April 2021 POLICY KEY CLINICAL QUESTION IN THE LITERATURE Volume 25 No. 4 Hospitalists engaging Checking EKGs in patients Screening for p8 in advocacy efforts p18 starting antipsychotics p24 postoperative delirium

Dr. Reginaldo Filho (left) leads the hospitalist team at Hospital São Vicente in Curitiba, Brazil.

Courtesy Hospital são ViCente, Curitiba Hospital medicine growing around the globe Similar needs, local adaptations

By Larry Beresford around the world in the U.S. model of hospital medicine. But adaptations of that model vary across – and within – ospital medicine has evolved rapidly and spread countries, reflecting local culture, health care systems, pay- widely across the United States in the past 25 ment models, and approaches to medical education. years in response to the health care system’s Other countries have looked to U.S. experts for consul- needs for patient safety, quality, efficiency, and tations, to U.S.-trained doctors who might be willing to Heffective coordination of care in the ever–more complex relocate, and to the Society of Hospital Medicine as an environment of the acute care hospital. internationally focused source of networking and other re- ® But hospital care can be just as complex in other coun- sources. Some U.S.-based institutions, led by the Cleveland the-hospitalist.org tries, so it’s not surprising that there’s a lot of interest Continued on page 22

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01_22_23_HOSP21_04.indd 1 3/23/2021 8:24:55 AM NEWS April 2021 Volume 25 No. 4

Heart failure redefined PHYSICIAN EDITOR THE SOCIETY OF HOSPITAL MEDICINE Weijen W. Chang, MD, SFHM, FAAP Phone: 800-843-3360 [email protected] Fax: 267-702-2690 Website: www.HospitalMedicine.org with new PEDIATRIC EDITOR Anika Kumar, MD, FHM, FAAP Chief Executive Officer [email protected] Eric E. Howell, MD, MHM classifications, staging COORDINATING EDITORS Alan Hall, MD Director of Communications

The FuTure hospiTalisT Brett Radler [email protected] By Debra L. Beck comprehensive, with near universal Keri Holmes-Maybank, MD, FhM applicability, prognostic and thera- inTerpreTing DiagnosTic TesTs Communications Specialist he terminology and classi- peutic viability, and acceptable sen- CONTRIBUTING WRITERS Caitlin Cowan Debra L. Beck; Larry Beresford; [email protected] fication scheme for heart sitivity and specificity.” Jeff Craven; Magna Dias, MD; failure (HF) is changing in Both left and right HF qualifies Perry H. Dubin, MD, MPH; SHM BOARD OF DIRECTORS ways that experts hope will under this definition, but conditions Kevin Dunsky, MD; President Tdirectly impact patient outcomes. that result in marked volume over- Marcia Frellick; Danielle Scheurer, MD, MSCR, SFHM Jennifer Heinen, MD; President-Elect In a new consensus statement, a load, such as chronic kidney disease, Michael Hession, MD; Jerome C. Siy, MD, SFHM multisociety group of experts pro- which may present with signs and Douglas J. Koo, MD, MPH, FHM; Treasurer posed a new universal definition of symptoms of HF, do not. Omar Mirza, DO; Rachel Thompson, MD, MPH, SFHM Caleb Rans, PharmD; Secretary heart failure and made substantial “Although some of these patients Samantha Platt; David Portnoy, MD; Kris Rehm, MD, SFHM revisions to the way in which the may have concomitant HF, these pa- Sarah Ludwig Rausch; Immediate Past President disease is staged and classified. tients have a primary abnormality David W. Rawson, MD; Christopher Frost, MD, SFHM Brian Rice; Diana Swift; Board of Directors The authors of the statement, led that may require a specific treat- Amanda Trask, MBA, MHA, FACHE, SFHM, Tracy Cardin, ACNP-BC, SFHM by writing committee chair and im- ment beyond that for HF,” said the FACMPE; Steven B. Deitelzweig, MD, mediate past president of the Heart consensus statement authors. Miriam E. Tucker MMM, FACC, SFHM Bryce Gartland, MD, FHM FRONTLINE MEDICAL Failure Society of America Biykem Overall, minimal changes have Flora Kisuule, MD, MPH, SFHM COMMUNICATIONS EDITORIAL STAFF Bozkurt, MD, PhD, hope their efforts been made to the HF stages, with Mark W. Shen, MD, SFHM Executive Editor Kathy Scarbeck, MA will go far to improve standard- tweaks intended to enhance under- Darlene Tad-y, MD, SFHM Editor Richard Pizzi Chad T. Whelan, MD, FACP, FHM ization of terminology, but more standing and address the evolving Creative Director Louise A. Koenig importantly will facilitate better role of biomarkers. Director, Production/Manufacturing Rebecca Slebodnik FRONTLINE MEDICAL management of the disease in ways The authors proposed an ap- COMMUNICATIONS ADVERTISING STAFF that keep pace with current knowl- proach to staging of HF: EDITORIAL ADVISORY BOARD Senior Director Business Development Hyung (Harry) Cho, MD, SFHM; edge and advances in the field. • At-risk for HF (stage A), for patients Angelique Ricci, 973-206-2335 Marina S. Farah, MD, MHA; cell 917-526-0383 [email protected] “There is a great need for refram- at risk for HF but without current Ilaria Gadalla, DMSc, PA-C; Classified Sales Representative ing and standardizing the terminol- or prior symptoms or signs of HF James Kim, MD; Heather Gonroski, 973-290-8259 Ponon Dileep Kumar, MD, FACP, CPE; [email protected] ogy across societies and different and without structural or biomark- Shyam Odeti, MD, MS, FHM; stakeholders, and importantly for pa- ers evidence of heart disease. Venkataraman Palabindala, MD, SFHM; Linda Wilson, 973-290-8243 [email protected] tients because a lot of the terminol- • Pre-HF (stage B), for patients with- Tiffani M. Panek, MA, SFHM, CLHM; Adhikari Ramesh, MD, MS; Senior Director of Classified Sales ogy we were using was understood out current or prior symptoms or Raj Sehgal, MD, FHM; Tim LaPella, 484-921-5001 by academicians, but were not being signs of HF, but evidence of struc- Kranthi Sitammagari, MD; cell 610-506-3474 [email protected] translated in important ways to en- tural heart disease or abnormal Amith Skandhan, MD, FHM; Advertising Offices 7 Century Drive, Lonika Sood, MD, FACP, FHM; Suite 302, Parsippany, NJ 07054-4609 sure patients are being appropriately cardiac function, or elevated natri- Amit Vashist, MD, FACP treated,” said Dr. Bozkurt, of Baylor uretic peptide levels. 973-206-3434, fax 973-206-9378 College of Medicine, Houston. • HF (stage C), for patients with cur- The consensus statement was a rent or prior symptoms, signs of THE HOSPITALIST is the official newspaper of the THE HOSPITALIST (ISSN 1553-085X) is published Society of Hospital Medicine, reporting on issues monthly for the Society of Hospital Medicine by group effort led by the HFSA, the HF caused by a structural and/or and trends in hospital medicine. THE HOSPITALIST Frontline Medical Communications Inc., 7 Century Heart Failure Association of the Eu- functional cardiac abnormality. 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- ropean Society of Cardiology, and the • Advanced HF (stage D), for patients health care administrators interested in the practice cine members. Annual paid subscriptions are avail- Japanese Heart Failure Society, with with severe symptoms and/or signs and business of hospital medicine. Content for able to all others for the following rates: THE HOSPITALIST is provided by Frontline Medical endorsements from the Canadian of HF at rest, recurrent hospital- Communications. Content for the Society Pages is Individual: Domestic – $195 (One Year), Heart Failure Society, the Heart Failure izations despite guideline-directed provided by the Society of Hospital Medicine. $360 (Two Years), $520 (Three Years), Canada/Mexico – $285 (One Year), $525 (Two Years), Association of India, the Cardiac Soci- management and therapy (GDMT), Copyright 2021 Society of Hospital Medicine. All $790 (Three Years), Other Nations - Surface – $350 ety of Australia and New Zealand, and refractory or intolerant to GDMT, rights reserved. No part of this publication may be (One Year), $680 (Two Years), $995 (Three Years), reproduced, stored, or transmitted in any form or by Other Nations - Air – $450 (One Year), $875 (Two the Chinese Heart Failure Association. requiring advanced therapies such any means and without the prior permission in writing Years), $1,325 (Three Years) The article was published in the as consideration for transplant, from the copyright holder. The ideas and opinions expressed in The Hospitalist do not necessarily Institution: United States – $400; Journal of Cardiac Failure (doi: mechanical circulatory support, or reflect those of the Society or the Publisher. The Canada/Mexico – $485 All Other Nations – $565 10.1016/j.cardfail.2021.01.022), authored palliative care. Society of Hospital Medicine and Frontline Medical Student/Resident: $55 Communications will not assume responsibility for by a committee of 38 individuals with For his part, Douglas L. Mann, MD, damages, loss, or claims of any kind arising from Single Issue: Current – $35 (US), $45 (Canada/ domain expertise in HF, cardiomyopa- of Washington University, St. Louis, or related to the information contained in this Mexico), $60 (All Other Nations) Back Issue – $45 publication, including any claims related to the (US), $60 (Canada/Mexico), $70 (All Other Nations) thy, and cardiovascular disease. is happy to see what he considers a products, drugs, or services mentioned herein. POSTMASTER: Send changes of address (with old “[HF] is a clinical syndrome with more accurate and practical defini- Letters to the Editor: [email protected] mailing label) to THE HOSPITALIST, Subscription Services, P.O. Box 3000, Denville, NJ 07834-3000. symptoms and or signs caused by a tion for heart failure. The Society of Hospital Medicine’s headquarters structural and/or functional cardiac “We’ve had some wacky definitions 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, abnormality and corroborated by in heart failure that haven’t made or have any questions or changes related to your elevated natriuretic peptide levels sense for 30 years,” said Dr. Mann, 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]. and/or objective evidence of pulmo- who was not involved with the writ- nary or systemic congestion.” ing of the consensus statement. BPA Worldwide is a global industry resource for verified audience data and This proposed definition, said the The Hospitalist is a member. authors, is designed to be contem- A version of this article first To learn more about SHM’s relationship with industry partners, visit www.hospitalmedicine.com/industry. porary and simple “but conceptually appeared on Medscape.com. April 2021 | 2 | The Hospitalist

02_thru_11_HOSP21_04.indd 2 3/22/2021 3:28:49 PM HOSP_07.indd 1 7/21/2020 3:39:30 PM

ELUH20CDNY1932_M15_VTE_Hosp_JrnlAd_KING_BS_FM.indd 2 7/20/20 12:47 PM POLICY Making a difference Hospitalists engaging in advocacy efforts

By Sarah Ludwig Rausch Colorado Coalition for the Homeless of Diversity, Equity, and Inclusion impact and that I must accept that to start a joint task force. “Everyone for the department of pediatrics what I do and what I say may have ospitalists around the on our task force is motivated by at Children’s Hospital Los Angeles, unintended consequences,” he said. country are devoting large this powerful desire to improve the where he is also the division head of “When that happens, I must resist portions of their spare time health and lives of this community pediatric hospital medicine. “I was becoming defensive and instead be to a wide range of advocacy and that’s one of the silver linings in motivated to apply for this position willing to listen and learn.” Hefforts. From health policy to care for this pandemic for me,” she said. because I wanted to be an agent for Dr. Bryant is proud of his accom- the unhoused population to diversity Advocacy work has also increased change to eliminate the institutional plishments and enjoys his advocacy and equity to advocation for fellow Dr. Stella’s knowledge of what com- racism, social injustice, and margin- work. In his workplace, there are hospitalists, these physicians are pas- munity support options are avail- alization that continues to threaten few African Americans in leadership sionate about their causes and deter- able for the unhoused. This allows the lives and well-beings of so many roles. This means that he is in high mined to make a difference. demand when it comes to making sure there’s representation during Championing the unhoused I absolutely could not be a hospitalist various processes such as hiring and Sarah Stella, MD, FHM, a hospital- without“ being an advocate. For me, it vetting, a disparity known as the ist at Denver Health, was initially has been a protective strategy in terms “minority tax.” drawn there because of the popu- “I am thankful for the opportuni- lation the hospital serves, which of burnout because I have to feel like I’m ties, but it does take a toll at times,” includes a high concentration of working to advocate for better policies Dr. Bryant said, which is yet another people experiencing homelessness. reason why he is a proponent of As she cared for her patients, Dr. Dr. Stella and more appropriate resources … increasing diversity and inclusion. Stella, who is also associate pro- ” “This allows us to build the resource fessor of hospital medicine at the her to educate patients about their Americans,” Dr. Bryant said. pool as these needs arise and min- University of Colorado, increasingly options and how to access them. Between the pandemic, the eco- imizes the toll of the ‘minority tax’ felt the desire to help prevent the While she has colleagues who nomic decline it has created, and on any single person or small group negative downstream outcomes the are able to compartmentalize their the divisive political landscape, of individuals.” hospital sees. work, “I absolutely could not be a people of color have been especially This summer, physicians from Dr. To understand the experiences hospitalist without being an advo- affected. “These are poignant ex- Bryant’s hospital participated in the of the unhoused outside the hospi- cate,” Dr. Stella said. “For me, it has amples of the ever-widening divide national “White Coats for Black Lives” tal, Dr. Stella started talking to her been a protective strategy in terms and disenfranchisement many effort. He found it to be “an incredibly patients and people in communi- of burnout because I have to feel Americans feel,” said Dr. Bryant. moving event” that hundreds of his ty-based organizations that serve colleagues participated in. this population. “I learned a ton,” Dr. Bryant’s advice for hospitalists she said. “Homelessness feels like Advocacy means that I acknowledge that who want to get involved in advoca- such an intractable, hopeless thing, “intent does not equal impact and that I cy efforts is to check out the movie but the more I talked to people, the “John Lewis: Good Trouble.” “He more opportunities I saw to work must accept that what I do and what I say was a champion of human rights toward something better.” may have unintended consequences. … I and fought for these rights until his This led to a pilot grant to work death,” Dr. Bryant said. “He is a true with the Colorado Coalition for the must resist becoming defensive and instead American hero and a wonderful ex- Homeless to set up a community ad- be willing to listen and learn. Dr. Bryant ample.” visory panel. “My goal was to better ” understand their experiences and to like I’m working to advocate for “Gandhi said, ‘Be the change that Bolstering health care change develop a shared vision for how we better policies and more appropriate you want to see,’ and that is what I Since his residency, Joshua Lenchus, collectively can do better,” said Dr. resources to address the gaps that want to model.” DO, FACP, SFHM, has developed an Stella. Eventually, she also received a I’m seeing.” At work, advocacy for diversity, ever-increasing interest in legisla- grant from the University of Colora- Dr. Stella believes that physicians equality, and inclusion is an innate tive advocacy, particularly health do, and multiple opportunities have have a special credibility to advo- part of everything he does. From the policy. Getting involved in this arena sprung up ever since. cate, tell stories, and use data to new physicians he recruits to the requires an understanding of civics For the past several years, Dr. Stel- back their stories up. “We have to candidates he considers for leader- and government that goes beyond la has worked with Denver Health realize that we have this power, and ship positions, Dr. Bryant strives “to just the basics. leadership to improve care for the we have it so we can empower oth- have a workforce that mirrors the “My desire to effect change in my homeless. “Right now, I’m working ers,” she said. “The people I’ve seen diversity of the patients we humbly own profession really served as the with a community team on develop- in my community who are working care for and serve.” catalyst to get involved,” said Dr. ing an idea to provide peer support so hard to help people who are ex- Advocacy is intrinsic to Dr. Bry- Lenchus, the regional chief medical from people with a shared lived periencing homelessness are the he- ant’s worldview, in his quest to officer at Broward Health Medi- experience for people who are expe- roes. Understanding that and giving understand and accept each in- cal Center in Fort Lauderdale, Fla. riencing homelessness when they’re power to those people through our dividual’s uniqueness, his desire “What better way to do that than by hospitalized. That’s really where my voice and our well-respected place “to embrace cultural humility,” his combining what we do on a daily ba- passion has been in working on the in society drives me.” recognition that “our differences sis in the practice of medicine with partnership,” she said. enhance us instead of diminishing this new understanding of how laws Her advocacy role has been ben- Strengthening diversity, equity, us,” and his willingness to engage in are passed and promulgated?” eficial in her work as a hospitalist, and inclusion difficult conversations. Dr. Lenchus has been involved particularly when COVID began. In September 2020, Michael Bryant, “Advocacy means that I acknowl- with both state and national medi- Dr. Stella again partnered with the MD, became the inaugural vice chair edge that intent does not equal cal organizations and has served on April 2021 | 8 | The Hospitalist POLICY public policy committees as a mem- finished in 2015, Louisiana became ber and as a chair. “The charge of a Medicaid expansion state. This these committees is to monitor and We need to come together as a specialty impressed upon Dr. Newby how navigate position statements and “and make a decision, which is going to much Medicaid improved the lives policies that will drive the entire of patients who had previously been organization,” he said. This means be hard because there are competing uninsured. “We saw procedures get- becoming knowledgeable enough financial interests and various practice ting done that had been put on hold about a topic to be able to talk about models. because of financial concerns or it eloquently and adding supporting Dr. Vora medicines that were now affordable personal or professional illustra- ” that weren’t before,” she said. “It re- tions that reinforce the position to Questioning co-management ists are performing tasks that make ally did make a difference.” lawmakers. practices them feel they aren’t adding value. “I When repeated attempts to repeal He finds his advocacy efforts Though he says he’s in the minority, think that’s a huge topic in hospital the Affordable Care Act began, “it “incredibly rewarding” because Hardik Vora, MD, SFHM, medical medicine right now.” was a call to do health policy work they contribute to his endeavors director for hospital medicine at Dr. Vora believes there should be for me personally that just hadn’t “to help my colleagues practice Riverside Regional Medical Center more discussion and awareness of come up in the past,” said Dr. New- medicine in a safe, efficient, and in Newport News, Va., believes that the potential pitfalls. “Hospitalists by, who is also assistant professor productive manner.” For instance, co-management is going to “make or should get involved in co-manage- of medicine at Tulane University in some of the organizations Dr. break hospital medicine. It’s going to ment where they are adding value New Orleans. “I personally found Lenchus was involved with helped have a huge impact on our specialty.” and certainly not take up the at- that the best way to do (advocacy make changes to the Affordable In the roughly 25-year history of tending responsibility where they’re work) was to go through medical so- Care Act that ended up in its final hospital medicine, it has evolved from not adding value and it’s out of the cieties because there is a much stron- version, as well as changes after it admitting and caring for patients of scope of their training and exper- ger voice when you have more people passed. “There are tangible things primary care physicians to patients tise,” he said. “Preventing scope saying the same thing,” she said. that advocacy enables us to do in of specialists and, more recently, sur- creep and burnout from co-manage- Dr. Newby sits on the Council of our daily practice,” he said. Legislation for the Louisiana State When something his organiza- Medical Society and participates in tions have advocated for does not I think being involved in advocacy the Leadership and Health Policy pass, they know they need to try a efforts“ really helps people conduct (LEAHP) Program through the Soci- different outlet. “You can’t win every ety of General Internal Medicine. fight,” he said. “Every time you go meaningful work and educates them The LEAHP Program has been and comment on an issue, you have about what it means not just to them, but instrumental in expanding Dr. New- to understand that you’re there to do by’s knowledge of how health policy your best, and to the extent that the to the rest of the medical profession and is made and the mechanisms behind people you’re talking to are willing Dr. Lenchus the patients that we serve. it. It has also taught her “how we to listen to what you have to say, ” can either advise, guide, leverage, or that’s where I think you can make gical patients. “Now there are (hos- ment are some of the key issues I’m advocate for things that we think the most impact.” When changes pital medicine) programs across the really passionate about.” would be important for change and he has helped fight for do pass, “it country that are pretty much admit- Dr. Vora said it is important to set moving the country in the right di- really is amazing that you can tell ting everything,” said Dr. Vora. realistic goals and remember that it rection in terms of health care.” your colleagues about your role in As a recruiter for the Riverside takes time to make change when it Another reason involvement in achieving meaningful change in the Health System for the past eight comes to advocacy. “You still have to medical societies is helpful is be- profession.” years, “I have not met a single resi- operate within whatever environ- cause, as a busy clinician, it is im- Dr. Lenchus acknowledges that dent who is trained to do what we’re ment is given to you and then you can possible to keep up with everything. advocacy “can be all-consuming at doing in hospital medicine, because make change from within,” he said. “Working with medical societies, you times. We have to understand our you’re admitting surgical patients His enthusiasm for co-manage- have people who are more direct- limits.” That said, he thinks not en- all the time and you have primary ment awareness has led to creating a ly involved in the legislature and gaging in advocacy could increase attending responsibility,” Dr. Vora co-management forum through SHM can give you quicker notice about stress and potential burnout. “I said. “I see that as a cause of a sig- in his local Hampton Roads chapter. things that are coming up that are think being involved in advocacy nificant amount of stress because He was also a panelist for an SHM going to be important to you or your efforts really helps people conduct now you’re responsible for some- webinar last February in which the co-workers or your patients,” Dr. meaningful work and educates thing that you don’t have adequate panelists debated co-management. Newby said. them about what it means not just training for.” “I think we really need to look at Dr. Newby feels her advocacy to them, but to the rest of the medi- In the co-management discussion, this as a specialty. Are we going in work is an outlet for stress and “a cal profession and the patients that Dr. Vora notes that people often bring the right direction?” Dr. Vora asked. way to work at more of a macro we serve,” he said. up the research that shows that the “We need to come together as a spe- level on problems that I see with my For hospitalists who are interest- practice has improved surgeon sat- cialty and make a decision, which is individual patients. It’s a nice com- ed in health policy advocacy, there isfaction. “What bothers me is that … going to be hard because there are plement.” At the hospital, she can are many ways to get involved, you need to add one more question competing financial interests and help only one person at a time, but Dr. Lenchus said. You could join – how does it affect your hospitalists? various practice models.” with her advocacy efforts, there’s an organization (many organized And I bet the answer to that question potential to make changes for many. medical societies have public policy is ‘it has a terrible effect.’ ” Improving patient care “Advocacy now is such a large committees), participate in advo- The expectations surrounding Working as a hospitalist at Universi- umbrella that encompasses so many cacy activities, work on a political hospitalists these days is a big con- ty Medical Center, a safety-net hos- different projects at all kinds of campaign, or even run for office cern in terms of burnout, Dr. Vora pital in New Orleans, Celeste Newby, levels,” Dr. Newby said. She suggests yourself. “Ultimately, education and said. “We talk a lot about the drivers MD, PhD, sees plenty of patients who looking around your community some level of involvement really of burnout, whether it’s schedule or are underinsured or not insured at to see where the needs lie. If you’re will make the difference in who COVID,” he said. The biggest issue all. “A lot of my interest in health pol- passionate about a certain topic or navigates our future as hospital- when it comes to burnout, as he sees icy stems from that,” she said. population, see what you can do to ists,” he said. it, is not COVID; it’s when hospital- During her residency, which she help advocate for change there. the-hospitalist.org | 9 | April 2021 NATIONAL HOSPITALIST DAY The skill set of the ‘pluripotent’ hospitalist Wellness has become a critical issue during the pandemic

