September 2019 KEY CLINICAL QUESTION IN THE LITERATURE PEDIATRIC HM 2019 Volume 23 No. 9 Alcohol withdrawal in Antiplatelet therapy Conference coverage p13 hospitalized patients p16 after ICH p20 starts here

Battling hospitalist burnout Higher salaries are not sufficient

By Thomas R. Collins

ospitalist Rahul C. Borsadia, MD, had been working with Orlando Health Inpatient Medicine Group since the year of its founding in 2011. HThe salaries of the practice’s physicians back then were based on relative value units (RVU) – the more patients that physicians saw, the higher their salaries. But a problem arose, Dr. Borsadia said. Physicians were trying to squeeze in two dozen or more patients a day “in a practice that is modeled for quality.” “By the time the end of the day comes, it’s 9 or 10 p.m. and you are leaving but coming back at 6:30 the next morning. So, lack of sleep, more patients, striving to earn that higher salary,” he said. “The desire to perform quality work with that kind of patient load was not fulfilled and that led to dissatisfac- tion and stress, which led to irritation and exodus from the group.” Three years ago, the practice transitioned to a throughput process with a census limit of 18 patients or fewer, without an RVU system, but with salary incentives based on patient satis- faction, billing, and documentation.

Continued on page 11

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PHYSICIAN EDITOR THE SOCIETY OF HOSPITAL MEDICINE Danielle B. Scheurer, MD, SFHM, MSCR; Phone: 800-843-3360 Come for the Education. [email protected] Fax: 267-702-2690 Website: www.HospitalMedicine.org Stay for the Movement. PEDIATRIC EDITOR Laurence Wellikson, MD, MHM, CEO Anika Kumar, MD, FAAP Vice President of Marketing & [email protected] Communications COORDINATING EDITORS Lisa Zoks Dennis Chang, MD [email protected] The FuTure hospiTalisT Marketing Communications Manager Brett Radler Jonathan Pell, MD [email protected] Key CliniCal Guidelines Marketing Communications Specialist CONTRIBUTING WRITERS Caitlin Cowan [email protected] Veevek Agrawal, DO; Svetlana Chernyavsky, DO; Thomas R. Collins; SHM BOARD OF DIRECTORS Jeff Craven; Steven Deitelzweig, MD, President SFHM, MMM; Patricia Dharapak, MD; Halle Christopher Frost, MD, SFHM Field, MD; Erica Grabscheid, MD; Caley President-Elect McIntyre, MD; Eve Merrill, MD; Danielle Scheurer, MD, MSCR, SFHM Ryan Nelson, MD; Jeremiah Newsom, MD, Treasurer MSPH; M. Alexander Otto; Matt Pesyna; Tracy Cardin, ACNP-BC, SFHM Kamana Pillay, MD; Isha Puri, MD, MPH; Secretary Dahlia Rizk, DO, MPH; Kristen Rogers, MD, Rachel Thompson, MD, MPH, SFHM MPH; Matthew Tuck, MD, MEd, FACP Immediate Past President Nasim Afsar, MD, MBA, SFHM FRONTLINE MEDICAL Board of Directors COMMUNICATIONS EDITORIAL STAFF Steven B. Deitelzweig, MD, MMM, SFHM Editor in Chief Mary Jo M. Dales Bryce Gartland, MD, FHM Executive Editors Denise Fulton, Flora Kisuule, MD, MPH, SFHM Kathy Scarbeck Kris Rehm, MD, SFHM Editor Richard Pizzi Mark W. Shen, MD, SFHM Creative Director Louise A. Koenig Jerome C. Siy, MD, SFHM Director, Production/Manufacturing Chad T. 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To learn more about SHM’s relationship with industry partners, visit www.hospitalmedicine.com/industry. September 2019 | 2 | The Hospitalist HOSP_3.indd 1 7/25/2019 1:38:55 PM FROM THE SOCIETY Laurence Wellikson, MD, MHM, announces retirement as CEO of SHM Society recognizes Dr. Wellikson’s leadership, retains Spencer Stuart for successor search

fter serving as the first bership but also its diverse portfolio hospitalist specialty code, and earned “On behalf of the society and its and only chief executive of offerings for hospital medicine the John M. Eisenberg Patient Safety members, I want to extend a sincere officer of the Society of professionals under Dr. Wellikson’s and Quality Award for its quality im- thank you to Larry for his years Hospital Medicine since leadership. Its first annual confer- provement programs. These are just of dedication and service to SHM, AJanuary of 2000, Laurence Wellik- ence welcomed approximately 300 a few of the noteworthy accomplish- its staff, and the hospital medicine son, MD, MHM, has announced his attendees; the most recent confer- ments that professionals we serve,” said Chris- retirement effective on Dec. 31, 2020. ence, Hospital Medicine 2019, saw have elevat- topher Frost, MD, SFHM, president In parallel, the SHM Board of Direc- that number increase more than ed SHM as a of SHM’s Board of Directors. “His tors has commenced a search for his 10-fold to nearly 4,000. Its con- key partner legacy will allow SHM to continue successor. ferences, publications, online for hospital- its growth trajectory through key “When I began as CEO 20 years education, chapter program, advo- ists and their programs and services supporting ago, SHM – then known as the cacy efforts, quality improvement institutions. members’ needs for years to come. National Association of Inpatient programs, and more have evolved To assist Larry has taken the specialty of Physicians – was a young national significantly to ensure hospitalists with the hospital medicine and created a organization with approximately at all stages of their careers – and search for movement in SHM, where the entire 500 members, and there was mini- those who support them – have ac- SHM’s next hospital medicine team can come mal understanding as to the value cess to resources to keep them up to CEO, the for education, community, and that hospitalists could add to their date and demonstrate their value in Dr. Wellikson society has betterment of the care we provide health communities,” Dr. Wellikson America’s health care system. retained to our patients. We are indebted to said. “I am proud to say that, nearly During Dr. Wellikson’s tenure, Spencer Stuart, a leading global him beyond words.” 20 years later, SHM boasts a growing SHM launched its peer-reviewed executive and leadership advisory Those who are interested in lead- membership of more than 17,000, Journal of Hospital Medicine, the firm. The search process is being ing SHM into the future as its next and hospitalists are on the front line premier, ISI-indexed publication for overseen by a diverse search com- CEO are encouraged to contact ei- of innovation as a driving force in the specialty, successfully advocated mittee led by the president-elect of ther Jennifer P. Heenan (jheenan@ improving patient care.” for a Focused Practice in Hospital SHM’s Board of Directors, Danielle spencerstuart.com) or Mark Furman, SHM has grown not only its mem- Medicine certification option and C6 B. Scheurer, MD, SFHM, MSCR. MD ([email protected]). Hospitalist Movers and Shakers

By Matt Pesyna Technology Services. Previously, he was associate ty Board members work with chief of the division of hospital medicine, and he physicians and medical societies Mark Williams, MD, MHM, FACP, recently was also serves as medical director of telemetry. to develop Certification and appointed chief quality and transformation officer Dr. Chadha is the founder of the Kentucky MOC credentials to recognize for the University of Kentucky’s UK HealthCare chapter of SHM, where he is the immediate past physicians for their specialized (Lexington). Dr. Williams, a tenured professor in president. He is also the codirector of the Heart- knowledge and commitment to the division of hospital medicine land Hospital Medicine Conference. staying current in their field. at the UK College of Medicine, Dr. Gupta is a full-time prac- will serve as chair of UK Health- Amit Vashist, MD, MBA, CPE, FHM, FACP, FAPA, Dr. Gupta ticing hospitalist with Apogee Care’s Executive Quality Com- has been named chief clinical officer at Ballad Physicians and currently serves mittee. Dr. Williams will lead Health, a 21-hospital health as the director of the hospitalist program at Tex- integration of quality improve- system in Northeast Tennessee, as Health Arlington Memorial Hospital. He also ment, safety, and quality report- Southwest Virginia, Northwest serves as vice president for SHM’s North Central ing with data analytics. North Carolina, and Southeast Texas Chapter. Dr. Williams established the Kentucky. Dr. Williams first hospitalist program at a In his new role, he will focus T. Steen Trawick Jr., MD, was public hospital (Grady Memo- on clinical quality, value-based named the CEO of Christus rial Hospital) and academic hospitalist programs initiatives to improve quality Shreveport-Bossier Health at Emory University, Northwestern University, while reducing cost of care, per- System in Shreveport, La., in and UK HealthCare. An inaugural member of Dr. Vashist formance improvement, over- August 2019. SHM, he is a past president, was the founding sight of the clinical delivery of Dr. Trawick has worked for editor-in-chief of the Journal care, and will be the liaison to the Ballad Health Christus as a pediatric hospital- of Hospital Medicine, and led Clinical Council. Dr. Vashist is a member of The ist since 2005 and most recently SHM’s Project BOOST. Hospitalist’s editorial advisory board. has served concurrently as as- Dr. Trawick sociate chief medical officer for Also at UK HealthCare, Romil Nagendra Gupta, MD, FACP, CPE, has been ap- Sound Physicians. Through Sound Physicians, Dr. Chadha, MD, MPH, SFHM, pointed to the American Board of Internal Med- Trawick oversees the hospitalist and emergency FACP, has been named interim icine’s Internal Medicine Specialty Board. ABIM medical programs for Christus and other hospi- chief of the division of hospital Specialty Boards are responsible for the broad tals – 14 in total – in Texas and Louisiana. He has medicine and medical direc- definition of the discipline across Certification worked in that role for the past 6 years. tor of Physician Information Dr. Chadha and Maintenance of Certification (MOC). Special- Continued on following page September 2019 | 8 | The Hospitalist FROM THE SOCIETY Observation versus inpatient status A dilemma for hospitalists and patients

