compared with those taking Mr. Ingason reported that the baseline charac- apixaban or dabigatran, results from a large pop- teristics were similar between the rivaroxaban ulation-based study showed. group and the apixaban/dabigatran group. They “This may be due to the fact that rivaroxaban matched for several variables, including age, sex, is administered as a single daily dose as opposed Charlson score, the proportion being anticoagu- to the other two non–vitamin K anticoagulants, lant naive, moderate to severe renal disease, mod- which are given twice daily,” lead study author erate to severe liver disease, any prior bleeding, Arnar B. Ingason said at the annual Digestive Dis- and any prior thrombotic events. ease Week. “This may lead to a greater variance During the study period, 3,473 patients received in plasma drug concentration, making these pa- rivaroxaban, 1,901 received apixaban, and 1,086 re- tients more susceptible to bleeding.” ceived dabigatran. After propensity score match- Mr. Ingason, a medical student at the Universi- ing, the researchers compared 2,635 patients who Mr. Ingason ty of Iceland, Reykjavik, said that, although sev- received rivaroxaban with 2,365 patients who re- eral studies have compared warfarin with novel ceived either apixaban or dabigatran. They found patients in the rivaroxaban group had higher oral anticoagulants (NOACs), it remains unclear that patients in the rivaroxaban group had sig- rates of GI bleeding, compared with the apixaban/ which NOAC has the most favorable GI profile. In nificantly higher rates of GI bleeding, compared dabigatran group, during the entire follow-up pe- an effort to improve the research in this area, he with in the apixaban/dabigatran group (1.2 and. riod. At the end of year 4, the rivaroxaban group and his associates performed a nationwide, pop- 0.6 events per 100 patient-years, respectively). had a 4% cumulative event rate of GI bleeding, ulation-based study during March 2014–January This yielded a hazard ratio of 2.02, “which means compared with 1.8% for the apixaban/dabigatran 2018 to compare the GI bleeding risk of patients re- that patients receiving rivaroxaban are twice as group, a highly significant difference at P = .0057). ceiving rivaroxaban to that of a combined pool of likely to get GI bleeding compared to patients on When a meeting attendee asked Mr. Ingason patients receiving either apixaban or dabigatran. apixaban or dabigatran,” Mr. Ingason said. When why patients taking apixaban or dabigatran were They drew from the Icelandic Medicine Registry, the researchers examined the entire unmatched combined into one group, he said that it was done which contains all outpatient drug prescriptions cohort of patients, the rivaroxaban group also to increase the power of their study. “Our theory in the country. Next, the researchers linked the had significantly higher rates of GI bleeding, com- was that rivaroxaban was different because it is personal identification numbers of patients to pared with the apixaban/dabigatran group (1.0 administered as a single daily dose, while the oth- the Landspitali University diagnoses registry, and 0.6 events per 100 patient-years; HR, 1.75). ers are given twice daily,” he said. The researchers which includes more than 90% of all patients Mr. Ingason and his colleagues observed that reported having no financial disclosures. the-hospitalist.org | 11 | July 2019 CAREER Recertification: The FPHM option ABIM now offers increased flexibility

By Darlene Tad-y, MD option to recertify in internal med- I scheduled my exam through the icine, but with the designation that ABIM portal at a local testing center. veryone always told me that highlighted their clinical practice in The full-day exam consists of four my time in residency would the inpatient setting. sections broken up by lunch and fly by, and the 3 years of The first step in recertification section breaks. Specifically, the 220 internal medicine training for me was deciding to recertify single best answer, multiple-choice Ereally did seem to pass in just a few with the focus in hospital medicine exam covered diagnosis, testing, moments. Before I knew it, I had or maintain the traditional inter- treatment decisions, epidemiology, passed my internal medicine boards nal medicine certification. I talked and basic science content through and practiced hospital medicine at with several colleagues who are also patient scenarios that reflected the an academic medical center. practicing hospitalists and weighed scope of practice of a hospitalist. One day last fall, I received notice their reasons for opting for FPHM. The ABIM provided an exam from the American Board of Internal Ultimately, my decision to pursue a blueprint that detailed the specific Medicine that it was time to recer- recertification with a focus in hospi- clinical topics and the likelihood that tify. I was surprised – had it already tal medicine relied on three factors: a question pertaining to that topic been 10 years? What did I have to do First, my clinical practice since com- Dr. Tad-y would show up on the exam. Content to maintain my certification? pleting residency was exclusively was described as high, medium, or As I investigated what it would in the inpatient setting. Day in and hospital medicine since graduation, low importance and the number of take to maintain certification, I day out, I care for patients who are areas of clinical internal medicine questions related to the content was discovered that the recertification acutely ill and require inpatient med- that I did not frequently encounter 75% for high importance, no more process provided more flexibility, ical care. Second, I wanted my board in my daily practice became less ac- than 25% for medium importance, compared with original board cer- certification to reflect what I consid- cessible in my knowledge base. and no questions for low-importance tification. I now had the option er to be my area of clinical expertise, The next step then was to enter content. In addition, content was dis- to recertify in internal medicine which is inpatient adult medicine. the FPHM Maintenance of Certifica- tributed in a way that was reflective with a Focused Practice in Hospi- Pursuing the FPHM would provide tion (MOC) program. of my clinical practice as a hospital- tal Medicine (FPHM). Beginning in that recognition. Finally, I wanted to The ABIM requires two attesta- ist: 63.5% inpatient and traditional 2014, ABIM offered hospitalists, or study and be tested on topics that I tions to verify that I met the re- care; 6.5% palliative care; 15% consul- internists whose clinical practice is could utilize in my day-to-day prac- quirements to be a hospitalist. First tative comanagement; and 15% quali- mainly in the inpatient setting, the tice. Because I exclusively practiced was a self-attestation confirming ty, safety, and clinical reasoning. at least 3 years of unsupervised Beginning 6 months prior to inpatient care practice experience, my scheduled exam, I purchased and meeting patient encounter two critical resources to guide my Now Available thresholds in the inpatient setting. studying efforts: the SHM Spark The second attestation was from a Self-Assessment Tool and the Amer- “Senior Hospital Officer” confirming ican College of Physicians Medical the information in the self-attesta- Knowledge Self-Assessment Pro- tion was accurate. gram to review subject matter con- Once entered into the program tent and also do practice questions. with an unrestricted medical license The latest version of SHM’s pro- to practice, I had to complete the gram, Spark Edition 2, provides remaining requirements of earning updated questions and resources tai- MOC points, and passing a knowl- lored to the hospital medicine exams. edge-based assessment. I had to ac- I appreciated the ability to answer cumulate 100 MOC points in the past questions online, as well as on my 5 years, which I did through par- phone. Moreover, I was able to track ticipating in QI projects, recording which content areas were stronger or CME credits, studying for the exam, weaker for me, and focus attention Access sessions you missed and even taking the exam. I tracked on areas that needed more work. Im- from home and earn up to 85.5 my point totals through the ABIM portantly, the questions I answered CME and 49.50 MOC credits. Physician Portal, which updated my using the Spark self-assessment Don’t miss the collection of the most tally automatically for activities that tool closely aligned with the subject popular tracks from SHM’s Annual counted toward MOC, such as at- matter I encountered in the exam, as Conference, Hospital Medicine 2019. tending SHM’s Annual Conference. well as the clinical cases I encounter The final component was to pass every day in my practice. the knowledge assessment, the While the day-long exam was chal- dreaded exam. In 2018, I had the op- lenging, I was gratified to receive Accreditation Statement: The Society of Hospital Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to tion to take the 10-year FPHM exam notice that I had successfully recer- provide continuing medical education for physicians. or do a general internal medicine tified in internal medicine with a Fo- Knowledge Check-In. Beginning in cused Practice in Hospital Medicine! 2020, candidates will be able to sit SHM members save $150! for either the 10-year FPHM exam or Dr. Tad-y is a hospitalist at the Univer- Order today. begin the Hospital Medicine Knowl- sity of Colorado at Denver, Aurora, shmannualconference.org/on-demand edge Check-In pathway. I had al- and associate vice chair of quality in ready decided to pursue FPHM and the department of medicine at the began to prepare to sit for an exam. University of Colorado. July 2019 | 12 | The Hospitalist COMMENTARY When do I stop the code? A hospitalist’s dilemma