By Jeff Craven knowledge-based care coordination, and interpersonal skills as lanes If we connect to our purpose – ‘what are hospitalist isn’t just a where she can focus and improve. we“ doing here and how do we connect?’ physician who happens to “I’m always trying to work in, and work in a hospital. They sharpen, and find ways to get better – it’s either learning about patients and are medical professionals at something in each of those every their stories, being with a team of people Awith a robust skill set that they use day,” she said. that you work with, that really builds both inside and outside the hospital For Anika Kumar, MD, FHM, setting. But what skill sets do hos- FAAP, pediatric editor of the Hospi- Dr. Dhaliwal that purpose. pitalists need to become successful talist and clinical assistant profes- ” in their careers? And what skill sets sor of pediatrics at the Cleveland I love my clinical time. It’s one of my does a “pluripotent” hospitalist need Clinic Lerner College of Medicine, in their armamentarium? much of her work is focused on favorite“ things that I do. I feel like I am These were the issues discussed problem solving. “I approach that not only giving back to my patients and by participants of a virtual round- as: ‘How do I come up with my dif- table discussion on National Hospi- ferential diagnosis, and how do I my team, but I’m also giving back to talist Day – March 4, 2021 – as part diagnose the patient?’ I think that myself and reminding myself why it is I do of a joint effort of the Society of the lanes are a little bit different, what I do every day. Hospital Medicine and the Explore but there is some overlap.” Dr. Kumar the Space podcast. Adaptability is another important ” Maylyn S. Martinez, MD, clinician- part of the skill set for the hospital- researcher and clinical associate ist, Ndidi Unaka, MD, MEd, associate I think we always have a hard time at the University of Chicago, sees professor in the division of hospital leaving“ work at work and getting a good her hospitalist and research skill medicine at Cincinnati Children’s night’s sleep. I just could not let go of sets as two “buckets” of skills she Hospital Medical Center, said during can sort through, with diagnostic, the discussion. “I think we all really worrying about these patients and having value teamwork, and we take on the terrible insomnia, trying to leave work at Editor’s note role of being the coordinator and making sure things are getting done Dr. Martinez work and I couldn’t. National Hospitalist Day occurs in a seamless and thoughtful man- ” the first Thursday in March an- ner. Communicating with families, for the hospitalist” and how they Dr. Martinez said. Her time is spent nually, and serves to celebrate the communicating with our research can achieve a sense of wellness for 75% as a researcher and 25% as a fastest growing specialty in mod- team, communicating with primary themselves. Gurpreet Dhaliwal, MD, clinician, which is her ideal balance. ern medicine and hospitalists’ care physicians. I think that is some- clinician-educator and professor “I enjoy doing my research, doing my enduring contributions to the thing we’re very used to doing, and I of medicine at the University of own statistics and writing grants evolving health care landscape. think we do it well. I think we don’t California, San Francisco, said long- and just learning about this problem On National Hospitalist Day in shy away from difficult conversa- term satisfaction in one’s career is that I’ve developed an interest in,” 2021, SHM convened a virtual tions with consultants. And I think less about compensation and more she said. “I just think that’s an im- roundtable with a diverse group that’s what makes being a hospital- about autonomy, mastery, and pur- portant piece for people to focus on of hospitalists to discuss skill set, ist so amazing.” pose. as far as health care for the hospi- wellness, and other key issues. “Autonomy is shrinking a little talist, is that there’s no no-one-size- On the following pages, we also State of wellness for a bit in health care. But if we con- fits-all, that’s for sure.” highlight the work of two hospi- hospitalist nect to our purpose – ‘what are Dr. Kumar noted that her clinical talist clinician-educators. Another topic discussed during the we doing here and how do we con- time gives her energy for nonclin- roundtable was “comprehensive care nect?’ – it’s either learning about ical work. “I love my clinical time. patients and their stories, being It’s one of my favorite things that I with a team of people that you do,” she said. Although she is tired work with, that really builds that at the end of the week, “I feel like purpose,” he said. I am not only giving back to my Regarding mastery, there’s “tre- patients and my team, but I’m also mendous joy if you’re in an envi- giving back to myself and remind- ronment where people value your ing myself why it is I do what I do mastery, whether it is working in every day,” she said. a team or communicating or di- Wellness for Dr. Unaka meant agnosing or doing a procedure. If remembering what drew her to you think of setting up the work medicine. “It was definitely the op- environment and those things are portunity to build strong relation- in place, I think a lot of wellness ships with patients and families,” can actually happen at work, even she said. While these encounters can though another component, of sometimes be heavy and stay with a course, is balancing your life outside hospitalist, “the fact that we’re in it

maGeS of work,” Dr. Dhaliwal said. with them is something that gives a i

etty This may seem out of reach lot of us purpose. I think that when

S/G during COVID-19, but wellness is I reflect on all of those things, I’m so jelic

D still achievable during the pandemic, happy that I’m in the role that I am.” April 2021 | 10 | The Hospitalist

02_thru_11_HOSP21_04.indd 10 3/22/2021 3:30:00 PM NATIONAL HOSPITALIST DAY

It is important to acknowledge that, as“ hospitalists who have been out on the I learned – really from seeing some of bleeding edge for a year, mental health is our“ senior leaders here do it so well – the critically important, and we know that we importance of being visible, particularly at face shortages in that space for the public a time when people were not together and more isolated. Dr. Shapiro at large and also for our profession.” ” Dr. Unaka Unique skills during COVID-19 and a sense of community. I really unit, who had already seen patients for her, Dr. Kumar referenced the Mark Shapiro, MD, hospitalist and learned how important it was to be with COVID-19, helped ground him need for exercise, meditation, and host of the roundtable and the visible, and available, and how im- during those moments and gave him yoga. “My mental health was better Explore the Space podcast, also portant the little things mattered.” the courage to move forward. “They’d knowing that the people closest to asked the panelists what skills they Dr. Martinez said that worrying already been doing it and they were me – whether they be colleagues unexpectedly leveraged during the about her patients with COVID-19 the same. Same affect, same jokes, or friends or family – their mental pandemic. Communication – with in the hospital and the uncertainty same everything,” he said. “That actu- health was also in a good place and colleagues and with the community around the disease kept her up at ally really helped, and I’ve leaned on they were also in a good place. And they serve – was a universal answer night. “I think we always have a that every time I’ve been back on our that helped to build me up,” she said. among the panelists. hard time leaving work at work and COVID service.” Dr. Unaka called attention to “I learned – really from seeing getting a good night’s sleep. I just the stigma around mental health, some of our senior leaders here do could not let go of worrying about Importance of mental health particularly among physicians, and it so well – the importance of being these patients and having terrible The COVID-19 pandemic has also the lack of resources to address the visible, particularly at a time when insomnia, trying to leave work at shined a light on the importance issue. “It’s a real problem,” she said. people were not together and more work and I couldn’t – even after they of mental health. “I think it is im- “I think it’s at a point where we as a isolated,” Dr. Unaka said. “I think were discharged.” portant to acknowledge that, as profession need to advocate on be- being able to be visible when you Dr. Shapiro said the skill he most hospitalists who have been out on half of each other and on behalf of can, in order to deliver really com- needed to work on during the pan- the bleeding edge for a year, mental our trainees. And honestly, I think plicated or tough news or communi- demic was his courage. “I remember health is critically important, and we we need to view mental health as cate about uncertainty, for instance. the first time I took care of COVID know that we face shortages in that just ‘health’ and stop separating Being here for our residents – many patients. I was scared. I have no space for the public at large and also it out in order for us to move to a of our interns moved here sight un- problems saying that out loud. That for our profession,” Dr. Shapiro said. place where people feel like they can seen. I think they needed to feel like was a scary experience.” When asked about what men- access what they need without feel- they had some sense of normalcy The demeanor of the nurses on his tal health and self-care look like ing shame about it.”

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Masters Class of 2021 Nasim Afsar, MD, MBA, MHM Congratulations to the Shaun D. Frost, MD, MHM Jeffrey L. Schnipper, MD, MPH, MHM Fellows & Masters View the complete list of 2021 Fellows and Senior Fellows at hospitalmedicine.org/fellows.

the-hospitalist.org | 11 | April 2021

02_thru_11_HOSP21_04.indd 11 3/22/2021 3:29:17 PM NATIONAL HOSPITALIST DAY A ‘Hospitalist Plus’: Grace C. Huang, MD

race C. Huang, MD, is a hospitalist at teriorate, the need to change course in an instant Beth Israel Deaconess Medical Center because of new information, and wanting to be and associate professor at Harvard mentally present and available for my patients Medical School, both in Boston. and my learners. GDr. Huang currently serves as vice chair for It’s also hard to see suffering up close and per- career development and mentoring in the depart- sonal and to leave feeling helpless to change the ment of medicine at Beth Israel Deaconess, as well course of severe illness or to optimize care within as director of the Office of Academic Careers and the constraints of the health care system. This Faculty Development, and codirector of the Beth is why I do – and have to – extract satisfaction Israel Deaconess Academy of Medical Educators. from the smallest of wins and brief moments of She is also director of the Rabkin Fellowship in connection. Like seeing a patient turn the corner Medical Education, a program for Harvard Medical after being on the brink. Or gaining trust from School faculty designed to help develop the skills an initially upset family member. Getting a copy needed to launch or advance academic careers in of the eulogy from the daughter of my patient. A medical education or academic leadership. phone call from a patient I cared for 18 months Additionally, Dr. Huang is the editor in chief of ago, thanking me for my care. Visiting patients MedEdPORTAL, an open-access journal of the As- in the hospital socially that I had gotten to know

sociation of American Medical Colleges. g over the years. uan H e c

At what point in your training did you ra How has COVID-19 most impacted G . decide to practice hospital medicine? r hospitalist practice? D I trained at a point in time where it was rare for What you read in the lay press has put a spotlight ourtesy