By Isha Puri, MD, MPH comparison of the data challenging. observation stay. In some cases, hos- Interestingly, the 2017 CMS data on pitals have to apply a condition code federal effort to reduce Evaluation and Management Codes 44 and retroactively change the stay health care expenditures by Specialty for the first time in- to observation status. has left many older Medi- cluded separate data for hospitalists, I attended the 2019 Society of Hos- care recipients experienc- based on hospitalists who creden- pital Medicine Annual Conference Aing the sticker shock of “observation tialed with Medicare using the new in Washington. Hospitalists from all status.” Patients who are not sick C6 specialty code. Based on that data, parts of the country advocated on enough to meet inpatient admission as for only at inpatient (99238-99239) Capitol Hill against the “observation criteria, however, still require hospi- and observation (99217) codes, 83% bill,” and “meet and greets” with con- talization, and may be placed under of the discharges were inpatient and gressional representatives increased Medicare observation care. 17% were observation. their opposition to the bill. These ef- Seniors can get frustrated, con- Physicians feel the pressure of forts may work in favor of protect- fused, and anxious as their status ing patients from surprise medical can be changed while they are in bills. Hospital medicine physicians the hospital, and they may receive are on the front lines for providing Dr. Puri is a hospitalist at Lahey large medical bills after they are dis- health care in the hospital setting; Hospital and Medical Center in charged. The Centers for Medicare they have demanded a fix to this Burlington, Mass. & Medicaid Services’ “3-day rule” legislative loophole which brings mandates that Medicare will not strained patient-physician relation- high out-of-pocket costs to our pay for skilled nursing facility care ships as a consequence of patients nation’s most vulnerable seniors. chest pain, abdominal pain, syncope, unless the patient is admitted as an feeling the brunt of the financing gap The observation status “2-midnight and migraine headache; in other “inpatient” for at least 3 days. Ob- related to observation status. Patients rule” utilized by CMS has increased words, patients with diagnoses for servation days do not count toward often feel they were not warned ad- financial barriers and decreased ac- which it is suspected that a less this 3-day hospital stay. equately about the financial ramifi- cess to post–acute care, affecting the than 24-hour stay in the hospital There has been an increase in out- cations of observation status. Even if provision of high-quality care for could be sufficient. patient services over the years since Medicare beneficiaries have received patients. Observation care is increasing 2006. The 2018 State of Hospital the Medicare Outpatient Observation My hospital has a utilization re- and can sometimes contribute Medicine Report (SoHM) highlights Notice, outlined by the Notice of Ob- view committee which reviews all to work-flow impediments and the percentage of discharges based servation Treatment and Implication cases to determine the appropriate- frustrations in hospitalists; thus, on hospitalists’ billed Current Pro- for Care Eligibility Act, they have no ness of an inpatient versus an obser- hospitalists are demanding reform. cedural Terminology codes. Codes rights to appeal. vation designation. (An interesting It has been proposed that observa- 99217 (observation discharge) and Currently Medicare beneficiaries question is whether the financial tion could be eliminated altogether 99238-99239 (inpatient discharge) admitted as inpatients incur only resources used to support this by creating a payment blend of were used to calculate the percent- a Part A deductible; they are not additional staff could be better as- inpatient/outpatient rates. Anoth- ages. 80.7% of adult medicine hospi- liable for tests, procedures, and signed to provide high-quality care.) er option could be to assign lower talist discharges were coded using nursing care. On the other hand, in Distribution of these patients is Diagnosis Related Group coding inpatient discharge codes, while observation status all services are determined on very specific criteria to lower acuity disease processes, 19.3% of patients were discharged billed separately. For Medicare Part as outlined by Medicare. Observa- instead of separate observation with observation discharge codes. B services (which covers observa- tion is basically considered a billing reimbursement. In the 2016 SoHM report, the ratio tion care) patients must pay 20% method implemented by payers to Patients and doctors lament that was 76.0% inpatient and 21.1% obser- of services after the Part B deduct- decrease dollars paid to acute care “Once you are in the hospital, you vation codes, and in the 2014 report ible, which could result in a huge hospitals for inpatient care. It per- are admitted!” I don’t know the we saw 80.3% inpatient and 16.1% financial burden. Costs for skilled tains to admission status, not to the right answer that would solve the observation discharges. But in both nursing facilities, when they are not level of care provided in the hospi- observation versus inpatient dilem- of those surveys, same-day admis- covered by Medicare Part A, because tal. Unfortunately, it is believed that ma, but it is intriguing to consider sion/discharge codes were also sepa- of the 3-day rule, can easily go up to no two payers define observation changes in policy that might focus rately reported, which did not occur $20,000 or more. Medicare benefi- the same way. A few examples of on the complete elimination of ob- in 2018. That makes year-over-year ciaries have no cap on costs for an common observation diagnoses are servation status.

Continued from previous page General in a variety of clinical leadership roles and chief medical officer at Inova Alexandria. Scott Shepherd, DO, FACP, has been selected since 2009. chief medical officer of the health data tech- James Napoli, MD, has been named chief medical nology company Verinovum in Tulsa, Okla. Dr. Rina Bansal, MD, MBA, recently was appointed officer for Blue Cross and Blue Shield of Arizona, Shepherd is the medical director for hospitalist full-time president of Inova Alexandria (Va.) Hos- after serving in an interim role medicine with St. John Health System in Tulsa, pital, after serving as acting president since No- since March. He assumed those and also medical director of the Center for Health vember 2018. Dr. Bansal has been at Inova since duties on top of his role as Systems Innovation at his alma mater, Oklahoma 2008, when she started as a hospitalist at Inova BCBSAZ’s enterprise medical di- State University in Stillwater. Fairfax (Va.). rector for health care ventures Dr. Bansal created and led Inova’s Clinical and innovation. Amanda Logue, MD, has been elevated to senior Nurse Services Hospitalist program through Dr. Napoli served previous- vice president and chief medical officer at Lafay- its department of neurosciences and has done ly as director of hospitalist ette (La.) General Hospital. A hospitalist/internist stints as Inova Fairfax’s associate chief medical services at Abrazo Arrowhead by training, Dr. Logue has worked at Lafayette officer, medical director of Inova Telemedicine, Dr. Napoli Campus (Glendale, Ariz.). the-hospitalist.org | 9 | September 2019 FROM THE SOCIETY Introducing SHM’s president-elect

By Danielle B. Scheurer, MD, administrative burdens, and high groups, local chapter meetings, SFHM, MSCR emphasis on care transitions, our and committee work); stimulation skills (and our patience) need to rise of research, new knowledge, and t is with great pleasure that I en- to these increasing demands. As a innovation; and promotion of evi- ter my president-elect year for the member-based society, SHM (and dence-based practice through our Society of Hospital Medicine! I am the board of directors) seeks to en- educational resources, publications, hopeful that this year will allow sure we are helping hospitalists be and other communications. The pur- Ime time to get to know the organi- the very best they can be, regardless pose of our existence is to provide zation even better than I already do, of type or practice setting. you what you need to improve your and truly understand the needs of The good news is that we are still work lives and your patients’ health. our members so I can focus on meet- in high demand. There has been an SHM has always fostered a “big- ing and exceeding your expectations! explosive growth in the need for hos- tent” philosophy, so we will continue I have been a hospitalist now pitalists, as we now occupy almost to explore ways to expand member- for 17 years and have practiced in every hospital setting in the United ship beyond “the core” of internal Dr. Scheurer is chief quality officer both academic tertiary care and States. But as a current commodity, medicine, family medicine, and and professor of medicine at community hospital settings. As it is imperative that we continue pediatrics, and reach a better under- the Medical University of South a chief quality officer, I also work to prove the value we are adding to standing of what our constituents Carolina, Charleston. She is the with improving quality and safety our patients and their families, the need and how we can add value to medical editor of The Hospitalist, in all health care settings, including systems in which we work, and the their work lives and careers. In addi- and president-elect of SHM. ambulatory, nursing homes, home industry as a whole. That is where tion to expanding membership with- health, and surgical centers. As such, our board and SHM come into play – in our borders, other expansions I hope I can bring a broad lens of to provide the resources you need to already include working with in- care for hospitalized patients.” the medical industry to this posi- improve health care. ternational chapters and members, My humble hope, as it is with tion, improving the lives and careers These resources come in the form with an “all teach, all learn” attitude any of my leadership positions, is of hospitalists and the patients and of education and training; leader- to better understand mutually ben- to leave SHM better than I found it. families they serve. ship and professional development; eficial partnerships with interna- Please contact me if you have ideas The demands placed on hospi- practice management assistance; tional members. Through all these or suggestions on how we can better talists are greater than ever. With advocacy work; mentored quality expansions, we will come closer to help you be successful in improving shortening length of stay, rising improvement; networking and proj- truly realizing our mission at SHM, the care for your patients, your sys- acuity and complexity, increasing ect work (through special interest which is to “promote exceptional tems, and health care as a whole. Webinar series: Effective documentation and coding