By Bibhusan Basnet, MD is reasonable) and I have seen it expressed that in a similar scenario last for 50 minutes when the initial he would ask for opinions from oth- had just received my sign-out for rhythm was ventricular fibrillation. er members of the code team. The the day. My pager beeped, and And if perhaps the patient regains role of good communication among I heard it overhead “Code Blue a pulse temporarily, only to lose code team members is necessary to Room X.” Hospitalist physicians it again, we restart the clock. One exchange relevant knowledge in real Ilead the code team in our hospital; I needs to take into account various time in a collaborative, nonhierar- quickly headed to the room. factors including time to CPR, time chical environment. The code team A young man in his forties was to defibrillation, comorbid disease, can provide the team leader with found to be unconscious on the prearrest state, and initial arrest quick, accurate information about floor. One of the nurses had start- rhythm in making these decisions. the patient’s clinical history that is ed cardiopulmonary resuscitation It’s well understood that none of critical to good decision making. (CPR) as the patient was uncon- these factors alone or in combi- Family support is also an essential scious and had no palpable pulse. It nation is clearly predictive of out- part of any resuscitation. Health was a long, drawn-out battle: CPR, come.1 care providers need to offer the cracking bones, shouting, lots of Some selected patients potentially opportunity to be present to family needles – an extreme roller coast- have good outcomes with prolonged, members during the resuscitation er –style situation. The patient had aggressive resuscitation. So when attempts whenever possible. One recently had a hip surgery and our should we stop, and when should team member should be assigned suspicion was a massive pulmonary we continue resuscitation? This to the family to answer questions, embolism. We ran the exhaustive is always challenging. Physicians clarify information, and offer com- code for more than an hour and hate to stop CPR even when they fort, but physicians should not be then I started to debrief with my know it’s time. We are guided by asking family members to decide to Dr. Basnet is a hospitalist physi- code team; discussed that treatment the Hippocratic Oath to save lives. stop the code. It is important to note cian in the department of internal was getting futile and asked for Sometimes, even if we want to stop, that the decision should be made by medicine at Eastern New Mexico opinions. Finally, I asked the team we tend to continue to avoid being the team leader and not the patient’s Medical Center, Roswell. to stop and pronounced the patient criticized for stopping; we are sys- family members. Regardless of the dead. I felt terrible. Later that day I tematically biased against stopping age or condition of the patient, the returned to my house, tossed my bag CPR. We routinely run long codes, in loss of a loved one is difficult to deal in the corner, and sympathized with part because we are not sure which with, even if expected. The issue be- Regardless of the age or myself – “Hello Dr. B, It was a tough patients we can bring back. comes more difficult with changes condition of the patient, one.” A 2012 Lancet study highlighted in legal, cultural, or personal per- Stopping resuscitation was one that the median duration of resus- spectives. the loss of a loved one of the toughest decisions I had ever citation was 12 minutes for patients The AHA in 2018 stated that the is difficult to deal with, made, and I wondered if I would achieving the return of spontaneous treating physician is expected to un- even if expected. The be able to make such a decision the circulation and 20 minutes for non- derstand the patient and the arrest next day. What if I had carried on? I survivors.2 The ethical guidelines is- features, and the system factors that issue becomes more had led code teams during my resi- sued by AHA in 2018 highlight that, have prognostic importance for re- difficult with changes dency training and as an attending in the absence of mitigating factors, suscitation.3 For clinicians who work physician; but there was something prolonged resuscitative efforts for in critical care settings, the frame- in legal, cultural, or different that day. This patient was adults and children are unlikely to work presented by AHA is intuitive. personal perspectives. a young man with no history of be successful and can be discontin- As a code leader, I can always give medical problems. Every physician ued if there is no return of sponta- more epinephrine, try a clot-busting knows how to initiate resuscitation neous circulation at any time during drug, or deliver another shock. Sit- for cardiopulmonary arrest (CPA); 30 minutes of cumulative ACLS. If uations vary greatly during a code, only a few know when to stop it. Did the return of spontaneous circula- and the amount of time spent resus- team leader is to review the events I miss this learning during my in- tion of any duration occurs at any citating a patient before terminating of a code and exercise judgment ternal medicine training? I checked time, however, it may be appropriate efforts is not set in stone. In many while evaluating the length of a my red pocket leaflet with advanced to consider extending the resuscita- cases, it is a judgment call. The pro- code. This can be an intense and cardiac life support (ACLS) algo- tive effort.3 cess of CPR is almost as dishearten- emotional experience, but with rithms, and it had no mention of it. I believe a careful balance of the ing as its bleak outcomes. these principles in mind, we can feel I searched Google Scholar, PubMed, patient’s prognosis for both length In-hospital CPAs are inevitably reassured that we are making the and UpToDate and surprisingly, I of life and quality of life will deter- gruesome. Each day as an attend- best decision possible, for the pa- found no predetermined rule but mine whether continued CPR is ap- ing physician, we are faced with tient, the family, and our team. only a few recommendations on propriate. The responsible clinician difficult decisions, but experienc- when CPR should be stopped. The should stop the resuscitative effort ing these incredibly difficult and References American Heart Association is clear when he or she determines with a life-changing events can make for 1. Part 2: Ethical aspects of CPR and ECC. Circu- that the decision to terminate resus- high degree of certainty that the good learning. A CPA situation in lation. 2000;102(8):I12-21. citative efforts rests with the treat- arrest victim will not respond to action is very difficult for all con- 2. Goldberger ZD et al. Duration of resus- citation efforts and survival after in-hospital ing physician in the hospital. further efforts. But what will help cerned, particularly when there is cardiac arrest: An observational study. Lancet. In my experience, the length of me guide my decisions next time almost no chance of success. But 2012;380(9852):1473-81. time to continue a code can vary if I ever come across this situation an unsuccessful or aborted resus- 3. Sirbaugh PE et al. A prospective, popu- widely and is mostly dependent on again? citation is also a huge loss for both lation-based study of the demographics, epidemiology, management, and outcome the physician running the code. I I discussed my dilemma with one the family and the code team. One of out-of-hospital pediatric cardiopulmonary have seen it last 15 minutes (which of our intensivist physicians; he of the critical functions of the code arrest. Ann Emerg Med. 1999;33(2):174-84. the-hospitalist.org | 13 | July 2019 Key Clinical Question Gram-negative bacteremia: Are we doing it right?

By Jacob G. Imber, MD; Sarah J. Burns, MD; Krystal Chan, MD

Case A 42-year-old woman with uncon- trolled diabetes presents to the ED with fever, chills, dysuria, and flank pain for 3 days. On exam, she is febrile and tachycardic. Lab results show leu- kocytosis and urinalysis is consistent with infection. CT scan shows acute Dr. Imber is an assistant professor in the division of hospital medicine at the pyelonephritis without complication. University of New Mexico, Albuquerque, and director of the Internal Medicine She is admitted to the hospital and ock Simulation Education and Hospitalist Procedural Certification. Dr. Burns is an started on ceftriaxone 2 g/24 hrs. On assistant professor in the division of hospital medicine at the University of New hospital day 2, her blood cultures show Mexico. Dr. Chan is currently a chief resident in the department of internal gram-negative bacteria. medicine at the University of New Mexico. anjurul /T hinks T M

Brief overview bioavailability antibiotics have an increased risk The transition to oral is reasonable given the Management of gram-negative (GN) bacteremia of failure (2% vs. 16%).6 following criteria: the patient has improved on remains a challenging clinical situation for inpa- In their study, Kutob et al. highlighted the im- intravenous antibiotics and source control has tient providers. With the push for high-value care portance of choosing not only an antibiotic of been achieved; the culture data have demonstrat- and reductions in length of stay, recent literature high bioavailability, but also an antibiotic dose ed sensitivity to the oral antibiotic of choice, with has focused on reviewing current practices and which will support a high concentration of the special care given to higher-risk bacteria such as attempting to standardize care. Despite this, no antibiotic in the bloodstream.6 For example, they Pseudomonas; the patient is able to take the oral overarching guidelines exist to direct practice identify ciprofloxacin as a moderate bioavail- antibiotic; and the oral antibiotic of choice has and clinicians are left to make decisions based on ability medication, but note that most cases they the highest bioavailability possible and is given prior experience and expert opinion. Three key examined utilized 500 mg b.i.d., where the con- at an appropriate dose to reach its highest killing clinical questions exist when caring for a hospi- centration-dependent killing and dose-dependent and bioavailability concentrations.7 talized patient with GN bacteremia: Should blood bioavailability would advocate for the use of 750 After evaluating the appropriateness of transi- cultures be repeated? When is transition to oral mg b.i.d. or 500 mg every 8 hours. tion to oral antibiotics, the final decision is about antibiotics appropriate? And for what duration The heterogeneity of GN bloodstream infections duration of antibiotic therapy. Current Infectious should antibiotics be given? also creates difficulty in standardization of care. Disease Society of America guidelines are based The literature suggests that infection source plays on expert opinion and recommend 7-14 days of Overview of the data a significant role in the type of GN bacteria isolat- therapy. As with many common infections, recent When considering repeating blood cultures, it is im- ed.6,7 The best data for the transition to oral anti- studies have focused on evaluating reduction in portant to understand that current literature does biotics exists with urologic sources and it remains antibiotic durations. not support the practice for all GN bacteremias. unclear whether bacteria from other sources have Chotiprasitsakul et al. demonstrated no Canzoneri et al. retrospectively studied GN higher risks of oral antibiotic failure.8 difference in mortality or morbidity in 385 bacteremia and found that it took 17 repeat blood One recent study of 66 patients examined bac- propensity-matched pairs with treatment of En- cultures being drawn to yield 1 positive result, teremia in the setting of cholangitis and found terobacteriaceae bacteremia for 8 versus 15 days.10 which suggests that they are not necessary in that, once patients had stabilized, a switch from A mixed meta-analysis performed in 2011 evalu- all cases.1 Furthermore, repeat blood cultures in- intravenous to oral antibiotics was noninferior, but ated 24 randomized, controlled trials and found crease cost of hospitalization, length of stay, and randomized, prospective trials have not been per- shorter durations (5-7 days) had similar outcomes inconvenience to patients.2 formed. Notably, patients were transitioned to orals to prolonged durations (7-21 days).11 Recently, Ya- However, Mushtaq et al. noted that repeating only after they were found to have a fluoroquino- hav et al. performed a randomized control trial blood cultures can provide valuable information lone-sensitive infection, allowing the study authors comparing 7- and 14-day regimens for uncompli- to confirm the response to treatment in patients to use higher-bioavailability agents for the transi- cated GN bacteremia and found a 7-day course to with endovascular infection. Furthermore, they tion to orals.9 Multiple studies have highlighted the be noninferior if patients were clinically stable by found that repeated blood cultures are also rea- unique care required for certain infections, such as day 5 and had source control.12 sonable when the following scenarios are sus- pseudomonal infections, which most experts agree It should be noted that not all studies have pected: endocarditis or central line–associated requires a more conservative approach.5,6 found that reduced durations are without harm. infection, concern for multidrug resistant GN Fluoroquinolones are the bedrock of therapy Nelson et al. performed a retrospective cohort bacilli, and ongoing evidence of sepsis or patient for GN bacteremia because of historic in vivo analysis and found that reduced durations of decompensation.3 experience and in vitro findings about bioavail- antibiotics (7-10 days) increased mortality and Consideration of a transition from intrave- ability and dose-dependent killing, but they recurrent infection when compared with a longer nous to oral antibiotics is a key decision point in are also the antibiotic class associated with the course (greater than 10 days).13 These contrary the care of GN bacteremia. Without guidelines, highest hospitalization rates for antibiotic-asso- findings highlight the need for provider discre- clinicians are left to evaluate patients on a case- ciated adverse events.8 A recent noninferiority tion in selecting a course of antibiotics as well as by-case basis.4 Studies have suggested that the trial comparing the use of beta-lactams with the need for further studies about optimal dura- transition should be guided by the condition of fluoroquinolones found that beta-lactams were tion of antibiotics. the patient, the type of infection, and the cul- noninferior, though the study was flawed by the ture-derived sensitivities.5 Additionally, bioavail- limited number of beta-lactam–using patients Application of the data ability of antibiotics (see Table 1) is an important identified.8 It is clear that more investigation is Returning to our case, on day 3, the patient’s fe- consideration and a recent examination of oral needed before recommendations can be made re- ver had resolved and leukocytosis improved. In antibiotic failure rates demonstrated that lower garding ideal oral antibiotics for GN bacteremia. the absence of concern for persistent infection, July 2019 | 14 | The Hospitalist CLINICAL | Key Clinical Question

TABLE 1. Penetration of Select Oral Antimicrobials to Tissue Sites

Antimicrobial Bloodstream Bioavailability Lung Liver Urinary Tract Prostate Bone GI Skin Bile CSF Synovial