people to aspire to go into hospital medicine. It C on hospital-based work. What has been shared just wasn’t that common, and there were so few Dr. Grace C. Huang resonates with my own experience – the loss of examples of what a career trajectory in hospital connection from visitor restrictions, the isolation medicine would look like. So I don’t know that programming. I also direct a year-long medical ed- patients experience when everyone is wearing I actively chose to go into hospital medicine; I ucation fellowship. On the side, I am the editor in personal protective equipment, the worsening of chose it because it was what I knew how to do, chief for a medical education journal. everything that was already hard to begin with, based on my residency experience. like health care disparities, mental health, access But it is really easy and authentic for me now What are your favorite areas of clinical to community supports, financial challenges, the to share about what makes hospital medicine practice and research? disproportionate burden on unpaid caregivers, etc. such a vibrant career choice. I’m doing a lot of Being a generalist means I love a lot of areas of After the pandemic is “over,” I hope that we will things in my job other than hospital medicine, clinical practice. I’m not sure there’s a particular retain a sense of intentionality how we address but when I am on service, it reminds me acutely area that I enjoy more than others. I love teaching limited resources, the importance of social con- what it means to stay connected to why I became specific topics – antibiotics, pharmacology, direct nection, the structural racism that has disadvan- a doctor. The practice of hospital medicine means oral anticoagulants, the microbiology of common taged patients and physicians of color. to be there at the most intense time of many infections. I love thinking about how the heart and people’s lives, to shoulder the responsibility of kidney battle for dominance each day and being the Are there any particular mentors who have knowing that what I say to my patients will be re- mediator. I have a particular interest in high-value been influential in your journey? membered forever, and to be challenged by some care and lab ordering (or the fact that we should do Because I’m one of the older hospitalists in my of medicine’s hardest problems. much less of it). I love complex diagnostic problems group, there were fewer mentors, other than my Hospital medicine has a way of putting you at and mapping them out on paper for my team. boss, Joe Li, MD, SFHM [section chief in hospi- the nexus of individual, family, society, govern- The research that I’ve been doing over the past tal medicine at Beth Israel Deaconess], who has ment, and planet. But it also means that, even 20 years has focused on how we train internists been an amazing role model. I think also of my while I am witness to disease, suffering, broken and internists-to-be to do bedside procedures. It colleagues as peer mentors, who continue to relationships, social injustice, and environmental stemmed from my own ineptitude in doing pro- push me to be a better doctor. Whether it means issues, I get a privileged look at what it means to cedures, and it caused me to question the age-old remaining curious during the physical exam, or comfort, to identify what really matters to people, approach we took in sticking needles into pa- inspiring me with excitement about clinical cases. to understand what gives us dignity as human tients without standardized training, supervision, beings. Lastly, I always come back to the fact that or safety measures. Do you have any advice for students and working as a team has made my clinical job so I’ve been proud of the small role I’ve been able residents interested in hospital medicine? much more enriching; it’s not trench warfare, but to play in influencing how residents are taught to When I talk to trainees about career develop- you do create bonds quickly with learners, col- do procedures, and now I’m working with others ment, I encourage them to think about what will leagues, and other health professionals in such an to focus on how we should teach procedures to make them a “Hospitalist Plus.” Whether that intense, fast-paced environment. hospitalists, who don’t do procedures on a regular Plus is teaching, research, or leadership, being a basis, and aren’t under the same expectations for hospitalist gives you an opportunity to extend What is your current role at Beth Israel ongoing skill development. your impact as a physician into related realms. Deaconess Medical Center? I look around at our hospital medicine group, At Beth Israel Deaconess, I’m holding four different What are the most challenging aspects of and every person has their Plus. We have edu- jobs. It’s sometimes hard for me to keep track of practicing hospital medicine, and what are cators, quality improvement leaders, a health them, but they all center on career and faculty de- the most rewarding? services researcher, a health policy expert, a text- velopment. I’m a vice chair for career development The intensity is probably what’s hardest for me book editor – everyone brings special expertise to within the department of medicine, and I also have about hospital medicine. At this point in my ca- the group. My Plus now is much bigger than my an institutional role for faculty development for reer, if I’m on service for a week, it takes me just footprint as a hospitalist, but I would never have clinicians, educators, and researchers. I provide aca- as long to recover. It’s the cognitive load of need- gotten here had I not chosen a career path that demic promotion support for the faculty, provide ad ing to keep track of details that can make a big would allow me to explore the farthest reaches of hoc mentorship, and run professional development difference, the rapidity at which patients can de- my potential as a physician. April 2021 | 12 | The Hospitalist

12_to_17_HOSP21_04.indd 12 3/22/2021 3:44:47 PM NATIONAL HOSPITALIST DAY Owning all aspects of patient care: Bridget McGrath, PA-C, FHM

ridget McGrath, PA-C, FHM, variety of medicine that hospital- utilize resources like SHM’s NP/PA is a physician assistant and ists practice. One area that I find Hospital Medicine Onboarding Tool- director of the nurse practi- especially rewarding is my time kit and the SHM/American Academy tioner/physician’s assistant in our transplant comanagement of Physician Assistants Hospitalist Bservice line for the section of hos- services. To be able to walk with pa- Bootcamp On Demand. pital medicine at the University of tients on their transplant journey Mentoring is remarkably import- Chicago. She is a cochair of SHM’s is very rewarding, and I am very ap- ant. I have been incredibly blessed NP/PA Special Interest Group. preciative of the mentoring I have to have mentors that helped make received from colleagues with a me into the PA that I am. I could not Where did you receive your PA deeper understanding of transplant have done what I did in the field education and training? medicine. without people taking a chance on I graduated from the PA program In my administrative role, I have me, and it is important to pass that at Butler University, Indianapolis, the privilege of helping to expand on to the next generation of PAs. in 2014. In college, whenever I shad- the professional education and owed a PA, I was always impressed training of my colleagues. I have a How has COVID-19 changed the that each one loved their job and passion for medical education, and practice of hospital medicine, said they would never change it. we have been working to develop specifically for NPs and PAs? That universal passion for the PA interprofessional educational op- The pandemic has demonstrated profession really made an impres- portunities within our section. I opportunities for teamwork and sion on me. have had time to think about the utilization of NPs and PAs. COVID imprint of NPs and PAs in academic forced everyone to reflect on why At what point in your training medicine, and how we can continue they originally got into medicine – did you decide to practice to meet the professional educational to help patients. I think there will hospital medicine? needs of our section while improv- Bridget McGrath be many doors opening for NPs That occurred during my clinical ing the care of our patients. and PAs and pathways for leader- rotation year at Butler. I had always their NPs and PAs based on the ship. thought I wanted to practice neo- What are the most challenging skillsets of their NPs and PAs, and The hospitalist leadership at natology, but during my clinical ro- aspects of hospital medicine? the needs of the section and the the University of Chicago truly tation I really fell in love with adult The volume of diagnoses that we are hospital. I personally feel that the identified that we needed to make medicine. I recall that, during my expected to manage on a daily basis best way to utilize NPs and PAs is wellness a main priority during the clinical rotation, the preceptor said to can be challenging. This challenges to allow them to own all aspects of beginning of the pandemic. We de- me that the goal was not to have me you to continue learning. The com- patient care and work at the high- veloped a wellness work group that understand every aspect of medicine, plexity of discharge planning, par- est scope of practice. By doing this I have been coleading. but to learn how to exist in a hospital ticularly for patients in underserved you empower the NP or PA to con- setting. I was exposed to the breadth communities, can also be challenging. tinue to develop their skill set and What’s on the horizon for NPs of hospital medicine practice and I You have to make sure your patients set a precedent of collaboration and PAs in hospital medicine? fell in love with the complexity, the are ready mentally, physically, and and respect for interprofessional We are seeing significant increases variety, and the environment itself. emotionally for discharge. As a hospi- care models within your section’s in hospitalist program utilization, I initially accepted a job as a med- talist, you are continuously thinking culture. so this is a time where NPs and PAs peds hospitalist PA – which brought about how to optimize patients to Scope of practice for an NP or can be advocates for our profession both of my passions together at that leave your care. For example, patients PA is going to be based on a con- and articulate how we can use our time – at Schneck Medical Center have different insurance situations, glomeration of roles and bylaws. backgrounds and training to build in Seymour, Ind. During that time, different access to care at home – you We are certified nationally, and our better care models in order to meet Schneck was a 100-bed rural com- are always managing the medical scope of practice is determined at the needs of our patients. munity hospital which had recently needs of your patient in the context the state level and the hospital by I hope we will see more NPs and been the recipient of the Malcolm of these other issues. level. For the individual NP and PAs assuming leadership roles to Baldrige National Quality Award. It PA, it really depends on the hospi- ensure that our voices are heard. We was there that I was able to practice How does a hospitalist PA work tal medicine group, and how well should also be advocating for more with a phenomenal group of phy- differently from a PA in other a practice incorporates a sense of collaboration and teamwork with sicians, nurses, and social workers care settings? collegiality. our MD and DO colleagues. who really took me under their wing We are meant to be generalists. We and taught me how to be a hospi- serve as the main provider in own- What resources do hospitalist Do you have any advice for PA talist PA. I practiced at Schneck for ing our patients’ care. A hospitalist PAs need to succeed? students interested in HM? 3 years, and then moved to the Uni- PA serves as a cog in the wheel, with There are a few key things that I always tell my students that they versity of Chicago in 2017. connections to specialists, consul- need to happen in order for hospital should be sponges – you are not I am now the director of NP/PA tants, nurses, social workers, phar- medicine groups to set up their NPs expected to know everything as a services for the section of hospital macists, etc., and we are tasked with and PAs for success. The first is for hospitalist PA, but you are expect- medicine, overseeing a group of sev- synthesizing all aspects of patient PAs to have exposure to inpatient ed to continue learning in order to en on our NP/PA team, within a larg- care to ensure the best outcome. rotations during clinical rotations. A develop into the best PA you can er group of about 60 physicians. hospital medicine group also should be. Always be open to where your How can NPs and PAs best fit have a very intentional onboard- career path can take you. Hospital What are your favorite areas of into hospital medicine groups? ing process for NPs and PAs. They medicine is a relatively young field clinical practice? Each hospital medicine group should also establish a culture of within medicine, and the diversity Like many hospitalists, I enjoy the will know how to best integrate acceptance. To do this, they should of our field is very exciting. the-hospitalist.org | 13 | April 2021

12_to_17_HOSP21_04.indd 13 3/22/2021 3:44:55 PM PRACTICE MANAGEMENT The interplay between staffing and scheduling Top five findings from the 2020 SoHM

By Amanda Trask, MBA, MHA, in planning for your group’s future programs reported not having a FACHE, SFHM, FACMPE staffing and scheduling needs. backup call system. One could spec- ulate that the larger group size has he biennial State of Hospital 5. Average group size has allowed adult hospitalist groups Medicine (SoHM) Report increased better ability to staff upper fluctu- was released in fall 2020, Andrew White, MD, SFHM, asso- ations in daily volume. This could reflecting surveys collected ciate professor of medicine at the have resulted in day-to-day schedul- Tjust as the pandemic was ramping University of Washington, Seattle, ing ease and flexibility. up. Thus, a COVID Addendum of provided a deep-dive discussion on results was collected and published the increase of group sizes in the 4. Shift-type is shifting a few months later. What did these March 2021 issue of The Hospitalist. In scheduling adult hospitalist Group size has impacted the way a groups, fewer groups reported ded- hospitalist group schedules, when icated nocturnists and more groups reviewing correlating scheduling reported dedicated day admitters. survey responses. Just above a third of all adult hos- Group size can have a direct cor- pitalist programs report having ded- reports tell us about existing and relation to scheduling methodology. icated day admitter shifts, and the Ms. Trask is senior vice president, developing trends in staffing and The number of employed/contracted presence of nocturnists is at a 6-year clinical institutes & service lines, scheduling? physician hospitalists in individual low. One speculation that could be at CommonSpirit Health in Here is a top five list of findings groups is up about 25%. Alongside the made is that hospitalists are mak- Englewood, Colo. for hospital medicine programs increase in physician hospitalists is an ing more of an effort to ensure that (HMGs) serving adults only. These increase in both nurse practitioners more admissions are done during the are just highlights; for further de- (NPs) and physician assistants (PAs) day and not held over for nighttime. flexibility or changed their scheduling tail, visit the SHM website to learn in adult hospitalist groups, with the This would be consistent with the model. For about 11% of all groups, more and purchase your copy (www. largest growth in PAs. In fact, in 2020, strong pressure for hospitals to de- this change is likely to be permanent. hospitalmedicine.org/practice-man- the average number of NPs and PAs crease door-to-floor admission times. agement/shms-state-of-hospi- per hospitalist group is approaching However, the presence of noctur- 1. COVID-19 has changed tal-medicine/). The information in similar numbers. nists increases steadily with group scheduling methodologies – the SoHM is extraordinarily helpful In 2020, more than half of all size. Ninety-four percent of HMGs perhaps for the long-term with 30-49 physician full time equiv- Three out of four adult hospitalist alents and 98% of groups with 50 or groups have created new COVID-19– more physician FTEs reported using dedicated teams each day. This has dedicated nocturnists. likely had one of the most impacts. Unit-based assignment reported 3. COVID-19 impacts hospitalist in the 2020 SoHM was already up Stay workflows from the 2018 SoHM Report (42.7% It’s not hard to imagine that vs 36%). Now, in addition to noctur- COVID-19 has affected all hospitalist nists, day admitter, rounder roles, groups: adult, pediatric, and adult/ and unit-based assignments, hos- Curious pediatric groups. COVID-19 has pital medicine groups must also in- SHM's Education app affected all lives – at home and at corporate COVID-19 teams into daily work – across the world. scheduling considerations. One in offers you lifelong More than 80% of all adult hospital- five groups report this change may learning tools. ist groups report having implemented likely be a permanent addition to changes (beyond dedicated COVID-19 the hospitalist schedule. Wow. teams) in workflows and/or how work As we think forward to the 2022 is allocated among its providers. And SoHM, staffing and scheduling of nearly 20% report that this is likely a adult hospital medicine group will permanent change. be a key topic of the survey. How SHM members can earn up Study for the FPHM exam Access additional to 20 FREE CME and MOC anywhere, anytime. educational resources. does COVID-19 change hospital med- credits per year through the 2. Schedules have been icine groups in the medium and long Question of the Day. disrupted by COVID-19 term? One thing is for sure – hos- More than half of adult hospitalist pital medicine groups are resilient Download today groups report having their schedules and have proven to be creative in hospitalmedicine.org/eduapp disrupted by COVID-19. The top two ensuring our hospitalized patients disruptors are loss of staff time due are well cared for. to exposure quarantine, and lost pro- Post your thoughts and questions Not a member of SHM? Visit hospitalmedicine.org/join to become part of the hospital medicine movement. vider time due to COVID-19 illness. for your peer network on the SHM All the while, adult hospitalist groups Online Community: HMX. Let’s have been taking care of more and keep the conversation going on

Accreditation Statement more hospitalized patients. how we can help each other create The Society of Hospital Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) While some groups have not made sustainable staffing and schedul- to provide continuing medical education for physicians. any changes in scheduling because of ing models that are continuously COVID-19, many have. Nearly 60% of adapting to our peripandemic envi- all groups have increased scheduling ronment. April 2021 | 14 | The Hospitalist

12_to_17_HOSP21_04.indd 14 3/22/2021 3:45:02 PM PEDIATRICS What are we missing in our search for MIS-C?