ospitalists cannot bill for everything they care or comanagement. Hospitalists are hired to ent categories of services, including observation do, but they can document and code to ob- be the gatekeepers – the ones overseeing patient and same-day admission/discharge. The series Htain appropriate reimbursements. It is im- care. When other consultants are on board, they reviews rules and challenges specific to those portant to know the factors that influence coding wind up sharing responsibilities, which can mud- sites of service, which impact not only providers to ensure accuracy and compliance. dy the waters, especially with billing and coding. in other service lines but also those who work in SHM developed the Clinical Documentation & It is important for hospitalists to understand the revenue cycle at the parent institution. How Coding for Hospitalists webinar series (formerly their role in comanagement and, in turn, how the each of these parties understands the nuances known as CODE-H) to provide the latest informa- payers view their role. explained in the series can directly affect the suc- tion on best practices in coding, documentation, We highlight everything – including require- cessful processing of the submitted claims. and compliance from nationally recognized ex- ments for history, exam, and medical decision Interpretation of rules when it comes to coding perts, along with the opportunity to claim CME. making – and review each component in depth. and documentation can vary at a local level. We The Hospitalist spoke with Carol Pohlig, BSN, We also discuss billing based on these key compo- raise awareness of local interpretations to ensure RN, CPC, ACS, course director of the series and a nents or, when appropriate, billing based on time. everyone involved in the documentation and coding and documentation expert at the Universi- However, when billing time-based services, you coding process knows things to look out for when ty of Pennsylvania Medical Center in Philadelphia. have to meet certain qualifications because it is reading rules. Everyone involved with billing and different from the standard way of reporting. coding can reflect on the implications that incor- What inspired the creation of Clinical Related to mitigating risk, EMRs and their copy rect coding may have on their hospital. Documentation & Coding for Hospitalists? and paste function is another topic we delve into. Providers are so busy trying to keep up with reg- It’s easy to pull forward information from a previ- Who would benefit from this series? ulations for their institution, such as malpractice ous note to help save time. However, it is import- Although we primarily had hospitalists of all and quality issues, that the focus isn’t always on ant to understand the ramifications. Each copied types in mind during the development of course documentation required for reimbursement. The and pasted encounter must be modified to make content, anyone who works as a practice manag- series rose out of a need for providers to under- it applicable to the current day’s patient and en- er, biller, coder, or internal auditor has the poten- stand key issues related to documentation and sure care is not being misrepresented. tial to benefit from the series. If they understand billing and some of the hurdles that they need to We believe that each of the eight modules in broader challenges in coding, it could help them overcome – or need to be aware of. the series offers something unique that will help proactively prevent issues throughout the pro- improve documentation and coding practices. cess with more accurate documentation that What are some challenges that hospitalists could reduce claims denials. encounter when coding, and how does this How can this series go beyond the HM care series help to address these challenges? team and affect the institution as a whole? For more information, visit hospitalmedicine.org/ Some common challenges relate to concurrent Hospitalists are involved in a number of differ- coding. September 2019 | 10 | The Hospitalist that the feeling was similar to the dread inspired by the phrase “winter Burnout Continued from page 1 is coming” in the popular HBO series “Game of Thrones.” “We’ve not had anybody leave the reported high stress, 38% said they Annual Conference, questioned Systematic reviews of the liter- hospital because of burnout or dis- were “burned out,” 50% said they whether the standard 7-days-on, ature have found that it’s mostly satisfaction” since the new system felt they had “low control” over their 7-days-off work schedule – seven changes at the organization level was put into place, Dr. Borsadia said. work, and 60% said they felt high 12-hour shifts followed by 7 days – rather than changes that an indi- “Less burnout means more people documentation pressures. Still, 68% off – allows hospitalists to pair their vidual physician makes on his or her are happy.” said they were works lives with their personal lives own – that tend to make significant Although symptoms of burnout satisfied with the in a sustainable way. They described differences. Changes to structure, still seem to be rampant across hos- values of their de- the way that the stress and fatigue communication, and scheduling pital medicine, hospitalists are put- partments. of such an intense work period tend to work better than working on ting potential solutions into place. Hospitalists bleeds into the days off that follow mindfulness, education, or trying to And – sometimes – they are making surveyed were after it. improve resilience, Dr. Michtalik said. progress, through tweaks in sched- actually less “By the end of seven 12’s, they’re In one study discussed at the ules and responsibilities, incentives likely to say they bleary eyed, they’re upset, they go HM19 workshop, researchers suited to different goals, and better were burned out, home (for) 2 days of washout before compared a schedule in which an communication. Dr. Michtalik compared with they even start to enjoy whatever intensivist works in-house for 7 outpatient in- life they have left,” said Jonathan days, with home call at night, to a Scheduling problems ternists – 52%, compared with 55% Martin, MD, director of medicine schedule in which the intensivist The need for continuing efforts to – but they were more likely to score at Cumberland Medical Center in is completely off at night, with an improve the work experience for low on a scale measuring personal Crossville, Tenn. “It’s hard to get hos- in-house intensivist covering the hospitalists is apparent, said Henry accomplishments, compared with pitalists to buy in, which increases night shift. The schedule in which Michtalik, MD, MPH, MHS, assistant the outpatient clinicians – 20% ver- their dissatisfaction.” the intensivist was truly off for the professor of general internal med- sus 10%. The survey found no sig- Dr. Michtalik had a similar per- night significantly reduced reports icine at Johns Hopkins, Baltimore, nificant difference between the two spective. of burnout, while not affecting who led a workshop on the topic at groups in depression or suicidality. “You just shut the rest of your life length of stay or patient-experience the 2019 Annual Conference of the But with 40% reporting depression down completely for those 7 days outcomes. Society of Hospital Medicine (HM19). and 10% reporting thoughts of sui- and then, on your 7 days off, you’ve Dr. Michtalik said that another A 2016 survey of academic general cide, the numbers virtually cry out scheduled your life,” he said. “But study compared 4-week rotations to internal medicine clinicians – includ- for solutions. that last off day – day number 7 – 2-week rotations for attending phy- ing about 600 hospitalists and out- Hospitalists in the HM19 work- you feel that pit in your stomach, sicians. Researchers found that the patient physicians – found that 67% shop, as in other sessions at the that the streak is coming.” He joked Continued on following page

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Ruth M. Thomson Chirag Raini Patel Kate M. Lally

Edited by Joseph W. Shega Miguel A. Paniagua Visit aahpm.org/essentials to learn how your team can best care for these patients.

the-hospitalist.org | 11 | September 2019 Continued from previous page nurse in an office taking calls from grams for wellness, offering time 2-week version resulted in lower re- 6 p.m. to 7 a.m., so that rounders and funding for physician support ports of burnout, with readmissions can stop taking floor calls during meetings, supporting flexibility in and patient experience unaffected, that time. work hours, and creating programs although they noted that residents The system “takes the pressure off specifically to help clinicians with tended to prefer 4-week schedules our admitters at night and our nurs- burnout symptoms. because they felt it resulted in bet- es because they’re not getting floor She also touted the benefits of ter relationships with the attending calls anymore, so they’re just taking “Schwartz Rounds,” in which several physician. care of the admissions from the ER,” medical disciplines gather to talk Perhaps the dominant factor in he said. about a case that was particularly job satisfaction that’s been identi- A recurring theme of the discus- challenging, clinically complex, and fied in surveys is how physicians, sion was that salary alone seems emotionally draining for everyone patients, and administrators relate universally incapable of eradicating involved. to one another, Dr. Michtalik said. feelings of burnout. One hospitalist At Cumberland Medical Center, “The important concept here is said that in surveys, higher-paid Dr. Martin said he has two meet- that relationships were really im- physicians insist that monetary ings a month with executives in the portant in driving job satisfaction, compensation is their main driver, hospital’s C-suite. One is with his whether that be with our colleagues, but still often complain of burn- hospitalist group, TeamHealth, and our patients, or with the staff that out because they must work extra you’re working with,” he said. “It’s shifts to earn that higher level of always easier to decline a consulta- pay. By the time the end of tion or have a bad interaction with Dr. Rahul C. Borsadia Instead, burnout and satisfaction the“ day comes, it’s 9 or someone over the phone than it is if indicators tend to have more do to you actually know them or you are helps keep hospitalists involved in with time, control, and support, Dr. 10 p.m. and you are leaving communicating face to face. That’s hospital matters, limiting the effects Michtalik noted. but coming back at 6:30 why it’s important to develop these of burnout and improving work- Mangla Gulati, MD, SFHM, chief kinds of relationships, which also place satisfaction. quality officer at the University of the next morning. So, lack put a face to what’s going on.” Kevin McAninch, DO, a hospi- Maryland Medical Center in Balti- of sleep, more patients, talist with Central Ohio Primary more, said that there’s no big secret striving to earn that Beyond salary adjustments Care in Westerville, said a shift in about what hospitalists want from Hospitalists attending the HM19 work responsibilities has made an their places of employment. They higher salary. The desire workshop said they thought that improvement at his hospital. There want things like getting patients to to perform quality work participating in administration com- is now an “inpatient support cen- service faster so they can make diag- mittees at their own institutions ter” – which has a physician and a noses, making sure patients get the with that kind of patient care they need, fixing the problems load was not fulfilled and associated with electronic medical that led to dissatisfaction records, and having a work-life “inte- gration.” and stress, which led to “The questions is – how do we get irritation and exodus from there?” Dr. Gulati wondered. She suggested that hospitalists have to the group. be more assertive and explanatory ” in their interactions with members one is more direct, between him- Download the new of the hospital C-suite. self and hospital administrators. “I think it’s really important for It’s just 2 hours a month, but these SHM Education app you to understand or ask your conversations have undoubtedly C-suite, ‘Where are you in this helped, he said, although he cau- whole journey? What is your per- tioned that “the meetings them- ception of wellness? Tell me some selves don’t have as much meaning of the measures of staff wellness,’ ” if you aren’t communicating effec- she said. tively,” meaning hospitalists must If the C-suite says “we have no understand how the C-suite thinks money” to make improvements, and learn to speak in terms they hospitalists must be willing to say, understand. New member ‘Well, you’re going to have to invest “When I go to the administration benefit available! a little bit.’ ” Dr. Gulati said. “What now and I say ‘Hey, this is a problem is the ROI [return on investment] that we’re having. I need your help SHM members can earn up to 20 CME on the turnover of a physician? in solving it,’ the executives are and MOC credits each year FREE by Because when you turn a physician much more likely to respond to me answering the Question of the Day. over, you have to recruit and hire than if they’d never seen me, or only new staff.” see me rarely,” Dr. Martin said. Dr. Gulati said that hospitalists As a result, a collaborative ap- Accreditation Statement should provide C-suite leaders with proach to such conversations tends The Society of Hospital Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. a detailed walk-through of their to be more effective. actual workflows – what their work- “If you go to the C-suite and say, days look like – because “it’s not ‘Here’s our issue, how can you help something they’re familiar with.” us?’ – as opposed to telling the ad- hospitalmedicine.org/eduapp Aside from improving relations ministration, ‘This is what I need’ with hospital administration, Dr. – they are more likely to work with Gulati suggested creating CME pro- you to generate a solution.” September 2019 | 12 | The Hospitalist CLINICAL

Key Clinical Question Managing alcohol withdrawal in the hospitalized patient Symptom-triggered therapy has multiple benefits

By Veevek Agrawal, DO; Svetlana Chernyavsky, DO; Patricia Dharapak, MD; Erica Grabscheid, MD; Eve Merrill, MD; Kamana Pillay MD; and Dahlia Rizk, DO, MPH

gered regimens, however, depends monotherapy or in conjunction with Case on the reliability and accuracy of benzodiazepines, could have compa- A 57-year-old man with a history the patient assessment. A fixed-in- rable or superior results in compar- of alcohol abuse (no history of terval benzodiazepine-dosing ap- ison to other treatments, including seizures) presents to the ED “feeling proach where benzodiazepines are benzodiazepines monotherapy.10 Fur- awful.” He claims his last drink was administered regardless of symp- ther studies are needed to determine 1 day prior. Initial vital signs are: toms is useful when frequent mon- dosing and the most effective way to T = 99.1°F, HR 102 bpm, BP 162/85 mm itoring and reassessment are not incorporate the use of phenobarbital Hg, respirations 18/minute, and 99% feasible or are unreliable. in treatment of alcohol withdrawal es ma G

oxygen saturation. He is tremulous, i syndrome (AWS). diaphoretic, and has an unsteady What about phenobarbital? gait. What is the best way to manage Phenobarbital has similar pharma- Should gabapentin or any other his symptoms while hospitalized? cokinetics to the benzodiazepines medications be added to his treat- /G etty ispanolistic