Ciprofloxacin 70% ++ +++ +++ +++ +++ +++ +++ +++ + +++

Levofloxacin 99% +++ +++ +++ +++ +++ +++ +++ +++ + +++

Moxifloxacin 90% +++ +++ +++ +++ +++ +++ +++ +++ + +++

Trimethoprim-Sulfamethoxazole 90% ++ ++ +++ ++ ++ ++ +++ ++ + ++

Doxycycline 95% ++ ++ ++ ++ ++ ++ ++ ++ + ++

Minocycline 95% ++ ++ ++ ++ ++ ++ ++ ++ + ++

Linezolid 99% +++ ++ +++ ++ ++ ++ +++ ++ ++ ++

Metronidazole 90% ++ +++ ++ ++ ++ ++ ++ ++ ++ ++

Clindamycin 90% ++ ++ ++ ++ ++ ++ ++ ++ + ++

Ampicillin 50% + ++ ++ + ++ ++ ++ ++ ++ +

Penicillin V 50% ++ ++ ++ + ++ ++ ++ ++ ++ +

Amoxicillin 85% + ++ ++ + ++ ++ ++ ++ ++ +

Cephalexin 60% ++ ++ ++ ++ ++ ++ ++ ++ + ++

+++ Tissue concentrations equal to or higher than serum concentrations ++ Tissue concentrations at least 50% of the serum concentrations + Tissue concentrations less than 50% of the serum concentrations Bioavailability represents the percentage of the dose that reaches systemic circulation. Tissue penetration reflects the drug movement from the vascular to the interstitial and intracellular com- partments of a particular body site. Drugs passively diffuse through fenestrated capillaries into the interstitial compartment of most tissues. However, some tissue sites (eg, the brain and pros- tate) contain nonfenestrated capillaries and/or active transport pumps that prevent entry or remove the drug. Tissue concentrations are methodologically dependent on the various techniques used in their quantification, and, in some body sites, are influenced by the presence or absence of inflammation (eg, brain tissue). Thus, the values presented here are best approximations. repeat blood cultures were not 5. Hale AJ et al. When are oral antibiotics a safe and effective choice for bacterial bloodstream performed. On day 4 initial blood infections? An evidence-based narrative review. cultures showed pan-sensitive Esch- J Hosp Med. 2018 May. doi: 10.12788/jhm.2949. erichia coli. The patient was transi- 6. Kutob LF et al. Effectiveness of oral antibiotics tioned to 750 mg oral ciprofloxacin for definitive therapy of gram-negative blood- stream infections. Int J Antimicrob Agents. 2016. b.i.d. to complete a 10-day course doi: 10.1016/j.ijantimicag.2016.07.013. from first dose of ceftriaxone and 7. Tamma PD et al. Association of 30-day mortal- was discharged from the hospital. ity with oral step-down vs. continued intravenous Download the new therapy in patients hospitalized with Enterobac- Bottom line teriaceae bacteremia. JAMA Intern Med. 2019. doi: 10.1001/jamainternmed.2018.6226. Management of GN bacteremia re- 8. Mercuro NJ et al. Retrospective analysis SHM Education app quires individualized care based on comparing oral stepdown therapy for enterobac- clinical presentation, but the data teriaceae bloodstream infections: fluoroquinolo- nes vs. B-lactams. Int J Antimicrob Agents. 2017. presented above can be used as broad doi: 10.1016/j.ijantimicag.2017.12.007. guidelines to help reduce excess blood 9. Park TY et al. Early oral antibiotic switch cultures, avoid prolonged use of intra- compared with conventional intravenous anti- venous antibiotics, and limit the dura- biotic therapy for acute cholangitis with bacter- emia. Dig Dis Sci. 2014;59:2790-6. doi: 10.1007/ tion of antibiotic exposure. s10620-014-3233-0. References 10. Chotiprasitsakul D et al. Comparing the outcomes of adults with Enterobacteriaceae New member 1. Canzoneri CN et al. Follow-up blood cultures bacteremia receiving short-course versus benefit available! in gram-negative bacteremia: Are they needed? prolonged-course antibiotic therapy in a multi- center, propensity score-matched cohort. Clin Clin Infect Dis. 2017;65(11):1776-9. doi: 10.1093/ SHM members can earn up to 20 CME cid/cix648. Infect Dis. 2018;66(2):172-7. doi: 10.1093/cid/ cix767. and MOC credits each year FREE by 2. Kang CK et al. Can a routine follow-up blood 11. Havey TC et al. Duration of antibiotic ther- answering the Question of the Day. culture be justified in Klebsiella pneumoniae apy for bacteremia: a systematic review and bacteremia? A retrospective case-control study. meta-analysis. Crit Care. 2011;15(6):R267. doi: BMC Infect Dis. 2013;13:365. doi: 10.1186/1471- 10.1186/cc10545. 2334-13-365. Accreditation Statement 12. Yahav D et al. Seven versus fourteen days of The Society of Hospital Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to 3. Mushtaq A et al. Repeating blood cultures antibiotic therapy for uncomplicated gram-neg- provide continuing medical education for physicians. after an initial bacteremia: When and how often? ative bacteremia: A noninferiority randomized Cleve Clin J Med. 2019;86(2):89-92. doi: 10.3949/ controlled trial. Clin Infect Dis. 2018 Dec. doi: ccjm.86a.18001. 10.1093/cid/ciy1054. 4. Nimmich EB et al. Development of institu- 13. Nelson AN et al. Optimal duration of hospitalmedicine.org/eduapp tional guidelines for management of gram-neg- antimicrobial therapy for uncomplicated ative bloodstream infections: Incorporating gram-negative bloodstream infections. Infec- local evidence. Hosp Pharm. 2017;52(10):691-7. tion. 2017;45(5):613-20. doi: 10.1007/s15010- doi: 10.1177/0018578717720506. 017-1020-5. the-hospitalist.org | 15 | July 2019 NATIONAL HOSPITALIST DAY

The University of Mississippi Medical Center, Jackson, celebrated its hospitalists on National Hospitalist Day, including our board member Raman Palabindala, MD, SFHM, “for their achieve- ments in research, education, quality improvement & patient care.” John B. Romond, MD, hospitalist and assistant pro- fessor at the University of Kentucky, Lexington, cele- brated National Hospitalist Day with his colleagues.

Nina Lum, MD, a hospitalist and chief quality officer at CHI Saint Joseph London (Ky.) said that “Being a hospitalist facilitated my transition into becoming the Chief Quality Officer. Hospital med- The team of onco-hospitalists at the University of Texas MD Anderson Cancer Center in icine allowed me to grow into this hospital/physi- Houston celebrating National Hospitalist Day. (Shared on Twitter by Josiah K. Halm, MD, cian leader.” MS, FACP, FHM, CMQ, section chief, Hospital Medicine, at MD Anderson.)

Michigan Medicine celebrated its hospitalists in a series of social media posts, like this one: “Twenty years ago, we hired our first #hospitalist. Today, we have 112 of them.” Vinny Arora, MD, MAPP, MHM, shared images on Twitter of some of her University of Chicago hospitalist colleagues acknowledging National Hospitalist Day. July 2019 | 16 | The Hospitalist Register today! academichospitalist.org

Rush Hospital Medicine in Chicago tweeted “Celebrating the 1st ever national #hospitalist day at Journal Club today. Thank you to all of our fab- ulous hospitalists for your hard work and dedication! #HowWeHospitalist”

Which AHA level is right for you?

Level 1 September 9-12, 2019 Primarily designed for junior hospitalists pursuing academic careers, the Academy is an ideal learning resource for experienced hospitalists transitioning to academic medicine, or seeking to:

In celebration of National Hospitalist Day, the Division of Hospital Medi- cine at Cincinnati Children’s Hospital brought a coffee bar to their weekly division meeting. Become effective Create and disseminate Learnn the basicsbasic of QI teachers scholarly work andd patient safetysa

academichospitalist.org/level-1

Septemberber 1010-12, 2019019 NEW! Level 2 This program aims to meet the needs of academicc hospitalists,h spitalist addressing topics critical to all mid-career academics. By the end of Level 2, you will be able to:

Acquire the skills Describe the business Identify and pursue necessary to and cultural landscape a scholarly niche by advance your career of academic healthcare creating an individualized Sarah Marsicek, MD, a pediatric hospitalist at Johns Hopkins All Childrens systems career development plan Hospital in St. Petersburg, Fla., tweeted “Happy National Hospitalist Day! Honored to be training with some of the best.” academichospitalist.org/level-2

the-hospitalist.org | 17 | July 2019 CLINICAL In the Literature Clinician reviews of HM-centric research

By Rami Abdo, MD; Aparna Kamath, MD, MS, SFHM; Yasmin Marcantonio, MD, MPH; Shree Menon, DO, MPH; Danielle Richardson, MD, MPH; Poonam Sharma, MD, SFHM; Neil Stafford, MD; Adam Wachter, MD Division of Hospital Medicine, Duke University Health System, Durham, N.C.

IN THIS ISSUE recommended traditional long reg- results of this trial are encourag- imen? ing, further studies will be needed 1. Early or delayed cardioversion in recent-onset atrial fibrillation BACKGROUND: Multidrug-resis- to find a short, simple regimen for 2. Short medication regimen noninferior to long regimen for rifampin- tant TB is more difficult to treat multidrug- resistant tuberculosis resistant TB than is drug-susceptible TB. The 2011 with improved 3. Evaluating complications of midline catheters World Health Organization (WHO) safety outcomes. 4. Reducing low-value preop care for cataract surgery patients recommendations for the treatment BOTTOM LINE: 5. Patients’ perceptions and high hospital use of multidrug-resistant TB, based on Short medication 6. QI initiative can decrease unnecessary IV treatment of asymptomatic very-low-quality and conditional regimen (9-11 hypertension evidence, consists of an intensive months) is non- 7. Catheter ablation of AFib improves quality of life more than medications treatment phase of 8 months and inferior to the do total treatment duration of 20 traditional WHO- 8. Aspirin and warfarin together leads to increased bleeding without months. Although cohort studies recommended reducing thrombotic events have shown promising cure rates Dr. Kamath long regimen (20 among patients with multidrug-re- months) for treat- sistant TB who received existing ing rifampin-resistant tuberculosis. By Rami Abdo, MD bel study that was not powered drugs in regimens shorter than that CITATION: Nunn AJ et al. A trial of a Early or delayed enough to study harm between the recommended by the WHO, data shorter regimen for rifampin-resis- 1 cardioversion in recent- two strategies. It showed a 30% from phase 3 randomized trials were tant tuberculosis. N Engl J Med. 2019 onset atrial fibrillation incidence of recurrence of AFib lacking. Mar 28; 380:1201-13. regardless of study assignment. Hos- STUDY DESIGN: Randomized phase Dr. Kamath is an assistant professor of CLINICAL QUESTION: Is immediate pitalists should not feel pressured 3 noninferior trial. medicine at Duke University. restoration of sinus rhythm nec- to initiate early cardioversion for SETTING: Multisite, international; essary in early-onset symptomatic new-onset AFib. countries were selected based on By Yasmin Marcantonio, MD, atrial fibrillation (AFib)? Rate control, anti- background disease burden of TB, MPH BACKGROUND: Often atrial fibril- coagulation (if ap- multidrug-resistant TB, and TB-HIV Evaluating complications of lation terminates spontaneously plicable), prompt coinfection (Ethiopia, Mongolia, 3 midline catheters and occasionally recurs; therefore, follow-up, and South Africa, Vietnam). the advantage of immediate electric early discharge SYNOPSIS: 424 patients were CLINICAL QUESTION: What are the or pharmacologic cardioversion over (even from the randomized to the short and long rates of major and minor complica- watchful waiting and subsequent ED) seem to be a medication regimen groups with tions associated with placement of delayed cardioversion is not clear. safe and practical 369 included in the modified in- midline catheters? STUDY DESIGN: Multicenter, ran- Dr. Abdo approach. tention-to-treat analysis and 310 BACKGROUND: Midline catheters domized, open-label, noninferiority BOTTOM LINE: included in the final per protocol have gained popu- trial. In patients presenting with symp- efficacy analysis. The short regimen larity in inpatient SETTING: 15 hospitals in the Neth- tomatic recent-onset AFib, delayed included IV moxifloxacin, clofazi- medical settings erlands (3 academic, 8 nonacademic cardioversion in a wait-and-see mine, ethambutol, and pyrazinamide as a convenient teaching, and 4 nonteaching). approach was noninferior to early administered over a 40-week period, alternative to SYNOPSIS: Randomizing 437 pa- cardioversion in achieving sinus supplemented by kanamycin, isoni- PICC lines. This is tients with early-onset (less than rhythm at 4 weeks’ follow-up. azid, and prothionamide in the first primarily because 36 hours) symptomatic AFib pre- CITATION: Pluymaekers NA et al. 16 weeks, compared with 8 months of the ability to senting to 15 hospitals, the authors Early or delayed cardioversion in re- of intense treatment and total 20 avoid central line– showed that, at 4 weeks’ follow-up, cent-onset atrial fibrillation. N Engl months of treatment in the long associated blood- Dr. Marcantonio a similar number of patients re- J Med. 2019 Apr 18;380(16):1499-508. regimen. At 132 weeks after random- stream infections mained in sinus rhythm whether Dr. Abdo is a hospitalist at Duke ization, cultures were negative for (CLABSI) since these catheters they were assigned to an immediate University Health System. Mycobacterium tuberculosis in more terminate in the peripheral veins cardioversion strategy or to a de- than 78 % patients in both long- and and cannot be reported as such. Ad- layed one where rate control was at- By Aparna Kamath, MD, MS, short-regimen group. Unfavorable ditionally, they are potentially able tempted first and cardioversion was SFHM bacteriologic outcome (10.6%), cardiac to dwell longer than are traditional done if patients remained in fibrilla- Short medication regimen conduction defects (9.9%), and hepa- peripheral intravenous catheters. tion after 48 hours. Specifically the 2 noninferior to long regimen tobiliary problems (8.9%) were more However, insufficient data exist to presence of sinus rhythm occurred for rifampin-resistant TB common in the short-regimen group accurately describe the rate of com- in 94% in the early cardioversion whereas patients in long-regimen plications in these catheters, as prior group and in 91% of the delayed one CLINICAL QUESTION: Can a ran- group were lost to follow-up more studies are based on single-center (95% confidence interval, –8.2 to 2.2; domized trial reproduce results of frequently (2.4%) and had more met- experiences. P = .005 for noninferiority). Both observational cohort studies for abolic disorders (7.1%). More deaths STUDY DESIGN: Multicenter pro- groups received anticoagulation per treating rifampin-resistant tubercu- were reported in the short-regimen spective cohort study. current standards. losis (TB) with a shorter medication group, especially in those with HIV SETTING: Hospital medicine ward or This was a noninferiority, open-la- regimen compared to the WHO- coinfections (17.5%). Although the medical ICU. July 2019 | 18 | The Hospitalist CLINICAL | In the Literature