By Diana Swift and he was discharged home with an incredibly stressful time for phy- the hospital more frequently due to antibiotics. sicians and for families,” Dr. Molloy provider concern for MIS-C.” he emergence of multiple Calling this a case of “diagnosis said. “COVID-19 and related condi- inflammatory syndrome in derailed,” the authors noted that in tions like MIS-C are new, and we Cardiac involvement children (MIS-C) in associ- the pre-COVID era this child’s symp- are learning more and more about The most concerning of the five ation with COVID-19 may toms would likely have triggered a them every week. These diagnoses cases in terms of possible MIS-C, Dr. Tbe complicating the investigation more targeted and less costly eval- are understandably on the minds of Dean said in an interview, was that of and diagnosis of more common viral uation for more common infectious physicians and families when chil- a 12-year-old boy who had fever for and bacterial infections, potentially and noninfectious causes, including dren present with fever.” Notwith- 6 days in association with headache, delaying treatment and prolonging pyelonephritis, absent any physical standing, the boy’s case underscores eczematous rash, dry lips, and con- hospital stays. exam findings consistent with KD. the need for clinicians to consider junctivitis. Laboratory tests showed Two recent articles published on- “However, the patient presented alternative diagnoses and the value a mildly elevated C-reactive protein line in Hospital Pediatrics provide in the midst of the COVID-19 pan- of the care provided. level, hyponatremia, and thrombocy- evidence of this phenomenon. The demic with growing awareness of topenia, as well as sterile pyuria and articles outlined case studies of a new clinical entity,” they wrote. Impact of bias mildly elevated prothrombin time. children who underwent extensive “Anchored to the patient’s persistent Dr. Molloy’s group brings home the He was treated empirically with dox- investigation for MIS-C when in fact fever, the medical team initiated an cognitive biases practitioners often ycycline, and his fever resolved over they had less severe and more com- extensive, costly, and ultimately un- suffer from, including anchoring the next 24 hours. mon infections. MIS-C is a severe necessary workup to avoid missing and confirmation bias and diagnos- An echocardiogram at initial eval- but rare syndrome that involves sys- the diagnosis of MIS-C; a not yet tic momentum, according to J. How- uation, however, revealed mild dila- temic hyperinflammation with fever well described diagnosis with poten- ard Smart, MD, chief of pediatrics tion of the left anterior descending and multisystem organ dysfunction tially severe morbidity.” at Sharp Mary Birch Hospital for and right coronary arteries, which similar to that of Kawasaki disease Confirmation bias and diagnostic Women and Newborns, San Diego, led to the administration of intra- (KD). momentum likely contributed to the and an assistant clinical professor of venous immunoglobulin and aspi- In one of the articles (Hosp Pedi- early focus on MIS-C rather than pediatrics at University of Califor- rin for atypical KD, in contrast to atr. 2021 Jan 11. hpeds.2020-005579), more common alternatives, the au- nia, San Diego. MIS-C. The authors postulated that Matthew Molloy, MD, MPH, of the thors acknowledged. The addition of According to Dr. Smart, who was mild cardiac involvement in disor- division of pediatric hospital medi- mildly abnormal laboratory data not not involved in Dr. Molloy’s study, ders other than MIS-C and KD may cine at Cincinnati Children’s Hospi- typically obtained in the evaluation the team’s premature diagnostic fo- be underrecognized. tal Medical Center, and colleagues of fever led the team astray. “The cus on MIS-C was almost the inverse The lesson from these cases is that asked: “What are we missing in our diagnosis and definitive treatment of what typically happens with KD. hospitalists must maintain a wide search for MIS-C?” may have been made earlier had the “It is usually the case that Kawasaki differential diagnosis when assess- focus on concern for MIS-C not been disease does not enter the differen- ing a child with prolonged fever and E. coli, not SARS-CoV-2 present,” Dr. Molloy said. tial diagnosis until late in the course evidence of systemic inflammation. That question arose from a case of the fever, typically on day 5 or The Centers for Disease Control and involving a 3-year-old boy who had Keeping value in care later, when it may have been better Prevention stipulates that a diagnosis a 6-day history of fever and fatigue. The authors recognized that their to think of it earlier,” he said. of MIS-C requires the absence of a Three days earlier, he had tested initial approach to evaluating for In the second article (Hosp Pediatr. plausible alternative diagnosis. negative for strep antigen and MIS-C provided low-value care. “In 2021 Jan 11. hpeds.2020-005652), An- In addition to common viral, bac- COVID-19. He had a persistent, high our desire to not ‘miss’ MIS-C, we drea Dean, MD, of the department of terial, and noninfectious disorders, a fever, reduced appetite, and reduced were performing costly evaluations pediatrics at Baylor College of Med- range of regional endemic and par- urine output and was taken to the that at times produced mildly ab- icine and Texas Children’s Hospital, asitic infections must be considered ED. On physical examination, there normal, nonspecific results,” they both in Houston, and colleagues out- as alternative diagnoses. “Many of was no rash, skin peeling, redness of wrote. That triggered a cascade of lined the cases of five patients aged these diseases cannot be reliably dif- the eye or oral mucosa, congestion, specialty consultations, follow-up 8-17 years who were hospitalized in ferentiated from MIS-C on presen- rhinorrhea, cough, shortness of testing, and an unwarranted diag- May 2020 for suspected MIS-C. They tation, and as community exposure breath, chest pain, abdominal pain, nostic preoccupation with MIS-C. exhibited inflammatory and other to SARS-CoV-2 grows, hospitalists nausea, vomiting, or diarrhea. Determining the extra price tag concerning indicators but were even- should be prepared to admit febrile Urinalysis results and exam for the child’s workup would be tually discharged with a diagnosis of children with evidence of systemic findings were suspicious for py- complex and difficult because there murine typhus. inflammation for brief observation elonephritis. Other findings from is a difference in the cost to the This flea-borne infection, most periods to evaluate for MIS-C,” Dr. an extensive laboratory workup hospital and the cost to the family, commonly reported in the United Dean’s group wrote. In this context, raised the alarm that the boy was Dr. Molloy said. “However, there are States in the southeastern Gulf empiric treatment for common or suffering from MIS-C as opposed potential cost savings that would Coast region, Hawaii, and California, even uncommon infectious diseases to incomplete KD. After admission be related to making a correct diag- is often associated with a triad of may avoid overdiagnosis and over- to hospital medicine, the cardiology, nosis in a timely manner in terms fever, rash, and headache. treatment of MIS-C as well as im- rheumatology, and infectious dis- of preventing downstream effects Cases have been rising in south- prove patient outcomes. ease teams were called in to consult. from delayed diagnoses.” ern Texas, and Dr. Dean and col- “We do have specific MIS-C guide- Repeat labs were planned for the Even as clinicians struggle with leagues postulated that school lines at our institution,” Dr. Dean following day before initiating ther- the challenging SARS-CoV-2 learn- closures and social distancing may said, “but like all institutions, we are apy. On day 2, the child’s urine cul- ing curve, Dr. Molloy and associates have increased exposure as a result dealing with the broad definition of ture was positive for gram-negative urged them to continue to strive for of children spending more time MIS-C according to the World Health rods, later identified as Escherichia high-value care, with an unwavering outdoors or with pets: “Alternatively, Organization and the CDC, which is coli. The boy was started on ceftri- focus on using only necessary re- parental concern for SARS-CoV-2 the takeaway from this paper.” axone. Left renal scarring was ap- sources, a stewardship the pandemic infection could mean children with parent on ultrasound. The patient’s has shown to be critical. symptoms are presenting to care A version of this article first condition resolved after 36 hours, “The COVID-19 pandemic has been and being referred or admitted to appeared on Medscape.com. the-hospitalist.org | 15 | April 2021

12_to_17_HOSP21_04.indd 15 3/22/2021 3:45:08 PM CAREER Roots of physician burnout: It’s the workload Health care organizations must ‘get serious’ about clinician well-being

By Caleb Rans, PharmD relationship with burnout and pro- pared with workers in other fields. Among 30,456 physicians who re- MDedge News fessional satisfaction,” wrote Eliza- Cognitive-load theory, pioneered ceived the survey, 5,197 (17.1%) re- beth Harry, MD, SFHM, a hospitalist by psychologist Jonathan Sweller, sponded. In total, 5,276 physicians orkload, not personal at the University of Colorado at identified limitations in working were included in the analysis. vulnerability, may be at Denver, Aurora, and coauthors. The memory that humans depend on to The median age of respondents the root of the current results were reported in the Joint carry out cognitive tasks. was 53 years, and 61.8% self-identi- physician burnout cri- Commission Journal on Quality and Wsis, a recent study has concluded. Patient Safety (2021 Feb. doi: 10.1016/j. The cutting-edge research utilized jcjq.2020.09.011). cognitive theory and workload anal- The researchers investigated Quality improvement literature has ysis to get at the source of burnout whether task load correlated with demonstrated“ that improvements in among practitioners. The findings burnout scores in a large national inefficiencies that lead to increased indicate that, although some insti- study of U.S. physicians from Octo- tutions continue to emphasize per- ber 2017 to March 2018. demand in the workplace often has the sonal responsibility of physicians As the delivery of health care benefit of reduced cost. to address the issue, it may be the becomes more complex, physicians Dr. Harry amount and structure of the work are charged with ever-increasing ” itself that triggers burnout in doc- amount of administrative and Cognitive load refers to the fied as male. Twenty-four specialties tors. cognitive tasks. Recent evidence amount of working memory used, were identified: 23.8% were from a “We evaluated the cognitive load indicates that this growing com- which can be reduced in the pres- primary care discipline, and internal of a clinical workday in a national plexity of work is tied to a greater ence of external emotional or phys- medicine represented the largest re- sample of U.S. physicians and its risk of burnout in physicians, com- iological stressors. While a potential spondent group (12.1%). link between cognitive load and Almost half of respondents (49.7%) burnout may seem self-evident, the worked in private practice, and correlation between the cognitive 44.8% had been in practice for 21 load of physicians and burnout has years or longer. not been evaluated in a large-scale Overall, 44.0% had at least one study until recently. symptom of burnout, 38.8% of par- Physician task load (PTL) was mea- ticipants scored in the high range sured using the National Aeronau- for emotional exhaustion, and tics and Space Administration Task 27.4% scored in the high range for Load Index (NASA-TLX), a validated depersonalization. The mean score questionnaire frequently used to in task-load dimension varied by evaluate the cognitive load of work specialty. environments, including health care The mean physician task load

Much like our efforts to improve quality, advancing“ clinician well-being requires organizations to make it a priority and establish the structure, process, and leadership to promote the desired outcomes.” Dr. Shanafelt environments. Four domains (percep- score was 260.9 (standard deviation, tion of effort and mental, physical, 71.4). The specialties with the high- and temporal demands) were used to est PTL score were emergency med- calculate the total PTL score. icine (369.8), urology (353.7), general Burnout was evaluated using the surgery subspecialties (343.9), inter- Emotional Exhaustion and Deper- nal medicine subspecialties (342.2), sonalization scales of the Maslach and radiology (341.6). Burnout Inventory, a validated tool Aside from specialty, PTL scores considered the gold standard for also varied by practice setting, gen- measurement. der, age, number of hours worked The survey sample consisted of per week, number of nights on call physicians of all specialties and was per week, and years in practice. assembled using the American Medi- The researchers observed a

es cal Association Physician Masterfile, dose-response relationship between g ma

I a record of nearly all U.S. physicians PTL and risk of burnout. For every

etty independent of AMA membership. 40-point (10%) reduction in PTL, /G All responses were anonymous and there was 33% lower odds of expe- participation was voluntary. riencing burnout (odds ratio, 0.67;

wutwhanfoto Assessing the results 95% confidence interval, 0.65-0.70; P April 2021 | 16 | The Hospitalist

12_to_17_HOSP21_04.indd 16 3/22/2021 3:45:17 PM CAREER

< .0001). Multivariable analyses workplace often has the benefit of reduced cost. also indicated that PTL was a “Many studies have demonstrated the risk of significant predictor of burn- Helping physicians work more turnover due to burnout and the significant cost out, independent of practice optimally“ and with less chronic of physician turn over,” she said in an interview. setting, specialty, age, gender, strain from excessive task load “This cost avoidance is well worth the investment and hours worked. in improved operations to minimize unnecessary would save far more than these task load.” Using organizational costs overall. Dr. Harry also recommended the NASA-TLX strategies to reduce Dr. West tool as a free resource for health systems and physician burnout ” organizations. She noted that future studies will Coauthors of the study, Tait D. Shanafelt, MD, sis of PTL is fairly straightforward for hospitals further validate the reliability of the tool. professor of medicine at Stanford (Calif.) Uni- and individual institutions. “The NASA-TLX “At the core, we need to focus on system re- versity and Colin P. West, MD, PhD, of the Mayo tool is widely available, free to use, and not design at both the micro and the macro level,” Clinic in Rochester, Minn., are both experts on overly complex, and it could be used to provide Dr. Harry said. “Each health system will need to physician well-being and are passionate about insight into physician effort and mental, phys- assess inefficiencies in their workflow, while reg- finding new ways to reduce physician distress ical, and temporal demand levels,” he said in an ulatory bodies need to consider the downstream and improving health care delivery. interview. task load of mandates and reporting require- “Authentic efforts to address this problem must “Deeper evaluations could follow to identify ments, all of which contribute to more cognitive move beyond personal resilience,” Dr. Shanafelt specific potential solutions, particularly sys- load.” said in an interview. “Organizations that fail to tem-level approaches to alleviate PTL,” Dr. West The study was supported by funding from the get serious about this issue are going to be left explained. “In the short term, such analyses and Stanford Medicine WellMD Center, the Amer- behind and struggle in the war for talent. solutions would have costs, but helping physi- ican Medical Association, and the Mayo Clinic “Much like our efforts to improve quality, cians work more optimally and with less chronic department of medicine program on physician advancing clinician well-being requires organi- strain from excessive task load would save far well-being. zations to make it a priority and establish the more than these costs overall.” Coauthors Lotte N. Dyrbye, MD, and Dr. structure, process, and leadership to promote the Dr. West also noted that physician burnout is Shanafelt are coinventors of the Physician desired outcomes,” said Dr. Shanafelt. very expensive to a health care system, and strat- Well-Being Index, Medical Student Well-Being One potential strategy for improvement is egies to promote physician well-being would be Index, Nurse Well-Being, and Well-Being Index. appointing a chief wellness officer, a dedicated in- a prudent financial decision long term for health Mayo Clinic holds the copyright to these in- dividual within the health care system that leads care organizations. struments and has licensed them for external the organizational effort, explained Dr. Shanafelt. Dr. Harry, lead author of the study, agreed with use. “Over 30 vanguard institutions across the United Dr. West, noting that “quality improvement liter- Dr. Dyrbye and Dr. Shanafelt receive a portion States have already taken this step.” ature has demonstrated that improvements in in- of any royalties paid to Mayo Clinic. All other au- Dr. West explained that conducting an analy- efficiencies that lead to increased demand in the thors reported no conflicts of interest.

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the-hospitalist.org | 17 | April 2021

12_to_17_HOSP21_04.indd 17 3/22/2021 3:45:26 PM CLINICAL

Key Clinical Question How often should we check EKGs in patients starting antipsychotic medications? Determining relative risk with available data

By Samantha Platt; Brian Rice; Omar Mirza, DO; Kevin Dunsky, MD; David Portnoy, MD

Case tial, and if possible, choosing alter- Key points An 88-year-old woman with history of native treatment in patients with osteoporosis, hyperlipidemia, and a re- baseline prolonged QTc. If the QT- • An increased QTc interval can mote myocardial infarction presents to prolonging medication is the best lead to TdP, ventricular fibrilla­ the ED with altered mental status and or only option, then the next step is tion, and cardiac death. agitation. The patient is admitted to the assessing the patient’s risk for QTc • The relative risk of each anti­ medicine service for further manage- prolongation based on that person’s psychotic medication should be ment. Her current medications include a current condition and medical his- determined based on available thiazide and a statin. Psychiatry is con- tory.5 They recommend using the data and the Tisdale scoring sulted and recommends administering QTc-prolonging risk point system system can provide a system maGes intravenous haloperidol. A baseline EKG I developed by Tisdale and colleagues, to assess a patient’s risk of QTc etty

shows a corrected QT interval (QTc) of /G which identified patient risk factors prolongation. 486 milliseconds (ms). How often should for elevated QTc intervals based on • Low­risk patients with a base­ poloskun

subsequent EKGs be ordered? - EKG findings in cardiac care units at line QTc <500 ms should 6 enot a large tertiary hospital center. receive a baseline EKG and Based on the patient’s demograph- inpatient EKG monitoring Overview of issue medication, it is recommended to ics, current condition, and medica- weekly while moderate­ to A prolonged QT interval can predis- get a baseline EKG, then perform tion list, the score can be used to high­risk patients should pose a patient to dangerous arrhyth- EKG monitoring after administering stratify patients into low-, medium-, receive EKG monitoring every mias such as torsades de pointes the medication. and high-risk categories (see Table 3 days. (TdP), which results in sudden car- According to American Heart 1). Risk factors include age 68 years • A QTc >500 ms suggests diac death in about 10% of cases.1,2 A Association guidelines, a prolonged and over, female sex, prior MI, con- the need for a management prolonged QTc interval can be caused QT interval is considered more than current use of other QTc-prolonging change (drug discontinuation, by cardiac, renal, or hepatic dysfunc- 460 ms in women or above 450 ms in medications, and sepsis, all of which dose reduction, or a switch to tion; congenital long QT syndrome men.3 If an abnormal rhythm and/or have differing ability to cause QTc another agent). If the antipsy­ (LQTS)2 or electrolyte abnormalities; prolonged QTc is detected via EKG prolongation and thus are weighted chotic is absolutely necessary, or as a result of many drugs, includ- monitoring, then the drug dosage differentially. This scoring system perform daily EKG monitoring ing most antipsychotic medications can be changed or an alternative is helpful in identifying high-risk until there are three unchanged such as quetiapine, olanzapine, therapy selected.4 However, there patients; however, the review does EKGs, and then consider dees­ risperidone, and haloperidol. are no current guidelines recom- not include recommendations for calating monitoring to every 3 To diminish risk of TdP while mending how often EKG monitoring management of these patients be- days. taking these medications, it150904a is nec- should be performed after a QT-pro- yond removing the offending drug essary to monitor the QTc interval. longing antipsychotic medication is or monitoring EKGs more aggres- Before commencing a QT-prolonging administered on an inpatient medi- sively in higher-risk patients once with a baseline QTc >500 ms, they cine unit. Without guidelines, there identified.6 recommend not administering the Table 1. Scoring scheme for is potential for health care providers Low-risk patients can be man- medication and consulting a cardiol- Headline for a Bar Graphic QTc-prolongation risk factors to under- or over-order EKG IMNGmoni- Print agedColors expectantly. If the baseline ogist. The review does not provide a toring, possibly putting patients at QTc is <500 ms, Ifthen a deck the headline provider is needed, recommendation use this style. on how often EKG risk of TdP or wasting hospital re- may administer the medication, monitoring should be performed Risk factor Point value sources, respectively. but should obtainLabel follow-up style and size EKG after prescribing an antipsychotic Age ≥ 68 years 1 5 monitoring to ensureAxes number the QTc style doesand size medication in an inpatient setting. Female sex 1 Headline for a Bar Graphic Overview of the data not rise above 500 ms; if it does, a A 2018 review article explored150904b IMNG Print Colors Loop diuretic 1 There are currently no universally management changeNote: Trade is necessitated. Gothic Medium, 8/11patient ush left risk factors for a prolonged If a deck headline is needed, use this style. Serum K+ ≤ 3.5 mEq/L 2 accepted guidelines regarding inpa- For moderate- toSource: high-risk Trade Gothicpatients Medium, 8/11QTc ushin the left setting of prescribing Admission QTc ≥ 450 ms 2 tient EKG monitoring for patients Label style and size Acute MI 2 started on QTc-prolonging antipsy- Table 2. Risk Styleof QTc Guide: prolongation with common antipsychotics Axes number style and size ≥ 2 QTc-prolonging drugs 3 chotic medications. A 2018 review of Keep the background white. Note: Trade Gothic Medium, 8/11 ush left Sepsis 3 the literature surrounding assess- Medication UseMean the increaseIMNG colors.in QTc (ms) Subjects with >60 ms increase ment and management of patients Source: Trade Gothic Medium, 8/11 ush left Heart failure 3 Thioridazine Move the entire35.6 graph to align the bar labels30.0% left at the blue guide bar. on QTc-prolonging medications was One QTc-prolonging drug 3 Ziprasidone (Resizing may20.3 need to be done on the graph22.6% to €t in the space.) performed to analyze the available Style Guide: Quetiapine If a deeper or14.5 shorter template is needed,11.1% adjust in Window > Artboards. Low risk ≤6 data and make recommendations; Keep the background white. ews (Standard, as shown here, is 28 picas x 20 picas.) n Risperidone Moderate risk 7-10 notably the evidence was limited as 11.6 4.0% Use the IMNG colors. ews eDGe To create the dotted lines if they change, use the clear arrow tool, click High risk ≥11 none of the studies were random- Olanzapine 6.8 4.0% n mD Move the entire graph to align the bar labels left at the blue guide bar. MDedge News

ized controlled trials. Haloperidol on the line4.7 that needs to be changed, use3.7% the eyedropper tool,DeGe then m MDedge News (Resizing may need to be done on the graph to €t in the space.) click on the dotted rule provided on the side of the template. Source: Circ Cardiovasc Qual Outcomes. The authors recommend assessing If a deeper or shorter template is needed, adjust in Window > Artboards. Source: Ms. Platt, Mr. Rice, Dr. Mirza, Dr. Dunsky, Dr. Portnoy 2013;6(4):479-87 the drug for QTc-prolonging poten- (Standard, as shown here, is 28 picas x 20 picas.) To create the dotted lines if they change, use the clear arrow tool, click April 2021 18 The Hospitalist on the line that needs to be changed, use the eyedropper tool, then | | click on the dotted rule provided on the side of the template.