H frequently used for alcohol with- ment regimen? drawal, including simultaneous ef- Chronic alcohol use induces a re- Brief overview of the issue ative effect and thus slows the pro- fects on gamma-aminobutyric acid duction in GABA activity (the major With over 15 million people with gression of withdrawal symptoms. (GABA) and N-methyl-D-aspartate inhibitory neurotransmitter in the alcohol use disorder (AUD) in the Long-acting benzodiazepines, such (NMDA) receptors, and has been brain) and alcohol cessation results United States alone, alcohol depen- as chlordiazepoxide and diazepam, proposed as a treatment option for in decreased inhibitory tone. This dence and misuse remain significant are the preferred choices for most delirium tremens. physiologic imbalance contributes issues among hospitalized patients.1 patients. Their active metabolites In 2019, as reported in the Ameri- to the syndrome of alcohol with- It is estimated that over 20% of ad- have a rapid onset of action and their can Journal of Emergency Medicine, drawal. As such, gabapentin has mitted patients meet DSM-5 criteria long half-lives allow for a lower in- Nelson et al. found that incorporat- emerged as a promising treatment for AUD and that over 2 million cidence of breakthrough symptoms ing phenobarbital into a benzodiaze- option in AWS and may help reduce will withdraw each year.2,3 Acute and rebound phenomena such as sei- pine-based protocol or as sole agent the need for benzodiazepines. withdrawal includes a spectrum zures.6 Benzodiazepines with shorter led to similar rates of ICU admission, Gabapentin has few drug-drug of symptoms ranging from mild half-lives, such as lorazepam and length of stay, and need for mechani- interactions and is safe for use in anxiety and diaphoresis to hallu- oxazepam, are preferred in patients cal ventilation in patients treated for patients with impaired liver func- cinations, seizures, and delirium with liver dysfunction and those alcohol withdrawal in the emergency tion; however, dosage adjustment is tremens. Onset of these symptoms prone to respiratory depression. department.9 The authors concluded required for renal dysfunction (CrCl ranges from 24 hours up to 5 days. Intravenous administration has a that “phenobarbital (was) a safe and less than 60 mL/min). Gabapentin’s Severe alcohol withdrawal syn- rapid onset of action and is the stan- effective treatment alternative for neuroprotective effects may also drome (SAWS) attributable to abrupt dard administration route of choice alcohol withdrawal.” The systematic help decrease the neurotoxic effects discontinuation of alcohol leads to in patients with acute severe with- review by Hammond et al. in 2017 associated with AWS. Common side increased morbidity and mortality; drawal, delirium tremens, and sei- found that phenobarbital, either as Continued on following page therefore, early detection and pre- zure activity. In patients with mild vention in the acute care setting is withdrawal symptoms or those in Key Points critical. Several factors can help pre- the outpatient setting, oral adminis- dict who may withdraw, and once tration is generally effective.6 • Alcohol use disorder and alcohol withdrawal are significant problems detected, pharmacological treatment The Clinical Institute Withdrawal in hospitalized patients; early detection and treatment are crucial in is necessary.4 Thorough evaluation Assessment (CIWA) is one common- preventing high morbidity and mortality. and treatment can help reduce mor- ly used titration model that requires • Long-acting benzodiazepines with active metabolites such as chlor- tality from the most severe forms of calculation of a symptom-based diazepoxide and diazepam are the preferred treatment for alcohol alcohol withdrawal including delir- withdrawal score. Data have consis- withdrawal except for patients with advanced liver disease or those ium tremens, which has up to 40% tently demonstrated that a symp- prone to respiratory depression. mortality if left untreated.5 tom-triggered method results in • Symptom-triggered therapy decreases the amount of medication, administration of less total benzodi- shortens treatment duration, and decreases inpatient length of stay, Overview of the data azepines over a significantly shorter compared with fixed-schedule dosing. How do we use benzodiazepines to duration, thereby reducing cost and • Gabapentin may be effective in the treatment of mild to moderate AWS treat alcohol withdrawal? duration of treatment and minimiz- but cannot yet be routinely recommended as monotherapy in severe Benzodiazepines are the mainstay of ing side effects. This regimen may withdrawal, in patients with seizure history, or in patients who are at alcohol withdrawal treatment. Ben- also reduce the risk of undermedi- high risk for progression to delirium tremens. zodiazepines work by stimulating the cating or overmedicating a patient • Thiamine deficiency is common in chronic alcohol use disorders; thia- gamma-aminobutyric acid (GABA) since the dosing is based upon an mine repletion should be considered for patients at risk or when Wer- receptor resulting in a reduction of individual’s symptoms.7,8 nicke’s encephalopathy and Korsakoff’s syndrome are suspected. neuronal activity. This leads to a sed- The efficacy of symptom-trig- the-hospitalist.org | 13 | September 2019 CLINICAL | Key Clinical Question Additional reading

Wernicke’s encephalopathy had 1. Perry EC. Inpatient man- been defined as a triad of ataxia, agement of acute alcohol with- ophthalmoplegia, and global con- drawal syndrome. CNS Drugs. fusion. However, Harper et al. dis- 2014;28(5):401-10. covered that only 16% of patients 2. Mayo-Smith MF. Pharmaco- presented with the classic triad logical management of alcohol and 19% had none of these signs.15 withdrawal: A meta-analysis Diagnosis is clinical since thiamine and evidence-based practice Dr. Agrawal Dr. Chernyavsky Dr. Dharapak Dr. Grabscheid serology results do not accurately guideline. JAMA. 1997;278(2):144- represent brain storage. 51. Dr. Agrawal, Currently, there are no consis- 3. Mayo-Smith MF et al. for Dr. Chernyavsky, tent guidelines regarding repletion the Working Group on the Man- Dr. Dharapak, of thiamine administration in the agement of Alcohol Withdrawal Dr. Grabscheid, treatment or prevention of WE Delirium, Practice Guidelines Dr. Merrill, Dr. attributable to alcohol overuse. Thi- Committee, American Society of Pillay, and Dr. Rizk amine has a safe toxicity profile as Addiction Medicine. Management are hospitalists at excess thiamine is excreted in the of alcohol withdrawal delirium: Mount Sinai Beth urine. Outside of rare reports of ana- An evidence-based practice Dr. Merrill Dr. Pillay Dr. Rizk Israel in New York. phylactoid reactions involving large guideline. Arch Intern Med. parenteral doses, there is no concern 2004;164(13):1405-12. for overtreatment. As Wernicke-Kor- Continued from previous page psychiatric comorbidities remains sakoff syndrome is associated with effects of gabapentin include dizzi- limited. Additional studies are need- significant morbidity and mortality, References ness, drowsiness, ataxia, diarrhea, ed to standardize dosing protocols high doses such as 200-500 mg are 1. CDC - Fact Sheets: “Alcohol Use And Health – Alcohol.” Centers for Disease Control and nausea, and vomiting. The potential and treatment strategies for both recommended to ensure blood-brain Prevention, 3 Jan 2018. for misuse has been reported. inpatients and outpatients. barrier passage. The intravenous 2. Rawlani V et al. Treatment of the hospital- In several small studies, gabapen- Alternative agents such as antipsy- route is optimal over oral adminis- ized alcohol-dependent patient with alcohol tin monotherapy was found to be chotics (e.g., haloperidol), centrally tration to bypass concerns of gastro- withdrawal syndrome. Internet J Intern Med. 2008;8(1). comparable to benzodiazepines in acting alpha agonists (e.g., clonidine), intestinal malabsorption. Thiamine 2 3. Grant BF et al. Epidemiology of DSM-5 alco- the treatment of mild to moderate beta-blockers, and an agonist of the 100 mg by mouth daily for ongoing hol use disorder: Results from the National AWS. Gabapentin is efficacious in GABA-B receptor (e.g., baclofen) may supplementation can be considered Epidemiologic Survey on Alcohol and Related reducing cravings as well as improv- also attenuate the symptoms of with- for patients who are at risk for WE. Conditions III. JAMA Psychiatry. 2015;72:757. ing mood, anxiety, and sleep, and drawal. Since these all have limited It is also important to recognize that 4. Wood E et al. Will this hospitalized patient develop severe alcohol withdrawal syndrome?: showed an advantage over benzodi- evidence of their efficacy and have magnesium and thiamine are in- The Rational Clinical Examination Systematic azepines in preventing relapse with potential for harm, such as masking tertwined in several key enzymatic Review. JAMA. 2018;320:825. no difference in length of hospital symptoms of progressive withdrawal pathways. For the responsiveness of 5. Sarkar S et al. Risk factors for the development stay. 6,11 Given the small sample sizes and lowering seizure threshold, these thiamine repletion to be optimized, of delirium in alcohol dependence syndrome: Clinical and neurobiological implications. Indian of these studies and the differing agents are not routinely recommend- magnesium levels should be tested J Psychiatry. 2017 Jul-Sep;59(3):300-5. methods, settings, and inclusion/ ex- ed for use. Valproic acid/divalproex, and repleted if low. 6. Sachdeva A et al. Alcohol withdrawal clusion criteria used, the generaliz- levetiracetam, topiramate, and zonis- syndrome: Benzodiazepines and beyond. J ability of these findings to patients amide have also showed some effica- Application of the data to our Clinical Diagn Res. 2015 Sep 9(9). with significant medical and/or cy in reducing symptoms of alcohol patient 7. Sullivan JT et al. Benzodiazepine require- ments during alcohol withdrawal syndrome: withdrawal in limited studies. The Nurses are able to frequently mon- Clinical implications of using a standardized data on prevention of withdrawal itor the patient so he is started on withdrawal scale. J Clin Psychopharmacol. Quiz seizures or delirium tremens when symptom-triggered treatment with 1991;11:291-5. used as monotherapy are less ro- chlordiazepoxide using the CIWA 8. Saitz R et al. Individualized treatment for alco- 12 hol withdrawal. A randomized double-blind A 51-year-old female with a bust. protocol. This strategy will help lim- controlled trial. JAMA. 1994;272(7):519. history of hypertension and it the amount of benzodiazepines he 9. Nelson AC et al. Benzodiazepines vs. barbitu- continuous alcohol abuse pres- A daily multivitamin and folate receives and shorten his treatment rates for alcohol withdrawal: Analysis of 3 differ- ents to the hospital with fever are ordered. What about thiamine? duration. Given the ataxia, the pa- ent treatment protocols. Am J Emerg Med. 2019 Jan 3. and cough. She is found to have Does the route matter? tient is also started on high-dose IV 10. Hammond DA et al. Patient outcomes asso- community-acquired pneumonia Alarmingly, 80% of people who chron- thiamine three times a day to treat ciated with phenobarbital use with or with- and is admitted for treatment. ically abuse alcohol are thiamine possible Wernicke’s encephalopathy. out benzodiazepines for alcohol withdrawal How else would you manage this deficient.13 This deficiency is attrib- Gabapentin is added to his regimen syndrome: A systematic review. Hosp Pharm. 2017 Oct;52(9):607-16. patient? utable to several factors including in- to help manage his moderate alcohol 11. Mo Y et al. Current practice patterns in the A. Start scheduled benzodiaze- adequate oral intake, malabsorption, withdrawal syndrome. management of alcohol withdrawal syndrome. pines and oral thiamine. and decreased cellular utilization. Thi- P T. 2018 Mar;43(3):158-62. B. Start CIWA protocol using a amine is a crucial factor in multiple Bottom line 12. Leung JG et al. The role of gabapentin long-acting benzodiazepine and enzymatic and metabolic pathways. Long-acting benzodiazepines using in the management of alcohol withdrawal and dependence. Ann Pharmacother. 2015 oral thiamine. Its deficiency can lead to free radical symptom-triggered administration Aug;49(8):897-906. C. Start scheduled benzodiaze- production, neurotoxicity, impaired when feasible are the mainstay of 13. Martin P et al. The role of thiamine deficiency pines and IV thiamine. glucose metabolism, and ultimately, treating alcohol withdrawal. Other in alcoholic brain disease. Alcohol Res Health. D. Start CIWA protocol using a cell death.14 A clinical concern stem- medications such as gabapentin, car- 2003:27(2):134-42. long-acting benzodiazepine and ming from thiamine deficiency is the bamazepine, and phenobarbital can 14. Flannery A et al. Unpeeling the evidence for the banana bag: Evidence-based recommenda- consider IV or oral thiamine. development of Wernicke’s enceph- be considered as adjunctive agents. tions for the management of alcohol-associated Answer: D. Symptom-triggered alopathy (WE), which is potentially Given the high rate of thiamine vitamin and electrolyte deficiencies in the ICU. benzodiazepine therapy is favored reversible with prompt recognition deficiency and the low risk of over- Crit Care Med. 2016 Aug:44(8):1545-52. as is consideration for thiamine and treatment, in comparison to its replacement, intravenous thiamine 15. Harper CG et al. Clinical signs in Wernicke Korsakoff complex: A retrospective analysis repletion in the treatment of AWS. irreversible amnestic sequela, Korsa- can be considered for inpatients of 131 cases diagnosed at autopsy. J Neurol koff’s syndrome. with AWS. Neurosurg Psychiatry. 1986;49(4):341-5. September 2019 | 14 | The Hospitalist Treating patients with my invasive fungal infection UNDERSTANDING (IFI), or at risk for one? invasive fungal infection