SYNOPSIS: With use of a large data- and benefits of midline catheter Medicine started the Choosing 95% confidence interval, –80% to base of adult patients from a quality placement in individual cases. Wisely campaign to help educate pa- –62%). Chest x-rays, laboratory tests, initiative supported by Blue Cross BOTTOM LINE: Midline catheter tients and providers about a crisis of and electrocardiograms also had a Blue Shield of Michigan and Blue placement more commonly leads to unnecessary testing and procedures. similar decrease in the intervention Care Network, this study identified minor rather than major complica- This prompted multiple centers to group. 1,161 patients who had midline cathe- tions, though patterns of use and create quality improvement (QI) The intervention hospital lost ters placed and showed a 10.3% com- outcomes vary substantially across projects to decrease low-value care. $42,241 the first year because of plication rate, of which 66.7% were sites. STUDY DESIGN: Observational training costs but 3-year projections minor (dislodgment, leaking, infiltra- CITATION: Chopra V et al. Varia- study of a health estimated $67,241 in savings. The tion, or superficial thrombophlebi- tion in use and outcomes related system quality authors estimated $217,322 savings in tis) rather than major complications to midline catheters: results from a improvement ini- 3 years from a societal perspective. (occlusion, symptomatic upper-ex- multicentre pilot study. BMJ Qual tiative. Interestingly, the decrease in utiliza- tremity deep venous thrombosis, or Saf. 2019 Mar 18. doi: 10.1136/bm- SETTING: Two ac- tion would lead to financial loss in bloodstream infection). However, a jqs-2018-008554. ademic, safety-net fee-for-service payment ($88,151 loss similar rate of removal of the cathe- Dr. Marcantonio is a Med-Peds hospitals in Los in 3 years). ters was reported for major and mi- hospitalist at Duke University Health Angeles. No causal relationship can be nor complications (53.8% vs. 52.5%; System. SYNOPSIS: The established since this was an obser- P = .90). Across sites, there was intervention hos- Dr. Menon vational study. Several assumptions substantial variation in utilization By Shree Menon, DO, MPH pital’s QI nurse were made for the cost analysis. Re- P rates (0.97%-12.92%; less than .001), Reducing low-value preop underwent an extensive formal QI sults are less generalizable since the dwell time and indication for use, 4 care for cataract surgery training program, followed by edu- study was at hospitals in a single and complication rates (3.4%-16.7%; patients cating all health care team members city and health system. It is unclear P = .07). involved in preoperative care for cat- which component of the QI initia- The article does not provide CLINICAL QUESTION: Can a qual- aract patients. New guidelines were tive was most effective. guidance on when and how midline ity improvement project decrease created and circulated, with a stated BOTTOM LINE: A multidisciplinary, catheters should be used in order to low-value, preoperative testing for goal of eliminating routine preoper- multicomponent initiative can be minimize risk; nor does it include a cataract patients? ative visits and testing. The control successful in decreasing low-value comparison with traditional periph- BACKGROUND: Although multiple hospital continued their usual pre- preoperative testing of patients un- eral intravenous catheters or with randomized, controlled trials have operative care. dergoing cataract surgery. Although PICC lines. Further studies are need- shown that routine preoperative Preoperative visits decreased this results in cost savings overall ed to guide indications and practices testing prior to cataract surgery has from 93% to 24% in the interven- and for capitated payment systems, for catheter placement in order to low yield, most Medicare beneficia- tion group and increased from it would actually cause revenue loss minimize risk. Providers should con- ries continue to undergo this test- 89% to 91% in the control group in fee-for-service systems. This em- tinue to carefully consider the risks ing. The American Board of Internal (between-group difference, −71%; Continued on following page

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the-hospitalist.org | 19 | July 2019 CLINICAL | In the Literature

Continued from previous page small sample size located at one sponse calls, ICU transfers, or code Short Takes phasizes a potential barrier to eradi- medical center, creating a data pool blues. Limitations include that this cate low-value care. that is potentially not generalizable is a single-center study and it is un- Vitamin K not recommended CITATION: Mafi JN et al. Evalua- to other medical centers. These clear if the performance improve- for reversal of excessive tion of an intervention to reduce findings, however, are an important ment seen will be vitamin K antagonist in low-value preoperative care for reminder to focus our interventions maintained over nonbleeding patients with patients undergoing cataract sur- with patients’ needs and perceptions time. INR 4.5-10 gery at a safety-net health system. in mind. BOTTOM LINE: Systematic review and meta-anal- JAMA Intern Med. Published online BOTTOM LINE: Frequently hospi- IV antihyper- ysis involving 1,074 participants 2019 Mar 25. doi: 10.1001/jamaint- talized patients have insights into tensive use for provided low- to moderate-quality ernmed.2018.8358. factors contributing to their high asymptomatic hy- evidence in favor of placebo over Dr. Menon is a hospitalist at Duke hospital use. Engaging patients in pertension is com- vitamin K for reversal of excessive University Health System. this discussion can enable us to mon despite lack vitamin K antagonist in nonbleed- create sustainable patient-centered Dr. Sharma of data to support ing patients with an international By Danielle Richardson, MD, programs that avoid rehospitaliza- its use, and re- normalized ratio (INR) of 4.5-10 MPH tion. duced use is possible using quality for outcomes of all-cause mortali- Patients’ perceptions and CITATION: O’Leary KJ et al. Fre- improvement interventions. ty (pooled relative risk, 1.42; 95% 5 high hospital use quently hospitalized patients’ per- CITATION: Jacobs Z et al. Reducing confidence interval, 0.62-2.47), ceptions of factors contributing to unnecessary treatment of asymp- major bleeding (pooled RR, 2.43; CLINICAL QUESTION: What are high hospital use. J Hosp Med. 2019 tomatic elevated blood pressure 95% CI, 0.81-7.27), and thrombo- patients’ perspectives of factors as- Mar 20;14:e1-6. with intravenous medications on embolism (pooled RR 1.29; 95% sociated with the onset and continu- Dr. Richardson is a hospitalist at Duke the general internal medicine wards: CI, 0.35-4.78) and for proportion ation of high hospital use? University Health System. a quality improvement initiative. J of patients who reached goal INR BACKGROUND: A small proportion Hosp Med. 2019 Mar;14(3):144-50. within 1 day of vitamin K adminis- of patients accounts for a large pro- By Poonam Sharma, MD, Dr. Sharma is associate medical tration (pooled RR, 1.95; 95% CI, portion of hospital use and readmis- SFHM director for clinical education in 0.88-4.33). sions. As hospitals and hospitalists QI initiative can decrease hospital medicine at Duke Regional CITATION: Khatib R et al. Vita- focus efforts to improve transitions 6 unnecessary IV treatment of Hospital and an assistant professor of min K for reversal of excessive of care, there is a paucity of data asymptomatic hypertension medicine at Duke University vitamin K antagonist anticoagu- that incorporates . lation: A systematic review and patients’ perspec- CLINICAL QUESTION: How com- By Neil Stafford, MD meta-analysis. Blood Adv. 2019 tives into the mon is treatment of asymptomatic Catheter ablation of AFib Mar 12;3(5):789-96. design of these hypertension in the hospital with IV 7 improves quality of life programs. medications and what is the impact more than medications do ED visits attributable to STUDY DESIGN: of a quality improvement initiative cannabis most commonly Qualitative re- to reduce use? CLINICAL QUESTION: Does cath- associated with inhaled use search study. BACKGROUND: Limited research eter ablation of atrial fibrillation Observational study shows SETTING: North- suggests IV treatment of asymp- (AFib) improve quality of life (QOL) that at a single urban academic Dr. Richardson western Memorial tomatic hypertension may be compared to medication therapy? hospital, visits to the emergency Hospital, a single widespread and unhelpful. There is BACKGROUND: Catheter ablation department attributable at least urban academic medical center in potential for unnecessary treatment of AFib (primarily pulmonary vein in part to cannabis were more Chicago. to have adverse outcomes, such as isolation) has frequently associated with the SYNOPSIS: Eligible patients had hypotension. been shown to inhaled form (90.7%) rather than two unplanned 30-day readmissions STUDY DESIGN: Retrospective co- result in better the edible form (9.3%), though within the prior 12 months in addi- hort study. maintenance of the latter accounted for more tion to one or more of the following: SETTING: A single academic hospi- sinus rhythm visits than expected and a higher at least one readmission in the last tal. than medications. proportion of acute psychiatric 6 months; a referral from a patient’s SYNOPSIS: Of 2,306 inpatients with Small studies of symptoms and intoxication. medical provider; or at least three asymptomatic hypertension, 11% QOL have shown CITATION: Monte AA et al. observation visits. were treated with IV medications mixed results. Acute illness associated with A research coordinator conducted to lower their blood pressure. Pa- Larger trials were Dr. Stafford cannabis use, by route of expo- one-on-one semistructured inter- tients with indications for stricter needed. sure: An observational study. views. Each interview was recorded, blood pressure control (such as STUDY DESIGN: Open-label ran- Ann Intern Med. 2019 Apr transcribed, and then coded using stroke, intracranial hemorrhage, domized multisite clinical trial of 16;170(8):531-7. a team-based approach; 26 patients aortic dissection) were excluded catheter ablation (pulmonary vein completed the interview process. from the study. Following the isolation with additional ablation From the analysis, four major baseline period, an education inter- procedure at the treating physician 36, 48, and 60 months. themes emerged: Major medical vention was employed that includ- discretion) versus standard rate SETTING: 126 centers in 10 countries. problems were universal but high ed presentations, handouts, and and/or rhythm control medications SYNOPSIS: The study included hospital use onset varied; partic- posters. A second phase of quality (chosen by clinician discretion). Pa- 2,204 patients with median age of 68 ipants noted that fluctuations in improvement intervention includ- tients were included for paroxysmal years, diagnosed with AFib a median their course were often related to ed adjustment of the electronic or persistent AFib and either age 65 of 1.1 years prior, who were followed social, economic, and psychological medical record blood pressure alert years or older or age younger than for a median of 48 months. The me- stressors; onset and progression parameters from more than 160/90 65 years with one additional stroke dian CHA2DS2-VASc score was 3.0. of episodes seemed uncontrollable to more than 180/90. After these risk factor. Quality of life surveys Self-reported AFib dropped from and unpredictable; participants interventions, a lower percentage – the Atrial Fibrillation Effect on 86.0% to 21.1% in the ablation group preferred to avoid hospitalization of patients received IV blood pres- Quality of Life (AFEQT) question- and from 83.7% to 39.8% in the and sought care when attempts at sure medications for asymptomatic naire and the Mayo AF-Specific medication group at 12 months. The self-management failed. The major hypertension without a significant Symptom Inventory (MAFSI) – were AFEQT score (range 0-100, higher limitation of this study was the change in the number of rapid re- completed at baseline, and at 3, 12, 24, score indicating better QOL) in- July 2019 | 20 | The Hospitalist CLINICAL | In the Literature