18_to_21_HOSP21_04.indd 18 3/22/2021 4:35:43 PM CLINICAL

potentially QTc-prolonging anti- gests that providers should know psychotics.7 The authors reiterate which antipsychotics carry a risk for that QTc-prolonging risk factors are QTc prolongation and what other important considerations when pre- treatment options are available. The scribing antipsychotics that can lead risk of QTc prolongation for com- to adverse events, though they note mon antipsychotic agents is pro- that much of the literature associ- vided in Table 2. Providers should ating antipsychotics with negative assess their patients’ risk factors for outcomes consists of case reports QTc prolongation and order a base- in which patients had independent line EKG to help quantify the cardi- Ms. Platt Mr. Rice Dr. Mirza Dr. Dunsky risk factors for development of TdP, ac risk associated with prescribing such as preexisting ventricular ar- the drug. Ms. Platt is a medical student at the Icahn School rhythmias. In patients with many risk factors of Medicine at Mount Sinai in New York. Mr. Rice is In addition, the data regarding the or complicated medication regi- a medical student at the Icahn School of Medicine. risk of each individual antipsychotic mens, a follow-up EKG should be Dr. Mirza is assistant clinical professor of psychiatry agent are not comprehensive. Some performed to assess the new QTc at the Icahn School of Medicine. Dr. Dunsky is a medications that have been deemed baseline. If the subsequent QTc is cardiologist and assistant professor at the Icahn School “QTc prolonging” were identified >500 ms, then an alternative medica- of Medicine. Dr. Portnoy is a hospitalist and assistant as such in only a handful of cases tion should be strongly considered. professor at the Icahn School of Medicine. where patients had confounding co- The majority of patients, however, morbid risk factors. This raises con- will not have a clinically significant Dr. Portnoy cern that some medications are being increase in their QTc, in which case unduly stigmatized in situations there is no need for a change in Quiz risk of QTc prolongation. If the where there is little chance of TdP. If medication and monitoring frequen- patient is at increased risk, avoid there is no equivalent or alternative cy can be deescalated. A 70-year-old male inpatient prescribing QTc-prolonging medica- treatment available, this may lead to on furosemide with last known tions where alternatives exist. an antipsychotic medication being Application of data to the case potassium level of 3.3 is going If a QTc-prolonging medication is held unnecessarily, which may exac- Our 88-year-old patient has multiple to be started on olanzapine. His used in a patient with a moderate- erbate the psychiatric illness. risk factors for a prolonged QTc, and baseline EKG has a QTc of 470 to high-risk score, check an EKG The authors note that the trend according to the Tisdale scoring sys- ms. every 3 days or daily if the QTc in- toward ordering baseline EKGs in tem is at moderate risk (7-10 points). How often should he receive creases to >500 ms. the inpatient setting following ad- Her risk of developing TdP increases EKG monitoring? ministration of a new antipsychotic with the addition of IV haloperidol A. Daily References may be partly attributed to the to her regimen. B. Every 3 days 1. Darpö B. Spectrum of drugs prolonging ready availability of EKG testing in Because of her increased risk, it is C. Weekly QT interval and the incidence of torsades hospitals. They recommend a base- reasonable to consider alternative D. Monthly de pointes. Eur Heart J Supplements. line EKG to assess the patient’s risk. management. If she can cooperate 2001;3(suppl_K):K70-80. doi: 10.1016/S1520- 765X(01)90009-4. For most agents, they recommend with PO medications, then olanzap- Answer (C): He is a low-risk no further EKG monitoring unless ine could be given, which has a less- patient (6 points: over 70 yrs, 2. Schwartz PJ and Woosley RL. Predicting the unpredictable: Drug-induced QT prolon- there is a change in patient risk fac- er effect on the QTc interval. loop diuretic, K+< 3.5, QTc > 450 gation and torsades de pointes. J Am Coll tors. Follow-up EKGs should be done If unable to take oral medications, ms), so he should receive weekly Cardiol. 2016;67(13):1639-50. doi: 10.1016/j. in patients with multiple or signifi- she could be given haloperidol in- EKG monitoring. jacc.2015.12.063. cant risk factors to assess their QTc tramuscularly, which causes less 3. Rautaharju PM et al. AHA/ACCF/HRS stability. In patients with a QTc >500 QTc prolongation than the IV for- recommendations for the standardization and interpretation of the electrocardiogram. Part ms on a follow-up EKG, daily moni- mulation. If an antipsychotic is ad- tocol should be utilized that balanc- IV: The ST segment, T and U waves, and the toring is encouraged alongside reas- ministered, she should receive EKG es the ability to capture a clinically QT interval. A Scientific Statement From the sessment of the current treatment monitoring. meaningful increase in the QTc American Heart Association Electrocardiogra- 7 150904c phy and Arrhythmias Committee, Council on regimen. Given the lack of evidence on the with appropriate stewardship of Clinical Cardiology; the American College of Overall, the current literature sug- optimal monitoring strategy, a pro- resources (Table 3). Our practice is Cardiology Foundation; and the Heart Rhythm to initially monitor the EKG every Society Endorsed by the International Soci- IMNG Print Colors Headlineety for Computerized for a Bar GraphicElectrocardiology. J Am Table 3. Decision-making process to prescribe QTc-prolonging drug 3 days in moderate- to high-risk Coll Cardiol. 2009 Mar 17;53(11):982-91. doi: patients with baseline QTc <500 ms.If a deck10.1016/j.jacc.2008.12.014. headline is needed, use this style. If the QTc remains below 500 ms Label style4. Drew and BJsize et al. Prevention of torsades de Recommendation: over three EKGs, then treatment pointes in hospital settings: A scientific state- Low risk < 7 Weekly ECG monitoring may continue with EKG monitoringAxes numberment from style theand Americansize Heart Association and the American College of Cardiology Foun- QTc < 500 ms weekly while the patient is hospi- dation. Circulation. 2010;121(8):1047-60. doi: Three Note: Trade Gothic Medium, 8/11 ush left Recommendation: talized. If the QTc rises above 500 10.1161/CIRCULATIONAHA.109.192704. Moderate or consecutive ECG monitoring ms, then a management change Source: Trade Gothic Medium, 8/11 ush left high risk > 7 ECGs without 5. Zolezzi M and Cheung L. A literature-based every 3 days change would be indicated (either dose algorithm for the assessment, management, and reduction or a change of agents). Style monitoringGuide: of drug-induced QTc prolongation If antipsychotic medications are Keepin the the backgroundpsychiatric population. white. Neuropsychiatr No suitable Dis Treat. 2019;15:105-14. doi: 10.2147/NDT. Recommendation: continued, we check the EKG dai- Use theS186474. IMNG colors. alternative Daily ECG monitoring ly while the QTc is >500 ms until Move the entire graph to align the bar labels left at the blue guide bar. treatment 6. Tisdale JE et al. Development and validation QTc > 500 ms there are three unchanged EKGS, (Resizingof a risk mayscore needto predict to beQT doneinterval on prolonga- the graph to €t in the space.) and then consider deescalating If a deepertion in hospitalized or shorter patients. template Circ is Cardiovasc needed, adjust in Window > Artboards. Alternative Recommendation: ews N monitoring to every 3 days. Qual Outcomes. 2013;6(4):479-87. doi: 10.1161/ treatment Change management (Standard,CIRCOUTCOMES.113.000152. as shown here, is 28 picas x 20 picas.) available plan eDge

MD To create the dotted lines if they change, use the clear arrow tool, click MDedge News Bottom line 7. Beach SR et al. QT prolongation, torsades de on pointes,the line and that psychotropic needs tomedications: be changed, A 5-year use the eyedropper tool, then Prior to prescribing, perform a base- Source: Ms. Platt, Mr. Rice, Dr. Mirza, Dr. Dunsky, Dr. Portnoy clickupdate. on the Psychosomatics. dotted rule 2018;59(2):105-22. provided on the doi: side of the template. line EKG and assess the patient’s 10.1016/j.psym.2017.10.009. the-hospitalist.org | 19 | April 2021

18_to_21_HOSP21_04.indd 19 3/22/2021 4:35:54 PM CLINICAL Inpatient sodium imbalances linked to adverse COVID-19 outcomes Are serum sodium values predictive of risk?

By Miriam E. Tucker of poor outcomes who would bene- fit from more intensive monitoring oth high and low serum so- and judicious rehydration,” Ploutar- It is common practice in critical care dium levels are associated chos Tzoulis, MD, PhD, and col- medicine“ to adjust water and salt intake with adverse outcomes for leagues wrote in their article, which hospitalized patients with was published in the Journal of to maintain serum sodium within the BCOVID-19, new research suggests. Clinical Endocrinology and Metabo- normal range, so the paper really doesn’t In the retrospective study of 488 lism (doi: 10.1210/clinem/dgab107). change any behavior. patients hospitalized with COVID-19 Dr. Simpson at one of two London hospitals Sodium considered for addition ” between February and May 2020, to COVID-19 risk calculator resuscitation in order to prevent tensivists as ‘on purpose much more hypernatremia (defined as serum Dr. Tzoulis, professor of endocrinolo- hypernatremia, which is induced by conservative than the usual one sodium level >145 mmol/L) at any gy at the University College London negative fluid balance and can often adopted in patients with commu- time point during hospital stay was Medical School, said in an interview be iatrogenic.” nity-acquired pneumonia at risk of associated with a threefold increase that “sodium could be incorporated Asked to comment, Steven Q. respiratory failure.’ ” in inpatient mortality. in risk calculators across other rou- Simpson, MD, professor of medicine Hyponatremia (serum sodium lev- tine biomarkers, such as white cell in the division of pulmonary, criti- Hyper- and hyponatremia linked el <135 mmol/L) was associated with count, lymphocytes, and CRP [C-re- cal care, and sleep medicine at the to adverse COVID-19 outcomes twice the likelihood of requiring ad- active protein], in order to provide a University of Kansas, Kansas City, In the study, 5.3% of the 488 patients vanced ventilatory support. In-hos- tool for dynamic risk stratification said that the article is missing key had hypernatremia at hospital pre- pital mortality was also increased throughout the clinical course of results that would assist in inter- sentation, and 24.6% had hyponatre- among patients with hypovolemic COVID-19 and assist clinical deci- preting of the findings. mia. Of note, only 19% of those with hyponatremia. sion-making.” “Data regarding diuretic use and hyponatremia underwent laborato- “Serum sodium values could be Moreover, he said, “we should sparing of fluid administration are ry workup to determine the etiology. used in clinical practice to identify follow less conservative strategies not in the paper. … It is simply not Of those, three-quarters had hypo- patients with COVID-19 at high risk in the rate and amount of fluid possible to tell whether serum sodi- volemic hyponatremia, determined um is a ‘predictor’ … or if it is a side on the basis of a urinary sodium effect of other issues or actions tak- cutoff of 30 mmol/L. en by physicians in patients who are The total in-hospital mortality rate progressing poorly. was 31.1%. There was a strong, al- “To say that sodium needs to be though nonsignificant, trend toward included in a risk calculator is to higher mortality in association with subtly suggest that there is some sodium status at admission. Death causal association with mortality, rates were 28.4%, 30.8%, and 46.1% and that has quite clearly not been for those who were normonatremic, established,” stressed Dr. Simpson, hyponatremic, and hypernatremic, who is president of the American respectively (P = .07). Baseline serum College of Chest Physicians but was sodium levels didn’t differ between not speaking for the organization. survivors (137 mmol/L) and nonsurvi- He added: “It is common practice vors (138 mmol/L). in critical care medicine to adjust In multivariable analysis, the oc- water and salt intake to maintain currence of hypernatremia at any Sharpen your documentation skills serum sodium within the normal point during the first 5 days in the range, so the paper really doesn’t hospital was among three indepen- and ensure you’re accurately change any behavior.” dent risk factors for higher in-hospi- Dr. Tzoulis said that, despite not tal mortality (adjusted hazard ratio, demonstrating the care you provide. having electronic medical record 2.74; P = .02). The other risk factors data on diuretic use or fluid input were older age and higher CRP level. Coming this Spring and output, “our acute physicians Overall, hyponatremia was not asso- and intensivists at both study sites ciated with death (P = .41). SHM’s Utilization Management and have been adamant that they’ve not “The key novel finding of our routinely used diuretics in COVID-19 study was that hospital-acquired hy- Clinical Documentation for Hospitalists patients. Diuretics have been spar- pernatremia, rather than hyperna- ingly used in our cohort, and also tremia at admission, was a predictor the frequency of pulmonary edema for in-hospital mortality, with the was reported as below 5%.” worst prognosis being reported in Regarding volume of fluid intake, patients with the largest increase in Dr. Tzoulis noted, “At our hospital serum sodium in the first 5 days of To learn more, please visit sites, the strategy has been that of hospitalization,” noted Dr. Tzoulis. hospitalmedicine.org/documentation cautious fluid resuscitation. In fact, the amount of fluid given has been A version of this article first appeared on reported by our physicians and in- Medscape.com. April 2021 | 20 | The Hospitalist

18_to_21_HOSP21_04.indd 20 3/22/2021 4:36:00 PM NEWS First pill for COVID-19 could be ready by year’s end

By Marcia Frellick Gilead Raday, RedHill’s chief operat- option for COVID-19 treatment, “belt-and-suspenders” approach, ing officer, said in an interview. Data questions will arise about their use, along with vaccines to combat ew pills to treat patients are expected midyear on its perfor- she said. COVID-19, Dr. Doernberg said. with COVID-19 are current- mance in 464 patients. The drug is One question is whether patients “We’re not going to eradicate ly in midstage clinical tri- being tested on top of remdesivir or who are getting remdesivir in the COVID,” she said. “We’re still going to als and, if successful, could in addition to dexamethasone. hospital and are ready to leave after need treatments for people who ei- Nbe ready by the end of the year. The second, upamostat (RHB-107), 5 days should continue treatment ther don’t respond to the vaccine or Only one treatment – remdesivir is currently undergoing a phase 2/3 with antiviral pills at home. haven’t gotten the vaccine or devel- (Veklury) – has been fully approved trial in the United States and is be- Another is whether the pills – if oped disease despite the vaccine.” by the U.S. Food and Drug Admin- ing investigated for use in nonhospi- they are shown to be effective – will Oral formulations are desperately istration for hospitalized patients, talized COVID-19 patients. be helpful for COVID post exposure. needed, agreed Kenneth Johnson, and it must be administered intrave- “I would expect data to be avail- That use would be important for PhD, professor of molecular biosci- nously. able in the second half of this year,” people who do not have COVID-19 ences at the University of Texas at Hopes for a day when patients Mr. Raday said. but who are in close contact with Austin. with COVID-19 can take a pill to rid Upamostat is a novel serine someone who does, such as a mem- Right now, remdesivir treatments their bodies of the virus got a boost protease inhibitor expected to be ber of their household. involve patients being hooked up to when early trial results were pre- effective against emerging variants “We have that model,” Dr. Doern- an IV for 30-120 minutes each day sented at the Conference on Retrovi- because it targets human cell factors berg said. “We know that oseltamivir for 5 days. And the cost of a 5-day ruses and Opportunistic Infections involved in viral entry, according to can be used for postexposure pro- course of remdesivir ranges from 2021 Annual Meeting. the company. phylaxis and can help to prevent $2,340 to $3,120 in the United States. These were interim phase 2 results Other drugs are being investigated development of clinical disease.” “We’re hoping we can come up for the oral experimental COVID-19 in trials that are in earlier stages. But she cautioned that a chal- with something that is a little bit drug molnupiravir, designed to do lenge with COVID is that people are easier to administer, and without for patients with COVID-19 what os- Urgent need for oral agents contagious very early. A pill would as many concerns for toxic side ef- eltamivir (Tamiflu) can do for pa- Infectious disease specialists need to come with the ability to test fects,” he said. tients with the flu. are watching the move toward a for COVID-19 early and get patients COVID-19 pill enthusiastically. linked to care immediately. A version of this article first appeared on We’re hoping we can “We badly need an oral treat- Treatments are part of the Medscape.com. ment option for COVID,” said Sarah come“ up with something Doern­berg, MD, an infectious dis- that is a little bit easier to ease specialist from the University of California, San Francisco. administer, and without Although some studies have as many concerns for toxic shown the benefit of monoclonal side effects. antibodies for prevention and early treatment, there are major logistical ” issues because all the current op- In the small study, the pill signifi- tions require IV administration. cantly reduced infectious virus in “If we had a pill to treat early patients who were symptomatic and COVID, especially in high-risk pa- had tested positive for COVID-19 tients, it would fill a gap,” she said, during the previous 4 days but were noting that a pill could help people not hospitalized. get better faster and prevent hospi- After 5 days of treatment, no par- tal stays. ticipants who received molnupiravir Studies of molnupiravir suggest had detectable virus, whereas 24% that it decreases viral shedding in who received placebo did. the first few days after COVID infec- Two other oral agents are being tion, Dr. Doernberg reported. Invest in the right developed by RedHill Biopharma: There is excitement around the one for severe COVID-19 infection for drug, but it will be important to see hospitalized patients and one for pa- whether the results translate into FPHM study tool tients at home with mild infection. fewer people requiring hospital The first, opaganib (Yeliva), pro- admission and whether people feel ceeded to a phase 2/3 global trial better faster. for hospitalized patients after the “I want to see the clinical data,” Dr. Spark Edition 2 company announced top-line safety Doernberg said. The engaging self-assessment app that’s catered to your and efficacy data in December 2020. She will also be watching for the educational needs and busy lifestyle. In phase 2, the drug was shown to upamostat and opaganib results in be safe in patients requiring oxygen the coming weeks. SHM members save $150 and effectively reduced the need for “If these drugs are successful, I oxygen by the end of the treatment think it’s possible we could use them period. – maybe under an emergency use Order today: hospitalmedicine.org/spark A key feature is that it is both an authorization – this year,” she said. antiviral and an anti-inflammatory, Once antiviral pills are a viable the-hospitalist.org | 21 | April 2021