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HOSP_15.indd 1 8/6/2019 2:38:49 PM CLINICAL In the Literature Clinician reviews of HM-centric research

By Steven Deitelzweig, MD, SFHM, MMM; Halle Field, MD; Caley McIntyre, MD; Ryan Nelson, MD; Jeremiah Newsom, MD, MSPH; and Kristen Rogers, MD, MPH Ochsner Health System, New Orleans

IN THIS ISSUE there are over 1 million visits to EDs an order placed in their record that for syncope with a greater than 50% was meant for another patient in 1. No rise in major hemorrhagic events with antiplatelet therapy after ICH hospitalization rate for older adult 2016. The Office of the National Coor- 2. Hospital vs. outpatient management comparable for elderly syncope patients. There remains uncertain- dinator for Health Information Tech- patients ty around which patients without nology and the Joint Commission 3. Order errors not reduced with limiting number of open records an identified cause for the syncope recommend that 4. Patent foramen ovale linked with increased risk of ischemic stroke in PE could be discharged from the ED and EHRs limit the 5. Restrictive IV fluid strategy comparable to usual care for severe sepsis, managed as an outpatient. number of open septic shock STUDY DESIGN: Propensity score records to one at 6. A dedicated mobility technician improves inpatient mobility analysis. a time based on 7. Successful bowel preps linked with modifiable risk factors SETTING: EDs from 11 nonprofit ac- expert opinion 8. Continued extension of time for thrombolysis in stroke ademic hospitals. only. There is wide SYNOPSIS: Prospective data for variation in the 2,492 patients aged 60 years and number of open By Steven Deitelzweig, MD, providers. No significant difference older who did not have an identified Dr. Field records allowed SFHM, MMM was identified in rates of recurrent cause in the ED for their presenting among EHRs No rise in major hemorrhagic ICH (adjusted hazard ratio, 0.51; 95% complaint of syncope were includ- across the United States currently. 1events with antiplatelet confidence interval, 0.25-1.03), major ed in the propensity score analysis STUDY DESIGN: Randomized clini- therapy after ICH hemorrhagic events (aHR, 0.71; 95% resulting in a sample size of 1,064 cal trial. CI, 0.39-1.30), or major occlusive vas- with 532 patients in each of the dis- SETTING: Large health system in CLINICAL QUESTION: Does the cular events (aHR, 1.02; 95% CI, 0.65- charged and hospitalized groups. New York. risk of increased recurrent intra- 1.60) between groups. There was no significant difference SYNOPSIS: There were 3,356 cli- cerebral hemorrhage (ICH) exceed Hospitalists should be aware in risk of 30-day post-ED serious nicians (inpatient, outpatient, ED) the benefits of decreased vaso-oc- that these data suggest that the adverse events between the hospital- randomized in a 1:1 ratio into either a clusive events for risk assessment for resumption of ized patients (4.89%; 95% confidence restricted group (one open record at patients resuming antiplatelet agents should not be interval, 3.06%-6.72%) and discharged a time) or an unrestricted group (up antiplatelet ther- affected by a history of nontraumat- patients (2.82%; 95% CI, 1.41%-4.23%; to four open records at a time). In this apy following an ic intracerebral hemorrhage when risk difference 2.07%; 95% CI, –0.24% study, 12,140,298 orders, in 4,486,631 ICH? weighed against the benefit of these to 4.38%). There was also no statisti- order sessions, were analyzed with BACKGROUND: medications in patients with occlu- cally significant difference in 30-day the Wrong-Patient Retract-and-Re- Antiplatelet sive vascular disease. mortality post–ED visit. order (RAR) measure to identify agents reduce BOTTOM LINE: Resumption of These results show no clinical wrong-patient orders. The proportion the risk of major antiplatelet agents following intra- benefit in hospitalization for older of wrong-patient order sessions were Dr. Deitelzweig vascular events cerebral hemorrhage showed no ev- adults with unexplained syncope 90.7 vs. 88.0 per 100,000 order sessions in patient with idence of increased risk of recurrent after ED evaluation suggesting that for the restricted versus unrestricted established vaso-occlusive disease, intracerebral hemorrhage or major it would be reasonable to proceed groups (odds ratio, 1.03; 95% confi- but they may increase the risk of hemorrhagic events. with outpatient management and dence interval, 0.90-1.20). There were ICH. Patients with prior ICH are CITATION: RESTART Collaboration. evaluation of these patients. no statistically significant differences at risk for both vaso-occlusive and Effects of antiplatelet therapy after BOTTOM LINE: Consider discharging in wrong-patient order sessions be- hemorrhagic events. Clarification of stroke due to intracerebral haem- older patients home from the ED who tween the restricted and unrestricted the relative risk and benefit of anti- orrhage (RESTART): A randomized, do not have high risk factors and no groups in any clinical setting exam- platelet agent use in this clinical sce- open-label trial. Lancet. 2019. doi: identified cause of their syncope. ined (inpatient, outpatient, ED). nario would serve to guide therapy. 10.1016/S0140-6736(19)30840-2. CITATION: Probst MA et al. Clinical Despite the ability to have up to STUDY DESIGN: Prospective, Dr. Deitelzweig is system department benefit of hospitalization for older four open records at one time in the open-label, randomized parallel chair of hospital medicine at Ochsner adults with unexplained syncope: A unrestricted group, 66% of the order group trial. Health System, New Orleans. propensity-matched analysis. Ann sessions were completed with only SETTING: 122 hospitals located in Emerg Med. 2019 Aug;74(2):260-9. one record open in that group. This the United Kingdom. By Halle Field, MD limited the power of the study to SYNOPSIS: The study included 537 Hospital vs. outpatient Order errors not reduced detect a difference in risk of order adult patients with imaging-con- 2 management comparable for 3 with limiting number of errors between the restricted and firmed, nontraumatic intracerebral elderly syncope patients open records unrestricted groups. hemorrhage who were previously BOTTOM LINE: Limiting clinicians prescribed antithrombotic medica- CLINICAL QUESTION: Is there a CLINICAL QUESTION: What is the to only one open record did not tions were randomized in 1:1 fashion difference in risk of post-ED serious risk of wrong-patient orders in an reduce the proportion of wrong-pa- to either start or avoid antiplatelet adverse events at 30 days in older EHR limiting clinicians to one open tient orders, compared with allowing therapy. Participants were followed adults with unexplained syncope record versus allowing up to four up to four open records concurrently. up on an annual basis with postal when managed as an outpatient ver- open records concurrently? CITATION: Adelman JS et al. Ef- questionnaires both to the par- sus with hospitalization? BACKGROUND: An estimated fect of restriction of the number ticipants and their primary care BACKGROUND: In the United States, 600,000 patients in U.S. hospitals had of concurrently open records in September 2019 | 16 | The Hospitalist CLINICAL | In the Literature an electronic health record on with contrast transthoracic echocar- in Patients With Pulmonary Embo- come of 30-day mortality was similar wrong-patient order errors: A diography and for ischemic stroke lism: A Prospective Cohort Study. between groups (odds ratio, 1.02; 95% randomized clinical trial. JAMA. with cerebral magnetic resonance Ann Intern Med. 2019;170:756-63. confidence interval, 0.41-2.53). 2019;32(18):1780-7. imaging. The overall frequency of Limitations to RIFTS include its Dr. Field is a hospitalist at Ochsner ischemic stroke at the time of PE Restrictive IV fluid strategy small sample size, single-system de- Health System, New Orleans. diagnosis was high (7.6%), and was 5 comparable to usual care for sign, and inadequate power to detect nearly four times higher in the PFO severe sepsis, septic shock noninferiority or superiority. While By Caley McIntyre, MD group than the non-PFO group larger, multicenter trials are required Patent foramen ovale (21.4% vs. 5.5%; difference in propor- CLINICAL QUESTION: Will restric- for further investigation, hospitalists 4 linked with increased risk of tions, 15.9 percentage points; 95% tive IV fluid resuscitation yield should note a trend toward conser- ischemic stroke in PE confidence inter- similar clinical outcomes for severe vative IV fluid administration in se- val, 4.7-30.7). sepsis and septic shock similar to vere sepsis and septic shock. CLINICAL QUESTION: Is patent This study adds those of usual-care resuscitation? BOTTOM LINE: Restrictive IV fluid foramen ovale (PFO) associated with to the growing BACKGROUND: Since the advent of resuscitation for severe sepsis and increased risk of ischemic stroke in body of data early goal-directed therapy (EGDT), septic shock may result in mortality patients diagnosed with acute pul- which supports studies have challenged the notion rates similar to those of usual care, monary embolism (PE)? the association of that high-volume IV fluid resuscita- but larger, multicenter studies are BACKGROUND: Studies have ischemic stroke tion improves clinical outcomes in needed to confirm noninferiority. demonstrated the increased risk for with PFO and PE. sepsis and septic shock. The optimal CITATION: Corl KA et al. The restric- ischemic stroke in patients diagnosed Dr. McIntyre Given the mod- IV fluid resuscitation strategy for tive IV fluid trial in severe sepsis with acute PE, and data support the erate indication severe sepsis and septic shock re- and septic shock (RIFTS): A ran- mechanism of paradoxical embolism for indefinite anticoagulation in pa- mains unclear. domized pilot study. Crit Care Med. via PFO. However, the frequency of tients at high risk for recurrent PE STUDY DESIGN: Prospective ran- 2019;47(7):951-9. this phenomenon is unknown and and stroke, there may be a role for domized controlled trial. Dr. McIntyre is a hospitalist at Ochs- the strength of the association be- screening for PFO in patients with SETTING: Two critical care units in ner Health System, New Orleans. tween PFO and ischemic stroke in acute PE so that they can be appro- one academic system. patients with PE is unclear. priately risk stratified. SYNOPSIS: The Restrictive IV Flu- By Ryan Nelson, MD STUDY DESIGN: Prospective cohort BOTTOM LINE: The presence of id Trial in Severe Sepsis and Septic A dedicated mobility study. ischemic stroke in patients with Shock (RIFTS) randomized 109 partic- 6 technician improves SETTING: Four French hospitals. acute pulmonary embolism is high, ipants ages 54-82 years to a restrictive inpatient mobility SYNOPSIS: 315 patients aged 18 and there is a strong association (less than 60 mL/kg) or to usual care years and older presenting with with PFO. (no prespecified limit) IV fluid resus- CLINICAL QUESTION: Does provid- acute symptomatic PE were evaluat- CITATION: Le Moigne E et al. Patent citation strategy for the first 72 hours ing a dedicated mobility technician ed at the time of diagnosis for PFO Foramen Ovale and Ischemic Stroke of ICU admission. The primary out- Continued on following page