Short Takes While the CABANA trial efficacy tient has another indication for Short Takes study (published separately) showed aspirin such as recent percutaneous TAVR for severe aortic that catheter ablation results in no coronary intervention (PCI) or a Shock index could be used stenosis in low-risk surgical significant difference in the com- mechanical heart valve. These rec- to predict inpatient hospital patients bined outcome of death, disabling ommendations are based on limited admission and mortality Multicenter randomized trial stroke, serious bleeding, or cardiac clinical trial data that showed an Retrospective study of more than demonstrates that, in patients arrest, the CABANA QOL study, increased risk of adverse events 500 million ED visits showed that with severe aortic stenosis who reviewed here, shows that ablation with combination therapy without a shock index (heart rate divid- were at low surgical risk, the does result in improved QOL and clinical benefit. Despite these rec- ed by systolic blood pressure) rate of the composite of death, reduced symptoms, compared with ommendations, recent studies have greater than 1.3 correspond- stroke, or rehospitalization at medical therapy. shown that aspirin use without a ed to a significant increase in 1 year was significantly lower BOTTOM LINE: Catheter ablation of clinical indication remains common the likelihood ratios of hospital with transcatheter aortic valve AFib can be done safely and success- in patients taking admission and inpatient mortal- replacement (TAVR) than with fully at experienced centers. In pa- warfarin for AFib. ity. This metric has traditionally surgery. While TAVR shows prom- tients with AFib-related symptoms, The prevalence of been used as a prognostic tool ise in the low-risk surgical patient, ablation reduces symptoms and aspirin use with- for trauma patients but may have the authors do comment that improves QOL somewhat more than out a clinical indi- some utility in general internal one major limitation of this study medications do. The most severely cation in patients medicine patients presenting to is the short duration of follow-up, symptomatic patients appear to ob- taking warfarin EDs. and caution that conclusions on tain the most benefit. for VTE is less CITATION: Al Jalbout N et al. the advantages and disadvantag- CITATION: Packer DL et al. Effect of well studied. Shock index as a predictor of es of TAVR compared to surgery catheter ablation vs. antiarrhythmic Dr. Wachter STUDY DESIGN: hospital admission and inpatient will depend on long-term follow- drug therapy on mortality, stroke, Registry-based mortality in a US national data- up. bleeding, and cardiac arrest among cohort study. base of emergency departments. CITATION: Mack MJ et al. Trans- patients with atrial fibrillation: The SETTING: Six anticoagulation clinics Emerg Med J. 2019;36:293-7. catheter aortic-valve replace- CABANA Randomized Clinical Tri- in Michigan. ment with a balloon-expandable al. JAMA. 2019 Mar 15. doi: 10.1001/ SYNOPSIS: Of the 6,539 patients valve in low-risk patients. N Engl jama.2019.0693. included in the study, 2,453 patients remains common in patients taking J Med. 2019 May 2;380(18):1695- Dr. Stafford is a hospitalist at Duke (37.5%) were taking both warfarin warfarin for AFib or VTE, and that 705. University Health System. and aspirin without an indication reducing inappropriate aspirin use for aspirin therapy; 3,688 propen- in this patient population may help By Adam Wachter, MD sity score–matched patients (1,844 prevent adverse outcomes. creased from 62.9 to 86.4 in the abla- Aspirin and warfarin in each group) were compared to BOTTOM LINE: Use of aspirin with- tion group and increased from 63.1 8 together leads to increased assess rates of bleeding and rates out a clinical indication in patients to 80.9 in the medication group (for bleeding without reducing of observed thrombosis at 1 year in taking warfarin is common and is a mean difference of 5.3 points [95% thrombotic events patients taking warfarin alone ver- associated with an increased risk of confidence interval, 3.7-6.9; P less sus warfarin plus aspirin. Patients bleeding without significant clinical than .001] favoring ablation). MAF- CLINICAL QUESTION: In patients treated with warfarin plus aspirin benefit. SI symptom frequency score and taking warfarin for atrial fibrillation experienced more bleeding events CITATION: Schaefer JK et al. Associ- symptom severity score also showed (AFib) or venous thromboembolism than did patients on warfarin mono- ation of adding aspirin to warfarin improvement in symptoms favoring (VTE), how often is aspirin used therapy (95% confidence interval, therapy without an apparent indi- ablation. Post hoc subgroup analysis without a clear indication, and what 23.8%-28.3% vs. 95% CI, 18.3%-22.3%; cation with bleeding and other ad- showed that those with the most are the clinical outcomes for these P less than .001). Rates of observed verse events. JAMA Intern Med. 2019 severe symptoms had the largest patients? thrombosis were similar between Mar 4;179(4):533-41. benefit from ablation. BACKGROUND: Current guidelines the two groups (95% CI, 1.6%-3.1% Dr. Wachter is an associate medical The primary limitation is the lack recommend against using aspirin vs. 95% CI, 2.0%-3.6%; P = .40). This director at Duke Regional Hospital of patient blinding (may bias self-re- in combination with warfarin for study demonstrates that aspirin and an assistant professor of ported symptoms). patients with AFib, unless the pa- use without a clinical indication medicine at Duke University. Eosinophil-guided therapy cut corticosteroids in COPD

By Bianca Nogrady exacerbations of COPD. Patients with higher eo- alive and out of hospital. MDedge News sinophilic blood counts were at increased risk of There were 12 more cases of readmission with acute exacerbations but were also more likely to COPD, including three fatalities, in the eosino- FROM LANCET RESPIRATORY MEDICINE / Using benefit from corticosteroid treatment. phil-guided group within the first month. How- eosinophil levels to guide steroid treatment in In the eosinophil-guided therapy arm of the ever the authors said these differences were not patients with chronic obstructive pulmonary study, 159 patients received 80 mg of intravenous statistically significant, but “because the study disease (COPD) was noninferior to standard treat- methylprednisolone on day 1, then from the sec- was not powered to detect differences in this ment in terms of the number of days out of hos- ond day were treated with 37.5 mg of predniso- absolute risk range, we cannot rule out that this pital and alive, new research has found. lone oral tablet daily – up to 4 days – only on days was an actual harm effect from the intervention- Pradeesh Sivapalan, MD, of the University of when their blood eosinophil count was at least al strategy.” Copenhagen, and coauthors reported the out- 0.3 x 10⁹ cells/L. The eosinophil-guided therapy group did show comes of a multicenter, controlled, open-label In the control arm, 159 patients also received 80 more than a 50% reduction in the median dura- trial comparing eosinophil-guided and standard mg of intravenous methylprednisolone on day 1, tion of systemic corticosteroid therapy, which therapy with systemic corticosteroids in 318 pa- followed by 37.5 mg of prednisolone tablets daily was 2 days in the eosinophil-guided group, com- tients with COPD. for 4 days. pared with 5 days in the control group (P less They wrote that eosinophilic inflammation After 14 days, there were no significant differ- than .0001), and the differences between the two had been seen in 20%-40% of patients with acute ences between the two groups for mean days groups remained significant at days 30 and 90. the-hospitalist.org | 21 | July 2019 HM19 REVIEW HM19: One chapter’s experience

By Amith Skandhan, MD, SFHM Avani Parekh, MD I enjoyed each educational session the SHM Annual Conference. I have First year, Internal Medicine Residency that I attended. I felt like I was able been serving in the local chapter he Society of Hospital Medi- Southeast Health Medical Center to bring something home with me during both my 3rd and 4th years cine is an organization vest- Dothan, Ala. that I can incorporate into my prac- in different roles, from helping as ed in improving the quality I am so thankful for the opportu- tice to better care for the patients a student liaison for our medical of inpatient medicine by nity that was given to me by the that I see each students to executive planning coor- Tempowering its members with ed- Wiregrass chapter by sponsoring my day. dinator for events. It was a surprise ucation and providing venues for attendance at the 2019 SHM Annual As mentioned when I got asked by the chapter professional development including Conference in Washington. This was above, I learned to be their student representative, networking, advocacy, and leader- my first SHM conference, and it was from each ses- but one that I was very excited to ship advancement. Every year, SHM truly a rewarding sion, but my accept. holds a national conference which experience. personal favorite This was my first medical con- is a focused meeting point for over I thoroughly was the “Up- ference. I had heard about what 5,000 hospitalists. enjoyed attend- dates in Hospital different conferences were like SHM hosts more than 50 local ing the lectures. Medicine” ses- Ms. Rivenbark from many of my attendings, so I chapters nationwide to increase They were very sion. I was very had some expectations, but this networking, education, and collabo- informative and impressed by the enthusiasm of experience was so much better. I ration within the hospital medicine engaging. Every the two speakers. The information enjoyed meeting community. The Wiregrass chapter presenter was so provided was presented so that it and networking of SHM is based in the southeast Dr. Parekh passionate and engaged each attendee. with people. I corner of Alabama, covering the inspiring. Coming Not only did I learn a wealth of also found myself counties of lower Alabama and the from an “all-female class” of PGY-1 valuable information that will help eagerly waiting panhandle of Florida. This year at my program, I especially enjoyed me in my career, I gained affirma- to get to the next we were recognized as a platinum the “Fe(male) in Medicine” talk, as tion concerning my future educa- lecture because I status chapter, which is the highest well as Quick Talks on women in tional endeavors. I was inspired to was getting an op- status, based on our work and par- medicine. The “Updates in Hospital pursue a higher level of learning portunity to hear ticipation to improve the quality of Medicine” session on various topics regarding my career. I witnessed Mr. Bancroft about different inpatient medicine. such as heart failure, pneumonia, this awesome organization that case studies, new As part of winning the platinum and sepsis was outstanding. I was is filled with encouraging and research outcomes, and new stan- ribbon, we were awarded three com- excited to apply the knowledge I motivating people, and I realized dards of care. plimentary registration scholarships gained from this event into my pa- I wanted to be more involved on a It was a real treat to learn about to the SHM Annual Conference in tient care. local level, and maybe one day, on all the new changes to treatment, 2019. The chapter leadership met Overall, it was a well-organized a larger level. In addition, this con- but even more encouraging to and selected three individuals who and up-to-date event. I am looking ference inspired me to continue to know that most of it was just rein- have been involved with the chap- forward to attending more SHM be a lifetime learner and to always forcing everything my attendings ter actively but have never had an conferences in the future. crave more knowledge. I am blessed have been teaching us as medical opportunity to experience SHM’s to be a part of hospital medicine. I students. I enjoyed my time at the Annual Conference. We selected a Madison Rivenbark, NP look forward to the future of this SHM Annual Conference so much first-year resident, Avani Parrekh, Department of Hospital Medicine specialty. that I emailed all my new coresi- MD; a hospital medicine nurse prac- Southeast Health Medical Center dents and encouraged them to join titioner, Madison Rivenbark, NP; and Dothan, Ala. William Bancroft, MS IV the Society. a fourth-year medical student who is I was extremely fortunate to be se- Alabama College of Osteopathic about to start his internal medicine lected to receive a scholarship that Medicine Dr. Skandhan is a hospitalist at South- residency, William Bancroft, MS IV. covered the conference fee for the Dothan, Ala. east Health Medical Center in Do- After the meeting we interviewed 2019 SHM Annual Conference. This I was honored to have been chosen than, Ala., as well as president and them to better understand their ex- was my first SHM conference, and by the Wiregrass chapter as the founder of the Wiregrass chapter of perience. Below are their thoughts. it was quite the learning experience. medical student representative for SHM. The impact of HM19 on my practice