18_to_21_HOSP21_04.indd 21 3/22/2021 5:06:16 PM INTERNATIONAL

share their experiences. Hospitalists medicine in the hospital setting,” Dr. from 33 countries were represented Vidyarthi said. Global HM Continued from page 1 at SHM’s 2017 conference, and the At UCSF, the professional identity upcoming virtual SHM Converge, of a hospitalist is broad but defined. May 3-7, 2021, includes a dedicated The research agenda, quality, safety, Clinic, Johns Hopkins Medicine, and working to solve remarkably similar international session. SHM chapters and educational competencies are Weill-Cornell Medical School, have problems: how to make health care have formed in a number of other specific, seen through a system lens, established teaching outposts in more affordable and higher quality countries. she added. “We take pride in that other countries, with opportunities while staying abreast of up-to-date Flora Kisuule, MD, MPH, SFHM, professional identify. This is an op- for resident training that prepares best practice for physicians,” he said. director of the Division of Hospital portunity for countries where gen- future hospitalists on the ground. “Hospital care is Medicine at Johns Hopkins Bayview eral medicine is underdeveloped and SHM CEO Eric E. Howell, MD, costly no matter Medical Center in Baltimore, said undervalued.” MHM, said that he personally has where you go. her international hospital medicine But the term hospital medicine – interacted with developing hospital Other countries work1 started 7 years ago when she or the American model – isn’t always medicine programs in six countries, are also trying to was invited to the Middle East to welcomed by health care systems in who called upon him in part because limit expense in help Aramco, the Saudi Arabian Oil other countries, Dr Vidyarthi said. of his past research on managing ways that don’t Company, develop a hospital medi- “The label of ‘hospital medicine’ length of hospital stays. Dr. Howell compromise the cine program based on the U.S. mod- brings people together in profes- counts himself among a few dozen quality of that el for its employees. This was a joint sional identity, and that professional U.S. hospitalists who are regularly care,” Dr. Howell Dr. Howell venture with Johns Hopkins Med- identity opens doors. But for it to invited to come and consult or to said. Also, hospi- icine. “We went there and looked have legs in other countries, those give talks to established or devel- talized patients are more complex at their processes and made rec- skills need to be of value to the local oping hospitalist programs in other than ever, with increasing severity ommendations such as duration of system. It needs to make sense, as it countries. Because of the COVID-19 of illness and comorbidities, which hospitalist shifts and how to expand did in the United States, and to add epidemic, in-person visits to other makes having a hospitalist available the footprint of hospital medicine in value for the identified gaps that countries have largely been cur- on site more important. the hospital,” she said. need to be filled.” tailed, but that has introduced a vir- Dr. Howell hopes to encourage Then Dr. Kisuule was asked to In Singapore, the health care sys- tual world of online meetings. more dialogue with international help develop a hospital medicine tem turned to the model of acute “I think the interesting thing colleagues. SHM has established col- program in Panama, where the driv- medical units (AMUs) and the acute about the ‘international consultants’ laborations with medical societies ers for developing hospital medi- medicine physician specialty devel- for hospital medicine is that, while in other countries and makes time cine were improving quality of care oped in the United Kingdom, which they come from professionally at its conferences for international and ensuring patient safety. The created a new way of delivering care, diverse backgrounds, they are all hospitalist participants to meet and biggest barrier has been remuner- a new geography of care, and new ation and how to pay salaries that set of competencies around which will allow doctors to work at only to build training one hospital. In Panama, doctors and certification. typically work at multiple hospitals AMUs manage or clinics so they can earn enough the majority of to make ends meet. acute medical patients who The need for professional present to the identity emergency de- The Glycemic Control Arpana Vidyarthi, MD, “grew up” partment and get professionally in hospital medicine Dr. Vidyarthi admitted, with eQUIPS Program at the University of California, San initial treatment Francisco, a pioneering institution for a maximum of 72 hours. Acute Benchmark against 100 sites to optimize glycemic for hospital medicine, and in SHM. physicians, trained in the special- control and minimize hyper- and hypoglycemia. “We used to say: If you’ve seen one ty of assessment, diagnosis, and hospital medicine group, you’ve seen treatment of adult patients with “We use data from the program to identify areas of one hospital medicine group,” she urgent medical needs, work in a unit opportunity. Our timeliness of hypoglycemia resolution said. situated between the emergency de- has has improved drastically, consistently within 30 Dr. Vidyarthi went to Singapore in partment entrance and the specialty minutes. To say the GC eQUIPS data has been ‘valuable’ 2011, taking a job as a hospitalist at care units. This specialty has been 2 is an understatement.” Singapore General Hospital and the recognized since 2009. - Community Hospital of the Monterey Peninsula affiliated Duke–National University “Acute medicine is the standard Medical School, eventually directing care model in the U.K. and is now To learn more and register, visit: hospitlalmedicine.org/gc the Division of Advanced Internal found in all government hospitals Medicine (general and hospital med- in Singapore. This model is being icine) at the National University adapted across Europe, Asia, and the Health System, before moving back Pacific Islands,” Dr. Vidyarthi said. to UCSF in 2020. “Advantages include the specific ge- “Professional identity is one of ography of the unit, and outcomes the biggest benefits hospital med- that are value-added to these sys- icine can bestow in Singapore and tems such as decreased use of hospi- across Asia, where general medicine tal beds in areas with very high bed is underdeveloped. Just as it did 20 occupancy rates.” years ago in the U.S., that profes- In many locales, a variety of titles sional identity offers a road map to are used to describe doctors who are achieving competency in practicing not hospitalists as we understand April 2021 | 22 | The Hospitalist

01_22_23_HOSP21_04.indd 22 3/25/2021 4:53:55 PM INTERNATIONAL

The question of what we can learn from others India-born, U.S.-trained hospitalist Anand Kartha, MD, MS, SFHM, cur- rently heads the Hospital Medicine Program at Hamad General Hospi- tal in Doha, Qatar. He moved from Boston to this small nation on the uritiba C

, Arabian Peninsula in 2014. Under

icente the leadership of the hospital’s De- V

ão partment of Medicine, this program S

was developed to address difficul- ospital

H ties such as scheduling, making A nurse treats a COVID-19 patient at Hospital São Vicente in Curitiba. transitions in care, and networking with home care and other providers them but whose work is based in South Korea’s 344 general hospitals – the same issues seen in hospitals the hospital, including house officer, tested the proposed fee schedule, around the world. duty officer, junior officer, registrar, said Wonjeong Chae, MPH, the first These are not novel problems, Dr. or general practitioner. Often these named author on the study, based Kartha said, but all of them have a hospital-based doctors, who may in in the Department of Public Health common solution in evidence-based fact be residents or nongraduated in the College of Medicine at Yonsei practice. “As hospitalists, our key is trainees, lack the training and the University in Seoul. “But we’re still to collaborate with everyone in the scope of practice of a hospitalist. Be- working on making the fee schedule hospital, using the multidisciplinary cause they typically need to consult better,” she said. approach that is a unique feature of the supervising physician before Ms. Chae estimates that there are hospital medicine.” making inpatient management de- about 250 working hospitalists in The model has continued to spread uritiba C

cisions, they aren’t able to provide South Korea today, which leaves a across hospitals in Qatar, including ,

the timely response to the patient’s lot of gaps in practice. “We did learn academic and community programs. icente V

changing medical condition that is from America, but we have a differ- “We now have a full-fledged academ- ão S

needed to manage today’s acute pa- ent system, so the American concept ic hospitalist system, which collabo- ospital

tients. had to be adapted. rates with community hospitals and H Hospital medicine community programs including a Dr. Reginaldo Filho. The definition of fee schedule is still growing women’s hospital and an oncologic In South Korea, a hospitalist model in Korea despite hospital,” he said. “Now the focus is Kartha said. The pandemic also has has emerged since 2015 in response the impact of the on expanding resource capacity and been an opportunity to show how to the insufficient number of hospi- pandemic. We the internal pipeline for hospitalists. hospital medicine is the backbone tal-based physicians needed to cover are at the begin- I am getting graduates from Weill of the hospital’s ability to respond, all admitted patients and to address ning stages of Cornell Medicine in Qatar.” Another although of course many other pro- related issues of patient safety, development, but key collaborator has been the Bos- fessionals also pitched in. health care quality, and limitations we expect it will Dr. Kisuule ton-based Institute for Healthcare Other countries around the world on total hours per week medical res- grow more with Improvement, helping to develop have learned a lot from the Ameri- idents are allowed to work. South government support.” best practices in Qatar and sponsor- can model of hospital medicine. But Korea in 1989 adopted a universal In Brazil, a handful of hospital ing the annual Middle East Forum on sources for this article wonder if U.S. National Health Insurance System, medicine pioneers such as Guil- Quality and Safety in Health Care. hospitalists, in turn, could learn from which took 12 years to implement. herme Barcellos, MD, SFHM, in The residency training program their adaptations and innovations. But inadequate coverage for medical Porto Alegre have tried to grow the at Hamad General is accredited by “We can all learn better how to work in the hospital has deterred hospitalist model, networking with Accreditation Council for Graduate practice our field of medicine in the physicians from choosing to work colleagues across Latin America Medical Education, with the same hospital with less resource utiliza- there. South Korea had longer through the Pan American Society expected competencies as in the U.S. tion,” Dr. Vidyarthi concluded. “So lengths of hospital stay, fewer prac- of Hospitalists and the Brazilian “We don’t use the term ‘hospitalist,’ ” many innovations are happening ticing physicians per 1,000 patients, chapter of SHM. Dr. Kartha said. “It’s better to focus around us. If we open our eyes to and a much higher number of hospi- Individual hospitals have devel- on the model of care – which clearly our global colleagues and infuse tal patients per practicing physician oped hospitalist programs, but there was American. That model has en- some of their ideas, it could be won- than other countries in the Orga- is no national model to lead the way. countered some resistance in some derful for hospital professionals in nization for Economic Cooperation Frequent turnover for the Minister countries – on many of the same the United States.” and Development, according to a of Health position has made it hard- grounds U.S. hospitalists faced 20 new study in the Journal of Hospital er to develop consistent national years ago. You have to be sensitive References Medicine detailing hospitalist devel- policy, and the country is largely to local culture. For hospitalists to 1. Kisuule F and Howell E. Hospital medicine opment in South Korea.3 still in the early stages of developing succeed internationally, they have beyond the United States. Int J Gen Med. A council representing leading hospital medicine, depending on iso- to possess a high degree of cultural 2018;11:65-71. doi: 10.2147/IJGM.S151275. medical associations was formed to lated initiatives, as Dr. Barcellos de- intelligence.” There’s no shortage of 2. Stosic J et al. The acute physician: The future of acute hospital care in the U.K. Clin Med develop a South Korean hospitalist scribed it in a November 2015 article issues such as language barriers, he (Lond). 2010 Apr;10(2):145-7. doi: 10.7861/clin- system and charged by the Ministry in The Hospitalist.4 Growth is slow said. “But that’s no different than at medicine.10-2-145. of Health with designing an official in Brazil but continuing, with new Boston Medical Center.” 3. Chae W et al. Development and evolution of proposal for implementing it. A programs such as the one led by SHM’s Middle East Chapter was hospital medicine in Korea. J Hosp Med. In press. pilot study focused on quality and Reginaldo Filho, MD, at Hospital São off to a great start and then was 4. Beresford L. Hospital medicine flourish- on defining a fee schedule for hos- Vicente in Curitiba standing out in slowed down by regional politics ing around the world. The Hospitalist. Nov 2015. www.the-hospitalist.org/hospitalist/ pital work was tested in 4 hospitals, the confrontation against COVID-19, and COVID-19, but is looking for- article/122050/hospital-medicine-flourish- and then a second phase in 31 of Dr. Barcellos said. ward to a great reboot in 2021, Dr. ing-around-world. the-hospitalist.org | 23 | April 2021

01_22_23_HOSP21_04.indd 23 3/22/2021 3:17:13 PM CLINICAL

In the Literature Clinician reviews of HM-centric research

By Perry H. Dubin, MD, MPH; Jennifer Heinen, MD; Michael Hession, MD; Douglas J. Koo, MD, MPH, FHM; David W. Rawson, MD Memorial Sloan Kettering Cancer Center, New York

IN THIS ISSUE STUDY DESIGN: Retrospective al medicine population but has not study and cross-sectional logistic examined high functioning adults 1. Prophylaxis with hydrochloroquine not superior to placebo in pre- and multinomial logistic regression over the age of 70 years undergoing venting SARS-CoV-2 analyses. elective major surgery. 2. Highly rated hospitals unlikely in minority communities or low-in- SETTING: Data review and analysis STUDY DESIGN: Secondary retro- come areas from a variety of sources including spective analysis of the ongoing 3. Ultrabrief screening tool developed for postoperative delirium www.medicare.gov, Health Resourc- Successful Aging After Elective Sur- 4. Short course of oral corticosteroids linked with increased risk of es and Services Administration, and gery prospective cohort study. severe adverse events Dartmouth Atlas Project. SETTING: Three academic medical 5. Opiate use associated with increased risk for CAP SYNOPSIS: The authors compared centers. 6. Integrating machine learning and performance feedback promotes Star Ratings from 3,075 acute care SYNOPSIS: The authors analyzed advanced care planning hospitals across the United States data from a series of daily in-hospi- 7. Use of inpatient metered-dose inhalers may result in cost savings with socioeconomic variables from tal assessments of 560 adults over 8. Assessing the impact of palliative care interventions in chronic the communities served by the hos- the age of 70 years with the Con- noncancer illness pital, including percentage minority fusion Assessment Method (CAM) 9. SGLT2 inhibitors improve CV- and kidney-related outcomes in pa- population, household income, delirium reference standard admin- tients with T2D education attainment, Medicare/ istered on postoperative days 1 and 10. Shared decision-making tool for anticoagulation decisions in AFib Medicaid dual eligibility, urban/rural 2. Of all the potential 1-, 2-, or 3-item may improve communication designation, and geographic region. combinations from the 12-item Regression models were used to CAM, the screen with the highest identify which variables might cor- sensitivity and By Perry H. Dubin, MD, MPH in the hydroxychloroquine group relate with lower Star scores. specificity for the Prophylaxis with was diarrhea. There were no signifi- The study found that high minori- detection of delir- 1hydrochloroquine not cant differences in cardiac AEs or in ty, lower socioeconomic, and lower ium consisted of superior to placebo in changes in corrected QT interval. educated populations had a higher three items: Does preventing SARS-CoV-2 BOTTOM LINE: Prophylaxis with hy- probability of living in counties with the patient report droxychloroquine did not significant- hospitals with one-star ratings. feeling confused? CLINICAL QUESTION: Does preex- ly prevent infection with SARS-CoV-2. BOTTOM LINE: Areas that have a Can the patient posure prophylaxis with hydroxy- Hydroxychloro- higher minority percentage, lower ed- complete the chloroquine reduce or prevent quine was asso- ucation level, and lower socioeconom- Dr. Heinen months of the infection with SARS-CoV-2 in high- ciated with more ic status were less likely to be served year backward? risk health care workers? adverse events by hospitals with higher star ratings. And does the patient appear sleepy? BACKGROUND: There is no known than placebo. CITATION: Shi B et al. Relationship (sensitivity 92%, specificity 72%). medication-based prevention regi- CITATION: Abella of hospital star ratings to race, ed- Given the inclusion of a major- men for the SARS-CoV-2 virus. BS et al. Efficacy ucation, and community income. ity white, highly educated cohort STUDY DESIGN: A double-blind pla- and safety of J Hosp Med. 2020;15:588-93. doi: in this analysis, the authors note cebo-controlled randomized study. hydroxychloro- 10.12788/jhm.3393. limitations including lack of gener- SETTING: The University of Penn- quine vs. placebo Dr. Dubin Dr. Dubin is an assistant attending alizability to racial/ethnic minorities sylvania health care system’s main for pre-exposure hospitalist at Memorial Sloan and those with lower educational Philadelphia hospitals. SARS-CoV-2 prophylaxis among Kettering Cancer Center, New York. attainment or preexisting physical/ SYNOPSIS: Study authors ran- health care workers. JAMA Intern mental disabilities. domized 132 health care workers Med. 2020 Sep 30;181(2):195-202. doi: By Jennifer Heinen, MD BOTTOM LINE: A three-item ultra- to receive hydroxychloroquine or 10.1001/jamainternmed.2020.6319. Ultrabrief screening tool brief screen may successfully iden- placebo. Participants underwent 3developed for postoperative tify delirium in older postoperative swab for SARS-CoV-2 RT-PCR test Highly rated hospitals unlikely delirium patients with a sensitivity of greater at baseline and at 4 and 8 weeks. 2in minority communities or than 90%. The second interim analysis met the low-income areas CLINICAL QUESTION: What combi- CITATION: Sillner AY et al. Ultra- predefined futility requirement, and nation of questions is most effective brief screens for detecting delirium the study was halted before the to- CLINICAL QUESTION: Is there an as a rapid screen for delirium in in postoperative cognitively intact tal accrual goal. association between socioeconomic older adults following major elective older adults. J Hosp Med. 2020 The rate of SARS-CoV-2 positivity factors and hospital star rating? surgery? Sept;15(9):544-7. doi: 10.12788/jhm.3410. by nasopharyngeal PCR swabs was BACKGROUND: Centers for Medi- BACKGROUND: One of the most similar in both groups (6.3% hy- care & Medicaid Services developed frequent postoperative issues in the Short course of oral droxychloroquine vs. 6.6% placebo; the Hospital Quality Star Rating as a elderly, delirium can lead to negative 4corticosteroids linked with P > .99). There were no grade 3 or 4 patient-oriented guide to identifying patient outcomes such as longer increased risk of severe adverse adverse events (AE) reported. How- hospitals that provide high-quality lengths of stay, increased morbidity events ever, there were significantly more care. This study aimed to examine and mortality, and increased risk AEs reported in the hydroxychloro- the relationship between hospital of discharge to a facility. Previous CLINICAL QUESTION: Do short (14 quine arm vs. placebo arms (45% vs. Star Rating performance, socioeco- research has identified sensitive ul- days or fewer) courses of oral corti- 26%; P = .03). The most frequent AE nomic factors, and geography. trabrief delirium screens in a gener- costeroids increase the risk of gas- April 2021 | 24 | The Hospitalist