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the-hospitalist.org | 17 | September 2019 CLINICAL | In the Literature

Continued from previous page ing mobility via in-hospital ambula- cluding opiate use within 3 days of for ischemic stroke recommend the to assist older inpatients with regu- tion protocol delivered by mobility colonoscopy, colonoscopy performed time to thrombolysis be within 4.5 lar ambulation improve functional technicians: A pilot randomized con- before noon, and solid diet the day hours after onset of stroke. Guide- status and outcomes? trolled trial. J Hosp Med. 2019;14:272-7. before colonoscopy, were associated lines are based on noncontrasted CT, BACKGROUND: Studies have shown Dr. Nelson is a hospitalist at Ochsner with IBP. After adjustment for these but CT perfusion and perfusion-dif- improved hospital outcomes in pa- Health System, New Orleans. variables, they found the rates of fusion MRI may show salvageable tients who ambulate regularly. Many IBP were reduced by 5.6%. They also brain tissue beyond the 4.5 hours. assisted mobility protocols aimed at By Jeremiah Newsom, MD, found that patients who had IBP had Studies have shown better outcomes ambulating patients multiple times MSPH increased length of stay by 1 day (6 in patients who were chosen for P daily are nurse centered. However, Successful bowel preps days vs. 5 days; less than .001). This reperfusion based on tissue viabil- implementation is difficult because 7 linked with modifiable risk translates into 494 unnecessary hos- ity rather than time from onset of of the large number of nursing duties factors pital days or approximately $1 million stroke. This has and difficulty finding time away from dollars in unnecessary costs based on resulted in a dis- other competing responsibilities. CLINICAL QUESTION: What are the number of patients (almost 9,000). parity between STUDY DESIGN: modifiable risk factors associated This study was performed in a sin- the time windows Single-blind with inadequate bowel preparation gle institution so it may be difficult used for throm- randomized con- (IBP), and what is the association in to extrapolate to other institutions. bolysis. trolled trial. hospitalized patients? Further studies need to be per- STUDY DESIGN: SETTING: Sin- BACKGROUND: IBP is very com- formed using multicenter institu- Multicenter, gle-center 1,440- mon and associated with increased tions to assess accuracy of data. randomized, pla- bed tertiary care length of stay and cost of care. BOTTOM LINE: Liquid diet or noth- Dr. Rogers cebo-controlled hospital. Many nonmodifiable risk factors ing by mouth (NPO) 1 day prior to trial. SYNOPSIS: This have been identified such as socio- colonoscopy, performing colonos- SETTING: Hospitalized patients Dr. Nelson study randomized economic status, male gender, and copy before noon, and avoiding with acute ischemic stroke from 16 102 moderately im- increased age, but no studies have opioids 3 days prior to colonoscopy centers in Australia, 10 centers in paired adult inpatients aged 60 years been done to look are modifiable risk factors that may Taiwan, 1 center in New Zealand, and older with Activity Measures for at modifiable risk decrease the rate of inadequate and 1 center in Finland. Post-Acute Care mobility scores of factors such as bowel preparations in hospitalized SYNOPSIS: 225 patients (aged 18 16-20 to either dedicated regular am- medication use, patients. years and older) with acute isch- bulation sessions with mobility tech- timing of colonos- CITATION: Garber A et al. Modifi- emic stroke with hypoperfused but nicians or usual care with hospital copy, and diet be- able factors associated with quality salvageable areas of brain detected nurse–driven protocol. Patients who fore colonoscopy. of bowel preparation among hospi- on CT perfusion imaging or perfu- achieved greater than 400 steps were Furthermore, no talized patients undergoing colonos- sion-diffusion MRI were randomly more likely to discharge to home studies have been copy. J Hosp Med. 2019;5:278-83. assigned to receive IV alteplase or rather than post–acute care (71% vs. Dr. Newsom done to assess the Dr. Newsom is a hospitalist at Ochs- placebo between 4.5 and 9 hours 46%; P = .01). Assisted ambulation did effects of these ner Health System, New Orleans. after onset of stroke or on awaken- not decrease length of stay or affect modifiable factors on IBP. ing with stroke. Primary outcome the discharge disposition, but it did STUDY DESIGN: Retrospective co- By Kristen Rogers, MD, MPH measured on modified Rankin scale increase the total daily number of hort study using multivariate logistic Continued extension of time was 0 (no neurologic deficit) or 1. steps taken by patients (1,182 vs. 726; regression analysis. 8 for thrombolysis in stroke Before the trial was fully enrolled, P = .02, per-protocol analysis) and the SETTING: Cleveland Clinic Hospitals it was terminated because of a patients’ mobility scores (18.90 vs. in Ohio and Florida. CLINICAL QUESTION: Is throm- loss of equipoise based on positive 18.27, P = .04). SYNOPSIS: Records of 8,819 patients bolysis beneficial between 4.5 and results from a previous trial. Of BOTTOM LINE: A dedicated mobil- (aged greater than 18 years) undergo- 9 hours after onset of stroke in the patients enrolled, the primary ity technician to provide assisted ing colonoscopy at Cleveland Clinic patients with hypoperfused but sal- outcome occurred in 35.4% of the ambulation for older inpatients can between January 2011 and June 2017 vageable regions of brain detected alteplase group and 29.5% in the pla- improve patient mobility. were reviewed. They found that 51% on automated perfusion imaging? cebo group (adjusted risk ratio, 1.44). CITATION: Hamilton AC et al. Increas- had IBP. Modifiable risk factors, in- BACKGROUND: Current guidelines Symptomatic intracerebral hemor- rhage was experienced in 6.2% of SHORT TAKES the patients in the alteplase group and 0.9% of patients in the placebo Routine serial TB screening for National Tuberculosis Controllers ically ill adults: The endotracheal group (adjusted risk ratio, 7.22). health care workers no longer Association and CDC, 2019. MMWR. tube securement (ETTS) random- Not all centers may have access recommended 2019;68(19):439-43. ized controlled trial. Critical Care. to perfusion imaging, so the study’s A systematic review of literature for 2019;23:161. findings may not be applicable to 2006-2017 reviewed by the National Fewer endotracheal multiple sites. Tuberculosis Controllers Associa- tube dislodgements with SGLT2 inhibitors associated BOTTOM LINE: Diffusion-perfusion tion-CDC work group led to a 2019 securement device with Fournier gangrene imaging may be useful in determin- update of the CDC screening guide- Randomized control trial shows Review of the FDA Adverse Event ing salvageable brain tissue in acute lines for tuberculosis (previously up- that overall incidence of primary Reporting System database iden- ischemic stroke that may benefit dated in 2005). One notable change is outcome (lip ulcers, facial skin tified 55 unique cases of Fournier from thrombolysis after the stan- a recommendation against routine tears, and endotracheal tube dis- gangrene in diabetic patients tak- dard 4.5-hour window, but further serial screening in health care work- lodgment) decreased by 30 per 1,000 ing SGLT2 Inhibitors. studies need to be conducted before ers in the absence of recognized ex- ventilator-days when using endo- CITATION: Bersoff-Matcha S et al. guidelines are changed. posure or symptoms. tracheal tube fastener rather than Fournier gangrene associated with CITATION: Ma H et al. Thrombolysis CITATION: Sosa LE et al. Tuber- adhesive tape. sodium-glucose cotransporter-2 guided by perfusion imaging up to 9 culosis screening, testing, and CITATION: Landsperger JS et al. inhibitors: A review of spontaneous hours after onset of stroke. N Engl J treatment of U.S. healthcare per- The effect of adhesive tape versus postmarketing cases. Ann Intern Med. 2019;380(19):1795-803. sonnel: Recommendations for the endotracheal tube fastener in crit- Med. 2019 Jun 4;170(11):764-70. Dr. Rogers is a hospitalist at Ochsner Health System, New Orleans. September 2019 | 18 | The Hospitalist CLINICAL Study: Cardiac biomarkers predicted CV events Change in usual practice needed to cut cardiovascular CAP complications

By Jeff Craven natriuretic peptide (proBNP), proendothelin-1, day 30, except for a decrease at day 4 or day 5. MDedge News and troponin T, and the inflammatory biomark- After adjustment for age, sepsis, previous cardiac ers interleukin 6 (IL-6), C-reactive protein (CRP), disease, and a partial pressure of oxygen in the al-