By Krystle D. Apodaca, DNP, FHM vanced practice provider (APP) insight into variable team structures at other in- hospitalists to give career path stitutions that could be considered for improved As an academic nurse practitioner hospitalist advice. efficiency in my group. The “Academic NP/PA” with faculty and leadership roles, I found that The “Adaptive Leadership for session provided ideas for how to apply for facul- HM19 had many important and helpful topics Hospitalists” workshop provid- ty positions in academic institutions. It also gave that apply directly to my practice. ed the opportunity to practice APPs who have faculty appointment specific The “Onboarding Best Practices” session provid- emotional intelligence and illustrations of using current educational, quality ed specific examples and tips for clinical ramp up, effective communication in improvement, and research projects to promote. enculturation, and orienting staff to an academic managing routine and difficult Dr. Apodaca I particularly found the “What Mentorship Has career. As a result of this talk, I began the process leadership interactions. The Meant to Me” talk significant. It gave practical of establishing a formal enculturation activity “Practice Models/Models of Care for Optimal In- essential advice on making sure there is chemis- for new hires that includes a panel of senior ad- tegration of NPs and PAs” presentation provided Continued on page 24 July 2019 | 22 | The Hospitalist Have you visited the my UNDERSTANDING website lately? invasive fungal infection

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HOSP_23.indd 1 6/18/2019 2:00:02 PM HM19 REVIEW HM19: Sepsis care update

By Shyam Odeti, MD, MS, pliance (2016) for expected care.3 positives. This created a need for the need 30 mL/kg crystalloids. Nor- FAAFP, FHM new Sepsis-3 definition, which used mal saline and lactated ringer are Session summary delta SOFA score of 2 indicating “or- preferred. Lactated ringer has the Presenter Dr. Kritek, of the division of pul- gan failure.” advantage over normal saline, Patricia Kritek MD, EdM monary, critical care, and sleep with a reduced incidence of major Session Title medicine at the University of Key takeaways: Screening adverse kidney events. Sepsis update: From screening to Washington, Seattle, presented to • Sepsis-3 with delta SOFA score • Importance of bundle compliance: refractory shock a room of over 1,000 enthusiastic of at least 2 and Quick SOFA N.Y. study showed use of protocols hospitalists. She was able to cap- (qSOFA) of at least 2 was best at cut mortality from 30.2% to 25.4%. Background ture everyone’s attention with a predicting in-hospital death, ICU Each year 1.7 million adults in great presentation. As sepsis is admission, and long ICU stay in Refractory septic shock America develop sepsis, and 270,000 one of the most ED. • Adding hydrocortisone and flud- Americans die from sepsis annually. common and se- • qSOFA was not helpful in the rocortisone improved mortality at Sepsis costs U.S. health care over $27 rious conditions admitted ICU population. An in- 28 days, helped patients get off va- billion dollars each year. Because we encounter, crease of at least 2 points in SOFA sopressors sooner, and ultimately of the wide range of etiologies and most hospital- score within 24 hours of admission resulted in less organ failure, but variation in presentation and in- ists are fairly to the ICU was the best predictor no difference in 90-day mortality. tensity, it is a challenge to establish well versed in of in-hospital mortality and long • A study of vitamin C use in septic homogeneous evidence-based guide- evidence-based ICU stays. patients needs further studies to lines.1 practices, and • SIRS has high sensitivity and low validate, as it included only 47 pa- The definition of sepsis based on Dr. Kritek was Dr. Odeti specificity. The Early Warning tients. the “SIRS” criterion was developed able to keep us Score has accuracy similar to qSO- • Early renal replacement therapy initially in 1992, later revised as engaged, describing in detail the FA. showed no difference in mortality Sepsis-2 in 2001. The latest Sepsis-3 evolving definition, pathophysi- • Understanding that there is no or length of stay. definition – “life-threatening organ ology, and screening procedures perfect answer regarding screen- dysfunction due to a dysregulated for sepsis. She also spoke about ing, but having a process is vital Dr. Kritek’s presentation made a pos- host response to infection” – was important studies and the latest for each organization. This ap- itive impact by helping to explain developed in 2016 by the Third Inter- evidence that will positively im- proach led to the Surviving Sepsis the reasoning behind the estab- national Consensus Definitions for pact each hospitalist’s practice in Campaign guideline: “Recommend lished and evolving best practices Sepsis and Septic Shock. This new- treating sepsis. health systems have a perfor- and guidelines for care of patients est definition has renounced the Dr. Kritek explained clearly how mance improvement program with sepsis and septic shock. Her SIRS criterion and adopted the Se- the Surviving Sepsis Campaign for sepsis including screening for approach will help hospitalists quential Organ Failure Assessment developed a vital and nontradi- high-risk patients.” provide cost-effective care, by un- (SOFA) score. Treatment guidelines tional guideline that “recommends derstanding which expensive inter- in sepsis were developed by the health systems have a performance Key takeaways: Treatment ventions and practices do not make Surviving Sepsis Campaign starting improvement program for sepsis • Meta-analysis showed that spe- a difference in patient care. with the Barcelona Declaration in including screening for high-risk pa- cifically targeted, early goal–di- 2002 and revised multiple times, tients.” In a 1-hour session, Dr. Kritek rected treatment (specifically, References with the development of 3-hour and did a commendable job untangling central venous pressure 8-12 mm 1. https://www.sepsis.org/wp-content/uploads/ 6-hour care bundles in 2012. The lat- this bewildering health care chal- Hg, central venous oxygen satu- 2017/05/Sepsis-Fact-Sheet-2018.pdf. est revision, in 2018, consolidated to lenge, and aligned each component ration greater than 70%, packed 2. http://www.survivingsepsis.org/News/Pages/ 2 SCCM-and-ACEP-Release-Joint-Statement- a 1-hour bundle. to explain how to best use available red blood cell inotropes used) About-the-Surviving-Sepsis-Campaign-Hour- Sepsis is a continuum of every resources and address sepsis in indi- did not show any improvement 1-Bundle.aspx severe infection, and with the com- vidual hospitals. in 90-day mortality, and actually 3. Specifications Manual for National Hospital bined efforts of the Society of Criti- She talked about the statistics generated worse outcomes, in- Inpatient Quality Measures Discharges 01-01-17 (1Q17) through 12-31-17 (4Q17). cal Care Medicine and the European and historical aspects involved in cluding cirrhosis, as well as high- Society of Intensive Care Medicine, the definition of sepsis, and the er costs of care. evidence-based guidelines have been Surviving Sepsis Campaign. With • Antibiotics: Though part of the Dr. Odeti is hospitalist medical direc- developed over the past 2 decades, three good case scenarios, Dr. Kritek 3-hour bundle, antibiotics are tor at Johnston Memorial Hospital in with the latest iteration in 2018. The explained how it was difficult to recommended to be administered Abingdon, Va. JMH is part of Ballad Centers for Medicare & Medicaid accurately diagnose sepsis using the within 1 hour. Health, a health system operating 21 Services still uses Sepsis-2 for diag- Sepsis-2/SIRS criterion, and how the • Intravenous fluids: Patients with hospitals in northeast Tennessee and nosis, and the 3-hr/6-hr bundle com- SIRS criterion led to several false sepsis-induced hypoperfusion southwest Virginia.

Continued from page 22 and that create excitement for APP practice in Dr. Apodaca is assistant professor and nurse prac- try and trust when seeking a mentor and staying hospital medicine. titioner hospitalist at the University of New Mexico. engaged to be a successful mentee. The Annual Conference also provides the very She is one of the first APPNP/PAs to receive faculty APPs, whether practicing in academic, private, unique opportunity to meet and establish rela- appointment at UNM. She serves as codirector of or community settings, should attend the SHM tionships with APP and physician colleagues and the UNM APP Hospital Medicine Fellowship and Annual Conference. SHM is very inclusive and leaders nationwide. These relationships lend to director of the APP Hospital Medicine Team. She is proud of APPs as colleagues and leaders. There career advancing opportunities for collaboration also the president of the New Mexico Chapter of are topics that directly apply to the needs of APP in clinical excellence, education, quality improve- SHM and is the first APP at her institution to achieve hospitalists – including career advancement – ment, research, and leadership. designation as a Fellow in Hospital Medicine. July 2019 | 24 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

ERIC TAKAHASHI, DO HOSPITAL MEDICINE

JOIN OUR HOSPITALIST TEAM:

■ PIEDMONT NEWTON HOSPITAL Medical Director Covington, GA ■ TENNOVA HEALTHCARE - LEBANON Lebanon, TN ■ GULF COAST MEDICAL CENTER Panama City, FL ■ SPOTSYLVANIA REGIONAL MEDICAL CENTER Fredericksburg, VA ■ NORTHSIDE HOSPITAL & HEART INSTITUTE Critical Care Hospitalist St. Petersburg, FL ■ REGIONAL MEDICAL CENTER AT BAYONET POINT Neuro Hospitalist Tampa Bay, FL

877.265.6869 [email protected]

the-hospitalist.org | 25 | July 2019 Make your next smart move. Visit shmcareercenter.org.