24_thru_31_HOSP21_04.indd 24 3/22/2021 5:25:22 PM SHORT TAKES CLINICAL | In the Literature

Multicomponent approaches trointestinal bleed, sepsis, and heart tion to their known sedating, as well calculations, clinician prompts, and to preventing delirium failure? as respiratory-suppressing, effects performance feedback, investigators associated with a decreased BACKGROUND: The negative impact – may increase the risk or severity sought to increase the rate of SICs. risk of delirium of long-term oral corticosteroid thera- of CAP resulting from immunosup- STUDY DESIGN: Stepped-wedge In a meta-analysis of 10 random- py is well established. Existing clinical pression through an unidentified cluster randomized controlled trial. ized controlled trials comparing guidelines often recommend short mechanism. This article seeks to SETTING: Medical oncology clinics multicomponent approaches steroid courses (otherwise known as identify opioids as an additional risk within the University of Pennsylva- (ranging from increased nursing “bursts”) for treatment of a variety of factor for CAP. nia Health System. protocols to pharmacologic in- inflammatory diseases; however, the STUDY DESIGN: Systematic review SYNOPSIS: The study included 78 terventions) with usual care to potential risks associated with these and meta-analysis. oncology clinicians, in eight clinic prevent hospital-acquired deliri- courses have not been well studied. SETTING: Health systems in the groupings, who received standardized um, multicomponent approaches STUDY DESIGN: Self-controlled United States, Canada, and Finland. training in SICs. In a stepped-wedge were associated with decreased case series. SYNOPSIS: Investigators identi- design, clinicians received SIC perfor- risk of delirium events and SETTING: National Health Insur- fied eight studies, including 567,472 mance feedback, a list of upcoming length of delirium-days. ance Research Database of medical patients, that examined opioid patients with a less than 10% 180-day CITATION: Leon-Salas B et al. claims records in Taiwan. exposures and risk of CAP. They mortality risk as predicted by a val- Multicomponent interventions for SYNOPSIS: Over a 3-year period, this found that opioid prescriptions are idated algorithm, and real-time text the prevention of delirium in hos- population-based study identified associated with an overall increase reminders to engage patients in SICs. pitalized older people: A meta anal- 2,623,327 patients between the ages of 57% in the risk of CAP requiring Over a 6-month study period in- ysis. J Am Geriatr Soc. 2020 Sep of 20 and 64 years (mean age, 38) who hospitalization (odds ratio, 1.57 [95% cluding 26,059 patient encounters, in- 9;68(12):2947-54. doi: 10.1111/jgs.16768. received an oral corticosteroid burst CI, 1.34, 1.84]; haz- vestigators found that a significantly (defined as 14 days or fewer of ther- ard ratio, 1.18 [95% increased rate of SICs occurred in the USPSTF recommends apy). Using a self-controlled design, CI, 1.00, 1.40]). None intervention group, compared with screening adults about they found that the risks of gastro- of these studies controls (4.6% vs. 1.3%) across all risk unhealthy drug use intestinal bleeding (incidence rate directly compared groups. Among high-risk patient en- The U.S. Preventative Services ratio, 1.8; confidence interval, 1.75-1.84), the risk of CAP for counters, the rate of SICs also signifi- Task Force recommends screen- sepsis (IRR, 1.99; CI, 1.7-2.32), and heart patients on immu- cantly increased (15.2% vs. 3.6%). ing by asking questions about failure (IRR, 2.37; CI, 2.13-2.63) were nosuppressive vs. BOTTOM LINE: Interventions com- unhealthy drug use (not testing significantly higher 5-30 days after nonimmunosup- bining predicted mortality with cli- biological specimens) in adults steroid initiation when compared pressive opioids; Dr. Hession nician-directed feedback and clinical age 18 years or older (B recom- with the reference period of 5-90 however, there reminders led to significantly increased mendation). In adolescents aged days prior to steroid initiation. was no significant difference between rates of SICs in the oncology clinic set- 12-17 years, the current evidence The population studied was pre- them in the author’s pooled analysis. ting, particularly for high-risk patients. is insufficient to assess the bal- dominantly young and relatively Different cut-off points for high- CITATION: Manz CR et al. Effect of in- ance of benefits and harms of healthy (85% had a Charlson Comor- dose morphine equivalent daily tegrating machine learning mortality screening (I statement). bidity Index of 0); thus, the results doses across studies precluded the estimates with behavioral nudges to CITATION: U.S. Preventive may not be generalizable to the elder- authors from investigating dose-re- clinicians on serious illness conver- Services Task Force. Screening ly (older than 65) and younger (young- sponse relationships. The authors sations among patients with cancer. for unhealthy drug use: U.S. er than 20) patients, or those with also note these findings may not be JAMA Oncol. 2020 Oct 15;6(12):e204759. preventive services task significant underlying comorbidities. generalizable beyond the postopera- doi: 10.1001/jamaoncol.2020.4759. force recommendation state- BOTTOM LINE: Short courses of oral tive and chronically ill patient popu- Dr. Hession is an assistant attending ment. JAMA. 2020;323(22):2301-9. corticosteroids may increase the risk lations included in the studies. hospitalist at Memorial Sloan doi:10.1001/jama.2020.8020. of gastrointestinal bleeding, sepsis, BOTTOM LINE: These findings sug- Kettering Cancer Center, New York. and heart failure within the first gest that, among chronically ill and Interventions targeting month after therapy. Physicians pre- postoperative patients, opioids are a By Douglas J. Koo, MPH, FHM mental health for physicians scribing steroid bursts should weigh risk factor for CAP. Use of inpatient metered- and nurses can improve benefits against the risks of rare but CITATION: Steffens C et al. The as- 7dose inhalers may result in levels of stress, anxiety, and potentially severe adverse events. sociation between prescribed opioid cost savings depression CITATION: Yao TC et al. Association receipt and community-acquired In a systematic review of 29 between oral corticosteroid bursts pneumonia in adults: A systematic CLINICAL QUESTION: Does tran- randomized controlled trials of and severe adverse events: A na- review and meta-analysis. J Gen In- sitioning from nebulizers to me- interventions to improve mental tionwide population-based cohort tern Med. 2020 Sep 3;35(11):3315. doi: tered-dose inhalers (MDI) result in health and well-being in health study. Ann Intern Med. 2020 Sep 10.1007/s11606-020-06155-9. cost savings? care workers, mindfulness- and 1;173(5):325-30. doi: 10.7326/M20-0432. BACKGROUND: MDIs with spacers cognitive-behavioral therapy– Dr. Heinen is an assistant attending Integrating machine learning are clinically equivalent to nebuliz- based interventions were often hospitalist at Memorial Sloan 6and performance feedback ers when used properly. effective in reducing levels of Kettering Cancer Center, New York. promotes advanced care planning STUDY DESIGN: Spreadsheet mod- stress, anxiety, and depression, al- el. though interventions that target- By Michael Hession, MD CLINICAL QUESTION: Can cli- SETTING: Academic medical center. ed physical activity, body mass Opiate use associated with nician-directed, electronic inter- SYNOPSIS: Using cost models which index, or blood pressure were increased risk for CAP ventions promote serious illness factored in number of patients, generally less efficacious. 5 conversations (SICs)? medication costs, labor costs for CITATION: Mazurek Melnyk B CLINICAL QUESTION: Are opioids a BACKGROUND: In prior research, nebulized medications, and educa- et al. Interventions to improve risk factor for community-acquired oncologists were able to identify tion for MDIs, this study showed mental health, well-being, physi- pneumonia (CAP) requiring hospi- fewer than half of cancer patients that switching to MDIs after 24 cal health, and lifestyle behaviors talization? expected to die within 6-12 months, hours of nebulizers results in cost in physicians and nurses. Am J BACKGROUND: CAP is among the while algorithms employing machine savings, compared with nebulized Health Promot. 2020;34(8):929-41. most common infectious causes of learning were more accurately able medications only. Specifically, the doi: 10.1177/0890117120920451. death in the United States. Emerging to predict mortality risk. By com- marginal cost saving for every five data suggest that opioids – in addi- bining machine learning mortality Continued on following page the-hospitalist.org | 25 | April 2021

24_thru_31_HOSP21_04.indd 25 3/22/2021 5:25:37 PM CLINICAL | In the Literature SHORT TAKES

Continued from previous page sociation of receipt of palliative causes (HR, 0.85; 95% CI, 0.78-0.93), Preop stress testing patients transitioning to MDIs was care interventions with health although significant heterogeneity prior to total hip or knee estimated at $288.20 for the internal care use, quality of life, and symp- was observed for this outcome, with arthroplasty is declining model and $187.50 for the external tom burden among adults with empagliflozin having the most sig- without an increase in cardiac model. Savings are largely from the chronic noncancer illness: A sys- nificant effect. Associations with complications reduction of labor costs of nebulizer tematic review and meta-analy- improved kidney outcomes and A large retrospective cross-sec- administration. The cost compari- sis. JAMA. 2020;324(14):1439-50. doi: decreased hospitalizations for heart tional study found that, between sons of providing the treatments are 10.1001/jama.2020.14205. failure were consistent across the 2006 and 2017, preoperative stress institution specific and depend on Dr. Koo is an associate attending class of SGLT2 inhibitors. testing for total hip and knee ar- staff delivering the medications and hospitalist at Memorial Sloan BOTTOM LINE: In patients with throplasties declined, while at the providing patient education (i.e., stu- Kettering Cancer Center, New type 2 diabetes, all SGLT2 inhibitors same time, rates of perioperative dent pharmacists vs. other staff). York. He is also assistant professor are associated with reductions in myocardial infarction and cardiac BOTTOM LINE: Transitioning from of clinical medicine, Weill Cornell major adverse cardiac events and arrest in patients with a Revised nebulizers to MDIs may result in Medical College, New York. adverse kidney-related outcomes, Cardiac Risk Index (RCRI) of 1 or cost savings from the reduction of but for rates of death from cardio- more did not significantly change. labor costs. By David W. Rawson, MD vascular causes, there is heterogene- The authors recommend addi- CITATION: Kondo R et al. Cost sav- SGLT2 inhibitors improve CV- ity across SGLT2 inhibitors. tional investigation as to when ing simulation for the transition 9and kidney-related outcomes CITATION: McGuire D et al. Associ- perioperative stress testing may from nebulizer to combination of in patients with T2D ation of SGLT2 inhibitors with car- be warranted. nebulizer and metered-dose inhalers diovascular and kidney outcomes in CITATION: Rubin DS et al. Fre- (MD). Chest. 2020; 158(4):A29. doi: CLINICAL QUESTION: Does the ef- patients with type 2 diabetes. JAMA quency and outcomes of preop- 10.1016/j.chest.2020.08.069. fectiveness of SGLT2 inhibitors for Cardiol;6(2):148-58. doi: 10.1001/jamac- erative stress testing in total hip cardiovascular- and kidney-related ardio.2020.4511. and knee arthroplasty from 2004 Assessing the impact of outcomes vary across the class of to 2017. JAMA Cardiol. 2020 Sep 8palliative care interventions medications or by the presence or Shared decision-making 30; 6(1):13-20. doi: 10.1001/jamacar- in chronic noncancer illness absence of preexisting cardiovascu- 10tool for anticoagulation dio.2020.4311. lar or chronic kidney disease? decisions in AFib may improve CLINICAL QUESTION: What is the BACKGROUND: Randomized, con- communication association between palliative care trolled trials have demonstrated including patient-reported out- interventions and acute health care that, in patients with type 2 diabe- CLINICAL QUESTION: Does the use comes (quality of communication, use, symptom burden, and quality of tes, SGLT2 inhibitors are associated of a shared decision-making (SDM) satisfaction with treatment deci- life in adults with chronic noncan- with favorable kidney-related and tool improve the quality of SDM sions), clinician-reported outcomes cer illness? cardiovascular outcomes, including and anticoagulation choices for pa- (satisfaction with discussion), and BACKGROUND: Evidence supports reductions in major adverse cardi- tients with atrial ratings of patient engagement by the benefits of palliative care for ac events and hospitalizations for fibrillation (AFib) independent observers. patients with cancer, yet there are heart failure; however, the consis- who are at risk of Patients in both arms reported twice as many patients with non- tency of effects across the four dif- stroke? high quality of communication, cancer illness and palliative care ferent SGLT2 inhibitors available in BACKGROUND: high levels of knowledge, and needs. the United States remains uncertain. Shared deci- low decisional conflict, with no STUDY DESIGN: Systematic review STUDY DESIGN: Meta-analysis. sion-making significant differences between and meta-analysis. SETTING: English-language search is widely rec- treatment arms. Clinicians were SETTING: Academic medical centers. of literature published between Jan- ommended to significantly more satisfied with SYNOPSIS: This study of 28 random- uary 1, 2015, and January 31, 2020. Dr. Rawson individualize the the quality of encounters in the ized controlled SYNOPSIS: The authors identified anticoagulation intervention arm (88.3%), compared trials of 13,664 six randomized, controlled trials treatment of patients with nonval- with the standard-care arm (61.8%). patients with that included 46,969 total patients vular AFib who are at risk of stroke. Scores of patient involvement in noncancer illness with type 2 diabetes, of whom Tools to help facilitate SDM about decision-making were higher in the (mostly heart 66.2% had known preexisting ath- anticoagulation have not been rigor- intervention arm. No significant failure) found erosclerotic cardiovascular disease. ously evaluated for efficacy in ran- difference was found with respect that receipt of Outcomes included major adverse domized controlled trials. to encounter duration or treatment palliative care cardiovascular events (myocardial STUDY DESIGN: Multicenter, non- decisions. interventions infarction, stroke, or death from car- blinded, randomized controlled trial. BOTTOM LINE: Use of a shared de- was statistical- Dr. Koo diovascular causes), hospitalization SETTING: Three academic medical cision-making tool led to significant ly significantly for heart failure, and composite kid- centers, one suburban group prac- improvements in clinician satisfac- associated with less ED use, less ney outcomes (including worsening tice, and one urban safety-net health tion and patient engagement with hospitalization, and lower symptom eGFR or creatinine, end-stage renal system in the United States, be- decision-making, without a signifi- burden; however, it was not signifi- disease, or death from kidney-relat- tween Jan. 30, 2017, and June 27, 2019. cant effect on treatment decisions cantly associated with disease-ge- ed causes). Median follow-up in the SYNOPSIS: Of patients with non- or duration of the encounter. neric or disease-specific measures of included trials ranged from 2.4 to 4.2 valvular AFib, 922 were randomized CITATION: Kunneman M et al. As- quality of life. This finding may re- years. to either the intervention arm, sessment of shared decision-making sult from significant heterogeneity Analysis showed that SGLT2 which incorporated a standardized for stroke prevention in patients in the interventions between trials inhibitors were associated with a tool for SDM about anticoagulation, with atrial fibrillation. JAMA In- and the statistical impact of a large lower risk of major adverse cardio- or to standard care. The SDM tool tern Med. 2020;180(9):1215-1224. doi: study with high risk of bias. vascular events (hazard ratio, 0.90; consisted of individualized patient 10.1001/jamainternmed.2020.2908. BOTTOM LINE: Palliative care, com- 95% CI, 0.85-0.95), kidney outcomes risk assessments for outcomes like Dr. Rawson is an assistant attending pared with usual care, is associated (HR, 0.62; 95% CI, 0.56-0.70), and hos- stroke and major bleeding, sample hospitalist at Memorial Sloan with less acute health care use and pitalization for heart failure (HR, language to describe those risks, Kettering Cancer Center, New modestly lower symptom burden 0.68; 95% CI, 0.61-0.76). SGLT2 inhibi- and a comparison of medication York. He is also assistant professor but no difference in quality of life. tors were also associated with lower options. Multiple measures of of clinical medicine, Weill Cornell CITATION: Quinn KL et al. As- rates of death from cardiovascular the quality of SDM were studied, Medicine, New York. April 2021 | 26 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