ardiac biomarkers were used to predict and procalcitonin (PCT). The researchers also veoli to fractional inspired oxygen ratio (PaO2/FiO2) the likelihood of cardiovascular events collected data on age, gender, smoking status, and of less than 250 mm Hg, cardiac biomarkers proen- at day 1 and day 30 in patients with vaccination history, as well as whether patients dothelin-1 (odds ratio, 2.25; 95% confidence interval, community-acquired pneumonia, in a had any cardiac, renal, pulmonary, neurological, 1.34-3.79), proADM (OR, 2.53; 95% CI, 1.53-4.20), proB- Crecently conducted study. or diabetes-related comorbidities. NP (OR, 2.67; 95% CI, 1.59-4.49), and troponin T (OR, These biomarkers were also used to predict late 2.70; 95% CI, 1.62-4.49) significantly predicted early cardiovascular events at day 30 of community-ac- Patients who experienced both cardiovascular events, while proendothelin-1 (OR, quired pneumonia (CAP) in patients who did not early“ and late cardiovascular events 3.13; 95% CI, 1.41-7.80), proADM (2.29; 95% CI, 1.01-5.19), have a history of cardiovascular disease, accord- and proBNP (OR, 2.34; 95% CI, 1.01-5.56) significantly ing to Rosario Menéndez, MD, from the Hospital had significantly higher initial predicted late cardiovascular events. For day 30 Universitario y Politécnico La Fe and Instituto de levels of proADM, proendothelin-1, results, when researchers added IL-6 levels to pro- Investigación Sanitaria La Fe in Valencia, Spain, endothelin-1, the odds ratio for late events increased and colleagues. troponin, proBNP, and IL-6. to 3.53, and when they added IL-6 levels to proADM, “Some patients have still high levels of inflam- ” the odds ratio increased to 2.80. matory and cardiac biomarkers at 30 days, when Overall, 95 patients experienced early cardio- Researchers noted the limitations of the study they are usually referred to primary care without vascular events, 67 patients had long-term cardio- included that they did not analyze cardiac bio- receiving any specific additional recommenda- vascular events, and 20 patients experienced both markers to predict specific cardiovascular events, tions,” Dr. Menéndez and colleagues wrote in early and late events. In hospital, the mortality did not identify the cause for mortality at 1 year CHEST (2019 Aug 2. doi: 10.1016/j.chest.2019.06.040). rate was 4.7%; the 30-day mortality rate was 5.3%, in most patients, and did not include a control “Our results suggest that a change in usual prac- and the 1-year mortality rate was 9.9%. group. tice is needed to reduce current and further car- With regard to biomarkers, patients who ex- This study was supported in part by funding diovascular CAP complications.” perienced both early and late cardiovascular from Instituto de Salud Carlos III, Sociedad Es- Dr. Menéndez and colleagues prospectively events had significantly higher initial levels of pañola de Neumología y Cirugía Torácica, and followed 730 patients for 1 year who were hospi- proADM, proendothelin-1, troponin, proBNP, the Center for Biomedical Research Network in talized for CAP, measuring the cardiac biomark- and IL-6. Patients who experienced later events Respiratory Diseases. The authors reported no ers proadrenomedullin (proADM), pro b-type had consistent levels of these biomarkers until relevant conflicts of interest.

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the-hospitalist.org | 19 | September 2019 FROM PHM19 IV fluid weaning unnecessary after gastroenteritis rehydration

By M. Alexander Otto tubes, severe electrolyte abnormalities, or feed- MDedge News ing problems were among those excluded. Overall length of stay was 36 hours in the stop SEATTLE – Intravenous fluids can simply be group versus 40.5 hours in the weaning group (P stopped after children with acute viral gastro- = .004). Children left the hospital about 6 hours enteritis are rehydrated in the hospital; there’s after IV fluids were discontinued, versus 26 hours no need for a slow wean, according to a review after weaning was started (P less than .001). at the Connecticut Children’s Medical Center, Electrolyte abnormalities on admission were Hartford. more common in the weaning group (65% versus ews

Researchers found that children leave the hos- n 57%), but not significantly so (P = .541). Electro- pital hours sooner, with no ill effects. “This study lyte abnormalities were also more common at edge suggests that slowly weaning IV fluids may not the end of fluid resuscitation in the weaning /M d O

be necessary,” said lead investigator Danielle Kli- tt arm, but again not significantly (65% 42%, P = ma, DO, a University of Connecticut pediatrics .077). resident. nder O Fluid resuscitation needed to be restarted in 15 The team at Connecticut Children’s noticed children in the stop group (16%), versus 11 (19%)

that weaning practices after gastroenteritis rehy- M. A lex in the wean arm (P = .459). One child in the stop dration varied widely on the pediatric floors, and Dr. Danielle Klima group (1%) versus four (7%) who were weaned appeared to be largely provider dependent, with were readmitted to the hospital within a week for “much subjective decision making.” The team acute viral gastroenteritis (P = .067). wanted to see if it made a difference one way The team at Connecticut Children’s “I expected we were taking a more conserva- or the other, Dr. Klima said at the 2019 Pediatric noticed that weaning practices tive weaning approach in younger infants,” but Hospital Medicine Conference. after gastroenteritis rehydration age didn’t seem to affect whether patients were During respiratory season, “our pediatric floors weaned or not, Dr. Klima said. are surging. Saving even a couple hours to get varied widely on the pediatric With the results in hand, “our group is taking a these kids out” quicker matters, she said, noting floors, and appeared to be largely closer look at exactly what we are doing,” perhaps that it’s likely the first time the issue has been with an eye toward standardization or even a studied. provider dependent, with “much randomized trial, she said. The team reviewed 153 children aged 2 months subjective decision making.” She noted that weaning still makes sense for to 18 years, 95 of whom had IV fluids stopped a fussy toddler who refuses to take anything by once physicians deemed they were fluid resusci- mouth. tated and ready for an oral feeding trial; the other groups. The mean age was 2.6 years, and there There was no external funding, and Dr. Klima 58 were weaned, with at least two reductions by were slightly more boys. The ED triage level was had no disclosures. The conference was spon- half before final discontinuation. a mean of 3.2 points in both groups on a scale of sored by the Society of Hospital Medicine, the There were no significant differences in age, 1-5, with 1 being the most urgent. Children with American Academy of Pediatrics, and the Aca- gender, race, or insurance type between the two serious comorbidities, chronic diarrhea, feeding demic Pediatric Association. In newborns, concentrated urine helps rule out UTI

By M. Alexander Otto reliably rule out infection, and are A specific gravity of 1.015 was used MDedge News even less reliable in infants because as the cutoff between concentrated they urinate frequently, which and dilute urine, which was “midway SEATTLE – The more concentrated means they usually flush out bacte- between the parameters reported” urine is in newborns, the more you ria before they have enough time to in every urinalysis, Dr. Parlar-Chun can trust negative nitrite tests to make the conversion, which takes said. rule out urinary tract infections, several hours, they said. Although the sensitivity of con- ews according to investigators at the n The lead investigator Raymond centrated urine was only 53%, “it’s University of Texas Health Science Parlar-Chun, MD, an assistant pro- a stark difference from” the 14% in edge Center, Houston. fessor of pediatrics at the University dilute urine, he said.“You should take /M d O

The researchers found that urine tt of Texas McGovern Medical School a look at specific gravity to interpret testing negative for nitrites with in Houston, said he had a hunch nitrites. If urine is concentrated, you a specific gravity above 1.015 in nder O that negative results might be more have [more confidence] that you children up to 2 months old had reliable when newborns urinate less don’t have a UTI if you’re negative.

a sensitivity of 53% for ruling out M. A lex frequently and have more concen- It’s better than taking [nitrites] at UTIs, but that urine with a specif- Dr. Raymond Parlar-Chun trated urine. face value.” ic gravity below that mark had a He and his team reviewed data The subjects were 31 days old, on sensitivity of just 14%. The find- nitrates to nitrites, so positive collected on 413 infants up to 2 average, and 62% were boys; 112 had ing “should be taken into account results are pretty much pathogno- months old who were admitted a specific gravity above 1.015, and 301 when interpreting nitrite results ... monic for UTIs, with a specificity for fever work-up and treated for below. in this high-risk population,” they of nearly 100%, according to the UTIs both in the hospital and af- There was no external funding, concluded. researchers. ter discharge. Nitrite results were and Dr. Parlar-Chun didn’t have any Bacteria in the bladder convert Negative results, however, don’t stratified by urine concentration. disclosures. September 2019 | 20 | The Hospitalist Combining Procalcitonin and a Highly Multiplexed Syndromic Respiratory Panel to Optimize Antimicrobial Stewardship in Patients With Lower Respiratory Tract Infections

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HOSP_21.indd 1 8/16/2019 4:17:56 PM FROM PHM19 Too many blood cultures ordered for pediatric SSTIs

By M. Alexander Otto quent codes for bacteremia or sep- MDedge News ticemia. Across 49,291 encounters, the me- SEATTLE – Blood cultures were dian rate of blood culture for skin in- ordered for over half of pediatric fection was 51.6%, with tremendous skin infection encounters across 38 variation between hospitals. With children’s hospitals, with rates vary- blood cultures, the hospital LOS was ing from about 20% to 80% between about 1.9 days, the hospital cost was hospitals, according to a review of $4,030, and the 30-day readmission almost 50,000 encounters in the Pe- rate was 1.3%. Without cultures, LOS diatric Health Information System was 1.6 days, the cost was $3,291, and database. the readmission rate was 1%. ews

It was a surprising finding, be- n Although infrequent, it’s likely cause current guidelines from that positive cultures triggered addi- edge the Infectious Diseases Society of tional work-up, time in the hospital, /M d O

America do not recommend blood tt and other measures, which might cultures as part of the routine eval- help account for the increase in LOS uation of uncomplicated pediatric nder O and costs. skin and soft-tissue infections As for why blood testing was so

(SSTIs), meaning infections in chil- M. A lex common, especially in some hospi- dren who are otherwise healthy Dr. John Stephens tals, “I think it’s just institutional without neutropenia or other com- culture. No amount of clinical vari- plicating factors. conditions, and severity of illness, that [routine] blood cultures for chil- ation in patient population could Just 0.6% of the cultures were culture draws were associated with dren with SSTI represents low-value explain” a 20%-80% “variation across positive in the review, and it’s like- a 20% increase in hospital length of practice and should be avoided,” said hospitals. It’s really just ingrained ly some of those were caused by stay (LOS), hospital costs, and 30-day lead investigator John Stephens, habits,” Dr. Stephens said at the 2019 contamination. After adjustment readmission rates. MD, a pediatrics professor and hos- Pediatric Hospital Medicine Confer- for demographics, complex chronic “Our data provide more evidence pitalist at the University of North ence. Carolina at Chapel Hill. “The rate of positive blood cul- Dr. Stephens ture was really became curious low, and the about how com- Our data provide more association was mon the prac- “evidence that [routine] for higher cost tice was across blood cultures for children and utilization. I hospitals after think this really he and a friend with SSTI represents reinforces the penned an article low-value practice and IDSA guidelines. about the issue We need to fo- for the Jour- should be avoided. cus on quality nal of Hospital ” improvement Medicine’s “Things We Do for No efforts to do this better,” he said, Reason” series. The single-center noting that he hopes to do so at his Leaders Wanted studies they reviewed showed sim- own institution. ilarly high rates of both testing and “I’d also like to know more on the negative cultures (J Hosp Med. 2018 positives. In the single-center stud- Jul;13[7]:496-9). ies, we know more than half of them Now recruiting for the SHM Dr. Stephens and his team queried are contaminants. Often, there’s the Pediatric Health Information more contamination than true Board of Directors System database for encounters in positives,” he said at the meeting children aged 2 months to 18 years sponsored by the Society of Hospital SHM is seeking nominations for three open positions with the diagnostic code 383, “cel- Medicine, the American Academy of on the Board of Directors. lulitis and other skin infections,” Pediatrics, and the Academic Pediat- from 2012 to 2017, during which time ric Association. Nominate yourself or a colleague to serve a three-year “there really wasn’t a change” in Instead of routine blood culture, term beginning in March 2020. IDSA guidance, he noted. Transfers, Dr. Stephens recommended in his encounters with ICU care, and im- article to send pus for a Gram stain Deadline for nominations: October 29, 2019 munocompromised children were and culture and sensitivity, while excluded. noting that blood cultures remain Hospital admissions were in- reasonable for complicated infec- cluded in the review if they had an tions, immunocompromised pa- To submit your nomination: additional code for erysipelas, cel- tients, and neonates. hospitalmedicine.org/shmboard lulitis, impetigo, or other localized There was no external funding, skin infection. The rate of positive and Dr. Stephens didn’t report any cultures was inferred from subse- disclosures. September 2019 | 22 | The Hospitalist FROM PHM19 Procalcitonin advocated to help rule out bacterial infections