Employment Opportunity in the Beautiful Adirondack Mountains of Northern New York

Current Opening for a full-time, Hospital Employed Hospitalist. This opportunity provides a comfortable 7 on/7 off schedule, allowing ample time to enjoy all that the Adirondacks have to offer! Come live where others vacation!

• Convenient schedules • Competitive salary & benefits • Unparalleled quality of life • Family friendly community • Excellent schools • Nearby Whiteface Mountain ski resort TOWER HEALTH IS HIRING • Home of the 1932 & 1980 Winter Olympics and current Olympic Training Center HOSPITALISTS • Annual lronman Competition • World Cup Bobsled and Ski Events Tower Health is a regional, integrated healthcare system comprised of six acute-care hospitals • Abundant arts community and a network of outpatient facilities providing leading-edge, compassionate healthcare and Hike, fish, ski, golf, boat or simply relax wellness services to a population of 2.5 million people across southeastern Pennsylvania. and take in the beauty and serenity of the Adirondack Mountains We are continuing to expand and are hiring Hospitalists for these locations: Reading Hospital (West Reading, PA), Chestnut Hill Hospital (Philadelphia, PA), and Phoenixville Hospital Contact: Joanne Johnson 518-897-2706 (Phoenixville, PA). [email protected] www.adirondackhealth.org n Board-Certified or Board-Eligible in Internal Medicine n H1b Visa Candidates Accepted n 14 Shifts/Month for Daytime Hospitalists n 12 Shifts/Month for Nocturnists n EMR is EPIC

Post-Acute Hospitalist opportunities are also available at the Tower Health Rehabilitation Hospital located in Wyomissing, PA. Hospitalist What We Offer: Bassett Healthcare Network, a progressive health care network in Central New York and major teaching affiliate of n Competitive Salary with Highly Obtainable Incentive Bonus Columbia University, is seeking a BC/BE Hospitalist to serve n Generous CME Stipend our patient population in Central New York. n Educational Loan and Relocation Assistance • 7 on/7 off Schedule • Highly Ranked Schools n Comprehensive Health Benefits • Closed ICU • Visa Support • Group Employed model • Stress Free Commute n 403(b) and 457(b) Retirement Plans • Full Benefits • Fully Integrated EMR n Claims-Made Malpractice Insurance with Tail Coverage Nestled in the foothills of the Adirondack and Catskill n Spousal/Domestic Partner Job Search Support Mountains, Bassett Medical Center is located in Cooperstown, New York, a beautiful resort village on Otsego Lake. Home to the National Baseball Hall of Fame For more information, contact: and Museum, the Glimmerglass Opera Company, and the Carrie Moore, Physician Recruiter Fenimore Art Museum, the area also boasts many cultural and four season recreational advantages including theater, Phone: 484-628-8153 • [email protected] music, museums, golf, sailing, hiking, and skiing. For confdential consideration, please contact: Joelle Holk, Medical Staff Recruitment Careers.TowerHealth.org EOE phone: 607-547-6982; fax: 607-547-3651: email: [email protected] or visit our web-site at www.experiencebassett.org

Bassett Medical Center provides equal employment opportunities (EEO) to all To learn more, visit www.the-hospitalist.org and employees and applicants for employment without regard to race, color, religion, creed, sex (including pregnancy, childbirth, or related condition), age, national click “Advertise” or contact origin or ancestry, citizenship, disability, marital status, sexual orientation, gender Heather Gonroski • 973-290-8259 • [email protected] or identity or expression (including transgender status), or genetic predisposition or carrier status, military or veteran status, familial status, status a victim of Linda Wilson • 973-290-8243 • [email protected] domestic violence, or any other status protected by law.

July 2019 | 26 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

Hospitalist Opportunity Available Join the Healthcare Team at Berkshire Health Systems!

Berkshire Health Systems is currently seeking BC/BE Internal Medicine physicians to join our comprehensive Hospitalist Department • Day, Evening and Nocturnist positions • Previous Hospitalist experience is preferred Located in Western Massachusetts Berkshire Medical Center is the region’s leading provider of GROW YOUR PHYSICIAN CAREER WITH US comprehensive health care services • 302-bed community teaching hospital with residency programs • Hospitalist Opportunities • • A major teaching affiliate of the University of Massachusetts Medical School and UNECOM Join our dedicated team of physicians providing outstanding care at St. Luke’s • Geographic rounding model University Health Network! • A closed ICU/CCU • A full spectrum of Specialties to support the team We have opportunities available at the following locations: • 7 on/7 off 10 hour shift schedule • PCP/Hospitalist Blend, Schuylkill County We understand the importance of balancing work with a • Hospitalist Float Position healthy personal lifestyle • Located just 2½ hours from Boston and New York City • Full Time Day Hospitalist, Miners Campus • Small town New England charm • Full Time Day Hospitalist, Monroe Campus • Excellent public and private schools • Full Time Day Hospitalist, Quakertown Campus • World renowned music, art, theater, and museums • Year round recreational activities from skiing to kayaking, • Full Time Day Hospitalist, Sacred Heart Campus this is an ideal family location. • Full Time Day Hospitalist, Allentown Campus Berkshire Health Systems offers a competitive salary and benefits • Full Time Day Hospitalist, Orwigsburg, PA (Brand new hospital campus package, including relocation. joining our Network!)

Interested candidates are invited to contact: To learn more about our Hospitalist program, please visit Liz Mahan, Physician Recruitment Specialist, Berkshire Health Systems www.slhn.org/hospitalistcareer 725 North St. • Pittsfield, MA 01201 • (413) 395-7866. Applications accepted online at www.berkshirehealthsystems.org In joining St. Luke’s you’ll enjoy:

• A unique and supportive culture • Unlimited potential for career growth • A collaborative, team oriented approach that serves our community and each other • Attractive location stipends for certain campus positions • Loan repayment program – up to $100,000 • Substantial compensation and a rich benefits package, including malpractice insurance, health and dental insurance, & CME allowance • Work/life balance in a vibrant community Find your • Teaching, research, quality improvement and strategic development opportunities next job today! For more information visit SHMCAREERCENTER.ORG please call:

Jillian Fiorino Physician Recruiter 484-526-3317 [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]

the-hospitalist.org | 27 | July 2019 Make your next smart move. Visit shmcareercenter.org.

Live. Hospitalists and Nocturnists Opportunities Available

Your work is your passion. But it’s not your whole life. Join a system that supports your need to balance work and home life. You can find great dining, art, entertainment, and culture in our cities, as well as peace and quiet in our rural areas. With opportunity for advancement and great schools and colleges nearby, it’s a great place to grow your career and your family. Work . UPMC Pinnacle — a growing, multisite health system in south central Pennsylvania — can meet your needs at one of our seven acute care hospitals.

Join our Hospitalist Team ■ Traditional block and flexible schedules ■ Closed and open ICU environments available with options for procedures and dedicated code teams ■ Competitive salary — above MGMA median salary ■ Additional compensation for nocturnist and ICU coverage Balance. ■ Strong advanced practice provider support at all locations ■ Great administrative and clinical leadership support

Schedule a call with our recruiter today! Contact Rachel Jones, MBA, FASPR Physician Recruiter [email protected] 717-231-8796

UPMCPinnacle.com/Providers

UPMC Pinnacle is an Equal Opportunity Employer. EOE

Hospitalist Opportunities with Penn State Health

Penn State Health is a multi-hospital health system serving patients and communities across central Pennsylvania. We are seeking IM/FM trained physicians interested in joining the Penn State Health family in various settings within our system. What We’re Offering: • Opportunities for both Community based and Academic settings • We’ll foster your passion for patient care and cultivate a collaborative environment rich with diversity • Commitment to patient safety in a team approach model • Experienced hospitalist colleagues and collaborative leadership • Salary commensurate with qualifications • Relocation Assistance What We’re Seeking: • Internal Medicine or Family Medicine trained • Ability to acquire license in the State of Pennsylvania • Must be able to obtain valid federal and state narcotics certificates • Current American Heart Association BLS and ACLS certification required • BE/BC in Family Medicine or Internal Medicine (position dependent) No J1 visa waiver sponsorships available What the Area Offers: Penn State Health is located in Central Pennsylvania. Our local neighborhoods boast a reasonable cost of living whether you prefer a more suburban setting or thriving city rich in theater, arts, and culture. Our surrounding communities are rich in history and offer 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. For more information please contact: Heather J. Peffley, PHR FASPR, Penn State Health Physician Recruiter [email protected]

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

July 2019 | 28 | The Hospitalist 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 you need to focus on the joy of healing. OchsnerOchsner Health System is seeking physicians toto join our We currently have opportunities for hospitalists and hospitalist team. BC/BE Internal Medicine and Family Medicine intensivists at hospitals and skilled nursing practices across the country. Some with sign-on bonuses up to $100,000! physicians are welcomed to apply. Highlights of our opportunities are:  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 • Redding • San Jose hospital patient care is provided across the region by Ochsner’s 29 owned, managed and • Modesto • San Diego • San Mateo affiliated hospitals and more than 80 health centers and urgent care centers. Ochsner is orld Report as a “Best Hospital” Illinois Missouri Oregon across four specialty categories caring for patients from all 50 states and more than 80 • Belleville • St. Louis • Eugene countries worldwide each year. Ochsner employs more than 18,000 employees and over • Greenville 1,100 physicians in over 90 medical specialties and subspecialties, and conducts more than 600 clinical research studies. For more information, please visit ochsner.org and follow us on Interested in travel? Twitter and Facebook. Check out our Reserves Program. Interested physicians should email their CV to [email protected] or call 800-488-2240 for more information. Future leader? Apply for our Administrative Fellowship. Reference # SHM2017. 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 For more information, please contact us at employment without regard to race, color, religion, sex, national origin, sexual orientation, disability [email protected]. status, protected veteran status, or any other characteristic protected by law

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]

the-hospitalist.org | 29 | July 2019 Make your next smart move. Visit shmcareercenter.org.