Hospitalists/Nocturnists Facing COVID-19 together on the Ochsner Health is seeking physicians to join our hospitalist team. front lines. BC/BE Internal Medicine and Family Medicine 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. Stronger • 7 on 7 off block schedule with flexibility • Dedicated nocturnists cover nights • Base plus up to 40 K in incentives • Average census of 14-18 patients Together • E-ICU intensivist support with open ICUs at the community hospitals • EPIC medical record system with remote access capabilities Stronger together means leadership • Dedicated RN and Social Work Clinical Care Coordinators by front-line physicians and advanced • Community based academic appointment providers to achieve our greatest goal: • The only Louisiana Hospital recognized by U.S. News and World Report Distinguished saving lives. Hospital for Clinical Excellence award in 3 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. Hospitalists Needed • Leadership support focused on professional development, quality improvement, and academic committees & projects Seeking board eligible/certified IM and FP • Opportunities for leadership development, research, resident and medical student physicians with inpatient experience in teaching the following areas: Arizona, California, • Skilled nursing and long term acute care facilities seeking hospitalists and mid-levels Illinois, Michigan, Missouri, Oregon, and South Carolina. with an interest in geriatrics • Paid malpractice coverage and a favorable malpractice environment in Louisiana Competitive income plus annual profit • Generous compensation and benefits package sharing bonus with premium benefits. Ochsner Health is a system that delivers health to the people of Louisiana, Mississippi and the Gulf South with a mission to Serve, Heal, Lead, Educate and Innovate. Ochsner Health Impact change at the local level. is a not-for-profit committed to giving back to the communities it serves through preventative screenings, health and wellness resources and partnerships with innovative organizations National network of support for urgent that share our vision. Ochsner Health healed more than 876,000 people from across the clinical and non-clinical needs that includes globe in 2019, providing the latest medical breakthroughs and therapies, including digital crisis support, equipment supplies, medicine for chronic conditions and telehealth specialty services. Ochsner Health is a national and burnout. leader, named the top hospital in Louisiana and a top children’s hospital by U.S. News & World Report. As Louisiana’s leading healthcare educator, Ochsner Health and its partners educate HM Administrative Fellowship, leadership opportunities and training available. thousands of healthcare professionals annually. Ochsner Health is innovating healthcare by investing in new technologies and research to make world-class care more accessible, Up to $100,000 sign-on bonus for affordable, convenient and effective. Ochsner’s team of more than 26,000 employees and select locations. 4,500 providers are working to reinvent the future of health and wellness in the region. To learn more about Ochsner Health, please visit www.ochsner.org. To transform your health, please visit www.ochsner.org/healthyyou. Why Vituity? For nearly 50 years, Vituity has been a catalyst for Interested physicians should apply to: positive change in healthcare. As a physician-led and https://ochsner.wd1.myworkdayjobs.com/en-US/OchsnerPhysician/job/ -owned multispecialty partnership, our 5,000 doctors New-Orleans---New-Orleans-Region---Louisiana/Hospital-Medicine-Sourcing-Requisition and clinicians care for nearly 8 million patients each year across 450 practice locations and nine acute care ---all-regions_REQ_00022186 specialties. Learn about our innovative solutions to Sorry, no opportunities for J1 applications. healthcare challenges at vituity.com. Ochsner is an equal opportunity employer and all qualified applicants will receive consideration for employment without Explore Jobs regard to race, color, religion, sex, national origin, sexual orientation, disability status, protected veteran status, or any vituity.com/careers other characteristic protected by law. 309952 Questions? [email protected]

To learn more, visit www.the-hospitalist.org and click “Advertise” or contact Linda Wilson • 973-290-8243 • [email protected] 313447 April 2021 | 27 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

About Concord, MA and Emerson Hospital

Emerson Hospital provides advanced medical services to more than 300,000 people in over 25 towns. We are a 179 bed hospital with more than 300 primary care doctors and specialists. Concord :25 Boston Our core mission has always been w o r l d - r e n o w n e d a f f i l i a t i o n s | 2 5 m i n u t e s f r o m b o s t o n | q u a l i t y o f l i f e to make high-quality health care accessible to those that live and work MASSACHUSETTS • Dedicated nocturnist program in our community. While we provide • Intensivists coverage of critical most of the services that patients will care unit ever need, the hospitals strong clinical Hospitalist Position Available • Competitive compensation and collaborations with Boston’s academic bonus structure medical centers ensures our patients Come join our well established Opportunities available for full time • Access to top specialty care hospitalist team of dedicated hospitalist hospitalist, part time nocturnist have access to world-class resources For more information please contact: at Emerson Hospital located in historic and moonlighting, just 25 minutes for more advanced care. Diane Forte Willis Concord, Massachusetts. Enjoy living from Boston. Director of Physician Recruitment in the suburbs with convenient access A great opportunity to join a well and Relations to metropolitan areas such as Boston, established program. 978-287-3002 New York and Providence as well as the [email protected] mountains, lakes and coastal areas. • Manageable daily census • Flexible scheduling to ensure work EMERSONHOSPITAL.ORG

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the-hospitalist.org | 28 | April 2021 Make your next smart move. Visit shmcareercenter.org.

Hospitalist Opportunities Hospitalist/Nocturnist Gorgeous Lakes, Ideal Climate, Award-winning Downtown Cambridge Health Alliance (CHA) Inspire health. Serve with compassion. Be the difference. Cambridge Health Alliance (CHA), a well-respected, nationally recognized and award-winning public healthcare system, is recruiting for part time and full time hospitalists/nocturnists. Prisma Health, the largest non-profit healthcare provider employs 16,000 people, CHA is a teaching affiliate of Harvard Medical School (HMS) including 1,200+ physicians on staff. Our system includes clinically excellent facilities and Tufts University School of Medicine. Our system is com- with 1,627 beds across 8 campuses. Additionally, we host 19 residency and fellowship prised of 3 campuses and an integrated network of primary and specialty outpatient care practices. programs and a 4-year medical education program: University of South Carolina School • Schedule will consist of daytime and nighttime shifts, of Medicine–Greenville, located on Prisma Health-Upstate’s Greenville Memorial Medical nocturnist positions are available Campus. Prisma Health-Upstate also has developed a unique Clinical University model in • Academic Appointment at Harvard Medical School collaboration with the University of South Carolina, Clemson University, Furman University, • Opportunity to teach medical students and residents • Two coverage locations approximately 5 miles apart and others to provide the academic and research infrastructure and support needed to • Physician assistant support at both locations become a leading academic health center for the 21st century. • CHA’s hospitalist department consists of 25+ clinicians Greenville, South Carolina is a beautiful place to live and work and is located on the I-85 Ideal candidates will be Board Certified, patient centered and demonstrate a strong commitment to work with a multicultural, corridor between Atlanta and Charlotte and is one of the fastest growing areas in the country. underserved patient population. Experience and interest in Ideally situated near beautiful mountain ranges, beaches and lakes, we enjoy a diverse performing procedures and community ICU coverage preferred. and thriving economy, excellent quality of life and wonderful cultural and educational We offer a supportive and collegial environment, strong infrastructure, fully integrated electronic medical record opportunities. Check out all that Greenville, SC has to offer! #yeahTHATgreenville system (EPIC) and competitive salary/benefits package. Please visit www.CHAproviders.org to apply through our secure Ideal Candidates: candidate portal or send your CV directly to Kasie Marchini at [email protected]. • BC/BE Internal Medicine Physicians We are an equal opportunity employer and all qualified applicants • IM procedures highly desired, but not required. Simulation center training & bedside will receive consideration for employment without regard to race, training available if needed. color, religion, sex, sexual orientation, gender identity, national origin, Comfort managing critically ill patients. disability status, protected veteran status, or any other characteristic • protected by law. 315100 Details Include: • Group comprised of career hospitalists with low turnover • Relocation allowance available • EPIC Electronic Medical Record system • 7 on/7 off schedule with 1 week of vacation per year • Additional shifts paid at a premium Available Opportunities: Nocturnist Hospitalist, Oconee Memorial Hospital • $340K base salary with $10K incentive bonus and CME stipend • Up to $40K sign on bonus for a 4 year commitment To advertise in Hospitalist, Laurens County Hospital $291K base salary with $40K incentive bonus and CME stipend The Hospitalist or the • • Up to $40K sign on bonus for a 4 year commitment Journal of Hospital Medicine Nocturnist or Traditional Hospitalist, Baptist Easley Hospital • $245-265K base salary with $40K incentive bonus and CME stipend for Traditional Hospitalist Contact: • $340K base salary with $10K incentive bonus and CME stipend for Nocturnist Linda Wilson • Up to $40K sign on bonus for a 4 year commitment as a Nocturnist 973.290.8243 [email protected] Please submit a letter of interest and CV to: Natasha Durham, Physician Recruiter, [email protected], ph: 864-797-6114 312627

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

April 2021 | 29 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

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✦ ✦ ✦ ✦ ✦ The University of Oklahoma Health Sciences Center, Department of Medicine, and Section of General Internal Medicine is seeking a BC/BE Internist/Hospitalist with Find your next job today! major commitment to teaching and clinical care. The position is for rank of Instructor visit SHMCAREERCENTER.ORG or Assistant Professor. Applicants must demonstrate proficiency in clinical internal medicine and be willing to dedicate this time to care of inpatients at OU Medical Center. Competitive salary and benefits package offered. Start date is anticipated as February 1, 2005. Interested applicants should send CV and summary of their experience and names of three references to Michael S. Bronze, MD, Professor and Chairman, Department of Medicine, OUHSC, PO Box 26901, WP 1140, Oklahoma City, OK 73190. OUHSC is an equal opportunity institution. Individuals with disabilities and protected veterans are encouraged to apply. 314566

the-hospitalist.org | 30 | April 2021 COMMENTARY

Community PHM The COVID-19 push to evolve

By Magna Dias, MD the number of hospitalists in the they will continue to offer telemed- group. Salaries decreased in 26% of icine with an additional 25% of pro- as anyone else noticed how reporting programs, and 20%-56% grams considering starting. There slow it has been on your described reduced benefits, ranging was also a slight increase during pediatric floors? Well, you from less CME/vacation time and the pandemic of coverage of men- are not alone. stipends to retirement benefits. The tal health units (from 11% to 13%), HThe COVID pandemic has had a three most frequent benefit losses which may have led 11% of respon- significant impact on health care included annual salary increases, ed- dents to consider the addition of volumes, with pediatric volumes ucational stipends, and bonuses. this service. The survey also noted decreasing across the nation. A Community hospitals felt the pal- that about 28% of PHM programs Children’s Hospital Association CEO pable, financial strain of decreasing performed circumcisions, frenec- survey, currently unpublished, not- pediatric admissions well before the tomies, and sedation prepandemic, ed a 10%-20% decline in inpatient pandemic. Hospitals like MedStar and 14%-18% are considering adding admissions and a 30%-50% decline Franklin Square Hospital in Balti- these services. in pediatric ED visits this past year. more and Harrington Hospital in Overall, the financial stressors are Even our usual respiratory surge has Southbridge, Mass., had decided to improving, but our need to adapt in been disrupted. The rate of influenza close their pediatrics units before PHM is more pressing than ever. The Dr. Dias is a clinical associate tracked by the CDC is around 1%, COVID hit. In a 2014 unpublished pandemic has given us the push for professor of pediatrics at Yale compared with the usual seasonal survey of 349 community PHM evolution and some opportunities University, New Haven, Conn., in flu baseline national rate of 2.6%. (CPHM) programs, 57% of respon- that did not exist before. One is the the division of pediatric hospital These COVID-related declines have dents felt that finances and justifi- use of telemedicine to expand our medicine. occurred amidst the backdrop of cation for a pediatric program were subspecialty support to community already-decreasing inpatient admis- primary concerns. hospitals, as well as to children’s hos- sions because of the great work of the Responding to financial stressors pitals in areas where subspecialists ing coverage within pediatric ICUs, pediatric hospital medicine (PHM) is not a novel challenge for CPHM are in short supply. These telemedi- EDs, and urgent care areas, along community in reducing unnecessary programs. To keep these vital pe- cine consults are being reimbursed with coverage of well newborns that admissions and lengths of stay. diatric programs in place despite for the first time, which allows more were previously covered by commu- For many hospitals, several factors lower inpatient volumes, those of access to these services. nity pediatricians. Also, the increase related to the pandemic have raised us in CPHM have learned many les- With the pandemic, many hospi- of mental health admissions is an- significant financial concerns. Ac- sons over the years on how to adapt. tals are moving to single room occu- other area where PHM programs cording to Becker Hospital Review, Such adaptations have included pancy models. Construction to add might expand their services. as of August 2020 over 500 hospitals diversification in procedures and more beds is costly, and unnecessary While I hope the financial stress- had furloughed workers. While 26 multifloor coverage in the hospital. if we can utilize community hospi- ors improve, hope is not a plan and of those hospitals had brought back Voiding cystourethrogram cathe- tals to keep appropriate patients in therefore we need to think and workers by December 2020, many terizations and circumcisions are their home communities. The op- prepare for what the post-COVID did not. Similar financial concerns now more commonly performed portunity to partner with commu- future may look like. Some have were noted in a Kaufmann Hall by CPHM providers, who may also nity hospital programs to provide predicted a rebound pediatric respi- report from January 2021, which cover multiple areas of the hospi- telemedicine support should not be ratory surge next year as the masks showed a median drop of 55% in tal, including the ED, NICU, and overlooked. This is also an oppor- come off and children return to operating margins. The CARES well-newborn nursery. Comanage- tunity for academic referral centers in-person learning and daycare. This Act helped reduce some of the ment of subspecialty or surgical to have more open beds for critical may be true, but we would be fool- detrimental impact on operating patients is yet another example of care and highly specialized patients. ish not to use lessons from the pan- margins, but it did not diminish the such diversification. Another opportunity is to expand demic as well as the past to consider added burden of personal protective Furthermore, the PERC survey scope by changing age limits, as 18% options in our toolkit to become equipment expenses, longer length showed that some PHM programs of respondents to the PERC survey more financially stable. POPCoRN, of stay for COVID patients, and a re- temporarily covered pediatric ICUs reported that they had started to as well as the American Academy imbursement shift to more govern- and step-down units and began do- care for adults since the pandemic. of Pediatrics’ listserv and subcom- ment payors and uninsured caused ing ED and urgent care coverage as The Pediatric Overflow Planning mittees, have been a source of col- by pandemic-forced job losses. primary providers Most programs Contingency Response Network laboration and shared knowledge COVID’s impact specific to pedi- reported no change in newborn vis- (POPCoRN) has been a valuable re- during a time when we have needed atric hospital medicine has been its while 16% reported an increase in source for education on caring for to quickly respond to ever-changing substantial. A recent unpublished newborn volume and 14% reported adults, guidance on which patient information. These networks and survey by the PHM Economics a decrease in newborn volume. My populations are appropriate, and the information sharing should be lever- Research Collaborative (PERC) own health system was one of the resources needed to do this. While aged once the dust settles for us to demonstrated how COVID has groups that had an increase in new- caring for older adults, even in their prepare for future challenges. affected pediatric hospital medi- born volume. This was caused by 90s, was a pandemic-related phe- New innovations may arise as we cine programs. Forty-five unique community pediatricians who had nomenon, there is an opportunity look at how we address the growing PHM programs from over 21 states stopped coming in to see their own to see if the age limit we care for need for mental health services and responded, with 98% reporting a newborns. This coverage adjust- should be raised to 21, or even 25, as incorporate new procedures, like decrease in pediatric inpatient ad- ment has yet to return to baseline some CPHM programs had been do- point-of-care ultrasound. As Charles missions as well as ED visits. About and will likely become permanent. ing prepandemic. Darwin said: “It is not the strongest 11% reported temporary unit clo- There was a 11% increase from Along with the expansion of age of the species that survives nor the sures, while 51% of all programs re- prepandemic baselines (from 9% to limits, there are many other areas of most intelligent that survives. It is ported staffing restrictions ranging 20%) in programs doing telemedi- opportunity highlighted within the the one that is most adaptable to from hiring freezes to downsizing cine. Most respondents stated that PERC survey. These include expand- change.” It is time for us to evolve. the-hospitalist.org | 31 | April 2021

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