Hospitalist & Nocturnist Opportunities in SW Virginia & NE Tennessee

Ballad Health, located in Southwest Virginia and Northeast Tennessee, is Full time positions with the following incentives: currently seeking Full Time, BE/BC, Day Shift Hospitalists and Nocturnist  Hospitalists to join its team. Hospital Employed (earning potential, exceeding $300K per year)  Day and Nocturnist Shifts (7 days on – 7 days off) Qualified candidates will work within Ballad Health Facilities and will need  Competitive Annual Salary an active Virginia and/or Tennessee license, depending on facility location.  Performance Bonus & Production Bonus  Excellent Benefits  Generous Sign On Bonus Facilities:  Relocation Assistance Ballad Health Southwest Virginia  Teaching and Faculty Opportunities with System Residency Programs Johnston Memorial Hospital, Russell County Medical Center, Smyth County  Critical Care Physician Coverage in most of the facilities CCU/PCUs Community Hospital, Norton Community Hospital, Mountain View Regional  Opportunity to Participate in Award-Winning Quality Improvement Projects Medical Center, Lonesome Pine Hospital

Ballad Health Northeast Tennessee Johnson City Medical Center, Holston Valley Medical Center, Bristol Regional Medical Center and Hawkins County Memorial Hospital

Please Contact: Ballad Health Physician Recruitment 800-844-2260 [email protected]

Med/Peds Hospitalist Opportuniti es Available Join the Healthcare Team at Berkshire Health Systems

Berkshire Health Systems is currently seeking BC/BE Med/Peds physicians to join our comprehensive Hospitalist Department • Day and Nocturnist positions DAYTIME & NIGHTTIME • Previous Med/Peds Hospitalist experience is preferred • Leadership opportunities available HOSPITALISTS Located in Western Massachusetts Berkshire Medical Center is the region’s leading provider of comprehensive health care services • Comprehensive care for all newborns and pediatric inpatients including: Long Island, NY. NYU Winthrop Hospital, a 591-bed, o Level Ib nursery university-affiliated medical center and an American College o 7 bed pediatrics unit of Surgeons (ACS) Level 1 Trauma Center based in Western o Care for pediatric patients admitted to the hospital Nassau County, NY is seeking BC/BE internists for academic • Comprehensive adult medicine service including: Hospitalist positions. o 302-bed community teaching hospital with residency programs o Geographic rounding model To advertise in o A closed ICU/CCU Ideal candidates will have exemplary clinical skills, a strong or the o A full spectrum of Specialties to support the team interest in teaching house staff and a long term commitment The Hospitalist o A major teaching affi liate of the University of Massachusetts Medical to inpatient medicine. Interest in research and administration Journal of Hospital Medicine School and University of New England College of Osteopathic Medicine a plus. Salaried position with incentive, competitive benefits • 7 on/7 off 12 hour shift schedule package including paid CME, malpractice insurance and vacation. We understand the importance of balancing work with a healthy personal lifestyle DRIVEN TO BE • Located just 2½ hours from Boston and New York City CONTACT: • Small town New England charm Interested candidates, please the best. • Excellent public and private schools email CV and cover letter to: Heather Gonroski [email protected] • World renowned music, art, theater, and museums 973.290.8259 • Year round recreational activities from skiing to kayaking, this is an ideal or fax to: (516) 663-8964 family location. Ph: (516) 663-8963 [email protected] Attn: Vice Chairman, Dept of Medicine-Hospital Operations Berkshire Health Systems offers a competitive or salary and benefi ts package, including relocation. An EOE m/f/d/v Linda Wilson Interested candidates are invited to contact: 973.290.8243 Liz Mahan, Physician Recruitment Specialist, Berkshire Health Systems NYU Winthrop Hospital is located in the heart of Nassau 725 North St. • Pittsfield, MA 01201 • (413) 395-7866. County in suburban Long Island, 30 miles from NYC and [email protected] Applications accepted online at www.berkshirehealthsystems.org just minutes from LI’s beautiful beaches. July 2019 | 30 | The Hospitalist Hospitalist Insights The hospitalist role in treating opioid use disorder Screen patients at the time of admission

By Richard Bottner, PA-C The number needed to treat with buprenorphine to prevent return to illicit opioid use is two.9 While et’s begin with a brief case. A 25-year-old pa- physicians require an 8-hour “x-waiver” training tient with a history of injection heroin use is (physician assistants and nurse practitioners in your care. He is admitted for treatment of require a 24-hour training) to prescribe buprenor- endocarditis and will remain in the hospital phine for the outpatient treatment of OUD, such Lfor intravenous antibiotics for several weeks. Over certification is not required to order the medica- the first few days of hospitalization, he frequently tion as part of an acute hospitalization. asks for pain medicine, stating that he is in severe Hospitalization represents a reachable moment pain and withdrawal, with opioid cravings. On day and unique opportunity to start treatment for 3, he leaves the hospital against medical advice. Af- OUD. Patients are away from triggering environ- ter 2 weeks, he presents to the ED in septic shock ments and surrounded by supportive staff. Un- and spends several weeks in the ICU. Or, alterna- fortunately, up to 30% of these patients leave the tively, he is found down in the community and hospital against medical advice because of inad- pronounced dead from a heroin overdose. equately treated withdrawal, unaddressed crav- These cases occur all too often, and hospitalists ings, and fear of mistreatment.10 Buprenorphine across the nation are actively building knowledge therapy may help tackle the physiological piece and programs to improve care for patients with of hospital-based treatment, but we also must Mr. Bottner is a hospitalist at Dell Seton Med- opioid use disorder (OUD). It is evident that opioid work on shifting the culture of our institutions. ical Center, Austin, Tex., and clinical assistant misuse is the public health crisis of our time. In Importantly, OUD is a medical diagnosis. These professor at the University of Texas at Austin. 2017, over 70,000 patients died from an overdose, patients must receive the same dignity, autonomy, and over 2 million patients in the United States and meaningful care afforded to patients with have a diagnosis of OUD.1,2 Many of these patients other medical diagnoses. Patients with OUD are Disorder Special Interest Group, which was recent- interact with the hospital at some point during not “addicts,” “abusers,” or “frequent fliers.” ly approved by the SHM board of directors. Details the course of their illness for management of over- Hospitalists have a clear and compelling role in on its rollout will be announced shortly. The inten- dose, withdrawal, and other complications of OUD, treating OUD. The National Academy of Medicine tion is that this group will serve as a resource to including endocarditis, osteomyelitis, and skin and recently held a workshop where they compared SHM membership and leadership soft tissue infections. Moreover, just 20% of the similarities of the HIV crisis with today’s opioid As practitioners of hospital medicine, we may 580,000 patients hospitalized with OUD in 2015 epidemic. The Academy advocated for the devel- not have anticipated playing a direct role in treat- presented as a direct sequelae of the disease.3 Pa- opment of hospital-based protocols that empower ing patients’ underlying addiction. By empowering tients with OUD are often admitted for unrelated physicians, physician assistants, and nurse practi- hospitalists and wisely using medical hospitaliza- reasons, but their addiction goes unaddressed. tioners to integrate the treatment of OUD into their tion as a time to treat OUD, we can all have an in- Opioid use disorder, like many of the other practice.11 Some in our field may feel that treating credible impact on our patients. Let’s get to work. conditions we see, is a chronic relapsing remitting underlying addiction is a role for behavioral health medical disease and a risk factor for premature practitioners. This is akin to having said that HIV References mortality. When a patient with diabetes is ad- specialists should be the only providers to treat 1. Katz J. You draw it: Just how bad is the drug overdose mitted with cellulitis, we might check a hemo- patients with HIV during its peak. There are simply epidemic? New York Times. https://www.nytimes.com/interac- tive/2017/04/14/upshot/drug-overdose-epidemic-you-draw-it. globin A1c, provide diabetic counseling, and offer not enough psychiatrists or addiction medicine html. Published Oct 26, 2017. evidence-based diabetes treatment, including specialists to treat all of the patients who need us 2. National Institute on Drug Abuse. Ohio – Opioid summaries by medications like insulin. We rarely build similar during this time of national urgency. state. 2018. https://d14rmgtrwzf5a.cloudfront.net/sites/default/ systems of care within the walls of our hospitals There are several examples of institutions that files/ohio_2018.pdf. to treat OUD like we do for diabetes or other are laying the groundwork for this important 3. Peterson C et al. U.S. hospital discharges documenting patient opioid use disorder without opioid overdose or treat- commonly encountered diseases like heart failure work. The University of California, San Francisco; ment services, 2011-2015. J Subst Abuse Treat. 2018;92:35-9. doi: and chronic obstructive pulmonary disease. Oregon Health & Science University, Portland; 10.1016/j.jsat.2018.06.008. We should be intentional about separating the University of Colorado at Denver, Aurora; 4. Guy GP. Vital Signs: Changes in opioid prescribing in the United prevention from treatment. Significant work has Rush Medical College, Boston; Boston Medical States, 2006-2015. Morb Mortal Wkly Rep. 2017;66. doi: 10.15585/ mmwr.mm6626a4. gone into reducing the availability of prescription Center; the Icahn School of Medicine at Mount 5. Chen Q et al. Prevention of prescription opioid misuse and opioids and increasing utilization of prescription Sinai, New York; and the University of Texas at projected overdose deaths in the United States. JAMA Netw drug monitoring programs. As a result, the av- Austin – to name a few. Offering OUD treatment Open. doi: 10.1001/jamanetworkopen.2018.7621. erage morphine milligram equivalent per opioid in the hospital setting must be our new and only 6. Liebschutz J et al. Buprenorphine treatment for hospitalized, prescription has decreased since 2010.4 An unin- acceptable standard of care. opioid-dependent patients: A randomized clinical trial. JAMA Intern Med. 2014;174(8):1369-76. tended consequence of restricting legal opioids What is next? We can start by screening patients 7. Moreno JL et al. Predictors for 30-day and 90-day hospital read- is potentially pushing patients with opioid addic- for OUD at the time of admission. This can be mission among patients with opioid use disorder. J Addict Med. tion toward heroin and fentanyl. Limiting opioid accomplished by asking two questions: Does the 2019. doi: 10.1097/ADM.0000000000000499. prescriptions alone will decrease opioid overdose patient misuse prescription or nonprescription opi- 8. Larochelle MR et al. Medication for opioid use disorder after mortality by only 5% through 2025.5 Thus, treat- oids? And if so, does the patient become sick if they nonfatal opioid overdose and association with mortality: A cohort ment of OUD is critical and something that hos- abruptly stop? If the patient says yes to both, steps study. Ann Intern Med. Jun 2018. doi: 10.7326/M17-3107. pitalists should be trained and engaged in. should be taken to provide direct and purposeful 9. Raleigh MF. Buprenorphine maintenance vs. placebo for opioid dependence. Am Fam Physician. 2017;95(5). https://www.aafp. Food and Drug Administration–approved OUD care related to OUD. Hospitalists should become org/afp/2017/0301/od1.html. Accessed May 12, 2019. treatment includes buprenorphine, methadone, familiar with buprenorphine therapy and work to 10. Ti L et al. Leaving the hospital against medical advice among and extended-release naltrexone. Buprenorphine reduce stigma by using people-first language with people who use illicit drugs: A systematic review. Am J Public is a partial opioid agonist that treats withdrawal patients, staff, and in medical documentation. Health. 2015;105(12):2587. doi: 10.2105/AJPH.2015.302885a. and cravings. Buprenorphine started in the hos- As a society, we should balance our past focus on 11. Springer SAM et al. Integrating treatment at the intersec- tion of opioid use disorder and infectious disease epidemics in pital reduces mortality, increases time spent in optimizing opioid prescribing with current efforts medical settings: A call for action after a National Academies of outpatient treatment after discharge, and reduces to bolster treatment. To that end, a group of SHM Sciences, Engineering, and Medicine workshop. Ann Intern Med. opioid-related 30-day readmissions by over 50%.6-8 members applied to establish a Substance Use 2018;169(5):335-6. doi: 10.7326/M18-1203. the-hospitalist.org | 31 | July 2019 Make some noise! Introducing 100% Paid Parental Leave for HM Clinicians.

At US Acute Care Solutions, our HM clinicians receive 100% Paid Parental Leave to ensure they get the time they need to be with their family and the financial support they deserve.Birth mothers receive eight weeks of paid time off at 100 percent pay, and another four weeks at 50 percent. Adoptive or surrogate parents, fathers, partners and spouses also get paid time off. As partners of one of the largest and fastest growing physician-owned groups in the nation, we are one family, united in our mission to care for our patients and each other.

Discover the difference ownership makes at USACS. Visit usacs.com/benefits

Visit USACS.com/HMcareers or call us at 1-844-863-6797. [email protected]

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