By M. Alexander Otto Different studies use different cutoffs, but a MDedge News procalcitonin below, for instance, 0.5 ng/mL is “certainly more sensitive [for IBI] than any sin- SEATTLE – Procalcitonin, a marker of bacterial gle biomarker we currently use,” including CRP, infection, rises and peaks sooner than C-reactive white blood cells, and absolute neutrophil count protein (CRP), and is especially useful to help rule (ANC). “If it’s negative, you’re really confident out invasive bacterial infections in young infants it’s negative,” but “a positive test does not neces- ews and pediatric community-acquired pneumonia n sarily indicate the presence of IBI,” Dr. McCulloh due to typical bacteria, according to a presenta- said. edge tion at the 2019 Pediatric Hospital Medicine Con- “Procalcitonin works really well as part of a val- /M d O

ference. tt idated step-wise rule” that includes, for instance, It’s “excellent for identifying low-risk patients” CRP and ANC; “I think that’s where its utility is. and has the potential to decrease lumbar punc- nder O On its own, it is not a substitute for you examin- tures and antibiotic exposure, but “the specific- ing the patient and doing your basic risk stratifi-

ity isn’t great,” so there’s the potential for false M. A lex cation, but it may enhance your decision making positives, said Russell McCulloh, MD, a pediatric (From left) Dr. Marie Wang, Dr. Russell McCulloh, incrementally above what we currently have,” he infectious disease specialist at the University of and Dr. Nivedita Srinivas said. Nebraska Medical Center, Omaha. In a study of 532 children a median age of 2.4 There was great interest in procalcitonin at the ter healthy subjects in one study were injected years with radiographically confirmed CAP, pro- meeting. Testing is available in many U.S. hospi- with bacterial endotoxins, and peaked as early calcitonin levels were a median of 6.1 ng/mL in tals, but a large majority of audience members, as 6 hours; CRP, in contrast, started to rise after children whose pneumonia was caused by Strep- when polled, said they don’t currently use it in 12 hours, and peaked at 30 hours. Procalcitonin tococcus pneumoniae or other typical bacteria, clinical practice, and that it’s not a part of diag- levels also seem to correlate with bacterial load and no child infected with typical bacteria had a nostic algorithms at their institutions. and severity of infection, said Nivedita Srinivas, level under 0.1 ng/mL (J Pediatric Infect Dis Soc. Levels of procalcitonin, a calcitonin precur- MD, a pediatric ID specialist at Stanford (Ca- 2018 Feb 19;7[1]:46-53). sor normally produced by the thyroid, are low lif.) University (J Pediatr Intensive Care. 2016 Below that level, “you can be very sure you or undetectable in healthy people, but inflam- Dec;5[4]:162-71). do not have typical bacteria pneumonia,” said mation, be it from infectious or noninfectious The presenters focused their talk on communi- Marie Wang, MD, also a pediatric ID specialist causes, triggers production by parenchymal cells ty-acquired pneumonia (CAP) and invasive bac- at Stanford. As procalcitonin levels went up, throughout the body. terial infections (IBI) in young infants, meaning the likelihood of having bacterial pneumonia Levels began to rise as early as 2.5 hours af- essentially bacteremia and meningitis. increased. Short-course azithromycin no benefit in pediatric asthma admissions

By M. Alexander Otto MD, assistant professor of pediatrics 4-12 years with persistent asthma to At 1 month, 23 placebo and 18 azi- MDedge News at Montefiore and Albert Einstein oral azithromycin 10 mg/kg per day thromycin children had persistent College of Medicine, New York. She for 3 days within 12 hours of admis- asthma symptoms (P = .5); 7 placebo SEATTLE – Adding a 3-day course of and her colleagues, including pri- sion, and 79 to placebo. and 6 azithromycin children had re- azithromycin to treatment regimens mary investigator Lindsey Douglas, LOS was 1.86 days in the placebo turned to the ED (P = .75). of children hospitalized with asth- MD, assistant professor of pediatrics arm, and 1.69 days in the azithromy- In short, “we really found no dif- ma did not shorten length of stay at the Icahn School of Medicine at cin group (P = .23). One placebo child ference” with short-course azithro- or bring other benefits in a random- Mount Sinai, New York, took a closer was transferred to the pediatric ICU, mycin. “Clinicians should consider ized, blinded trial of more than 150 look. versus none in the azithromycin [these] data before prescribing azi- youngsters at the Children’s Hospi- The negative results mean that arm (P = .50). The study was stopped thromycin [to] children hospitalized tal at Montefiore, New York. “we can stop doing this, giving kids short of its 214 subject enrollment with asthma,” Dr. Silver and her In recent years, some pediatri- unnecessary things. Word is starting goal because of futility, but even team concluded. cians at Montefiore had begun to get out” at Montefiore. “People so, it was well powered to detect a Subjects were an average of about giving short-course azithromycin are not using it as much,” she said at difference in LOS, the primary out- 7 years old, and about two-thirds to hospitalized children who were the 2019 Pediatric Hospital Medicine come, Dr. Silver said. were boys. They were not on azith- not recovering as quickly as they Conference, sponsored by SHM, the At 1-week phone follow-up, 7 pla- romycin or other antibiotics prior had hoped, spurred by outpatient American Academy of Pediatrics, cebo children and 11 in the azithro- to admission. About half had been reports of reduced exacerbations and the Academic Pediatric Associ- mycin arm had persistent asthma admitted in the previous year, and and other benefits with long-term ation. symptoms (P = .42), and 1 placebo about a quarter had at least one azithromycin (e.g., Lancet. 2017 Aug The team had expected azith- child and 2 azithromycin children previous pediatric ICU admission. 12;390(10095):659-68). romycin to shorten length of stay had been readmitted (P greater than Over two-thirds had been on daily “We had no evidence for doing (LOS) by about half a day, because .99). There were no differences in asthma medications. There were that at all” in the hospital, and it of its anti-inflammatory effects, but days of school missed, or workdays about 2 days of symptoms prior to might be going on elsewhere, said that’s not what was found when missed among parents and guard- admission. senior investigator Alyssa Silver, they randomized 80 children aged ians. Dr. Silver had no disclosures. the-hospitalist.org | 23 | September 2019 Make your next smart move. Visit shmcareercenter.org.

HOSPITALISTS/ NOCTURNISTS NEEDED IN SOUTHEAST LOUISIANA

HOSPITALISTS Ochsner Health System is seeking physicians to join our (BC/BE Internists) hospitalist team. BC/BE Internal Medicine and Family Medicine physicians are welcomed to apply. Highlights of our opportunities are: Long Island, NY. NYU Winthrop Hospital, a world-class 591-bed university-affiliated medical center and an American  Hospital Medicine was established at Ochsner in 1992. We have a stable 50+ member College of Surgeons (ACS) Level 1 Trauma Center based in West- group ern Nassau County, NY is seeking BC/BE internist for academic Hospitalist positions to staff its observation and short stay unit.  7 on 7 off block schedule with flexibility Ideal candidates will have exemplary clinical skills, a strong  Dedicated nocturnists cover nights interest in teaching and a commitment to inpatient medicine. Salaried position with incentive, competitive benefits package  Base plus up to 40K in incentives including paid CME, malpractice insurance and vacation.  Average census of 14-18 patients  E-ICU intensivist support with open ICUs at the community hospitals DRIVEN TO BE  EPIC medical record system with remote access capabilities For consideration, please email a cover letter and CV to: : the best.  Dedicated RN and Social Work Clinical Care Coordinators [email protected]  or fax to: (516) 663-8964 Community based academic appointment Ph: (516) 663-8963  The only Louisiana Hospital recognized by US News and World Report Distinguished Attn: Vice Chairman, Dept of Medicine-Hospital Operations Hospital for Clinical Excellence award in 3 medical specialties An EOE m/f/d/v  Co-hosts of the annual Southern Hospital Medicine Conference  We are a medical school in partnership with the University of Queensland providing Easy Commute: NYU Winthrop Hospital is conveniently located on Long Island in Western Nassau County just clinical training to third and fourth year students 25 miles from Manhattan and steps away from the  Leadership support focused on professional development, quality improvement, and Mineola LIRR station. academic committees & projects  Opportunities for leadership development, research, resident and medical student teaching Employment Opportunity in the Beautiful  Skilled nursing and long term acute care facilities seeking hospitalists and mid-levels with Adirondack Mountains of Northern New York an interest in geriatrics  Paid malpractice coverage and a favorable malpractice environment in Louisiana Current Opening for a full-time, Hospital Employed Hospitalist. This opportunity  Generous compensation and benefits package provides a comfortable 7 on/7 off schedule, allowing ample time to enjoy all that the Ochsner Health System is Louisiana’s largest non-profit, academic, healthcare system. Adirondacks have to offer! Driven by a mission to Serve, Heal, Lead, Educate and Innovate, coordinated clinical and hospital patient care is provided across the region by Ochsner’s 40 owned, managed and Come live where others vacation! affiliated hospitals and more than 100 health centers and urgent care centers. Ochsner is the only Louisiana hospital recognized by U.S. News & World Report as a “Best Hospital” across • Convenient schedules three specialty categories caring for patients from all 50 states and more than 70 countries • Competitive salary & benefits worldwide each year. Ochsner employs more than 25,000 employees and over 4,500 • Unparalleled quality of life employed and affiliated physicians in over 90 medical specialties and subspecialties, and • Family friendly community conducts more than 700 clinical research studies. For more information, please visit • Excellent schools ochsner.org and follow us on Twitter and Facebook. • Nearby Whiteface Mountain ski resort Interested physicians should click here to apply online. • Home of the 1932 & 1980 Winter Olympics and current Visit ochsner.org/physician Job Number 00022186 Olympic Training Center • Annual lronman Competition • World Cup Bobsled and Ski Events Sorry, no opportunities for J1 applications. • Abundant arts community

Ochsner is an equal opportunity employer and all qualified applicants will receive consideration for Hike, fish, ski, golf, boat or simply relax employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status. and take in the beauty and serenity of the Adirondack Mountains

Contact: Joanne Johnson 518-897-2706 [email protected] To learn more, visit www.the-hospitalist.org and www.adirondackhealth.org click “Advertise” or contact Heather Gonroski • 973-290-8259 • [email protected] or Linda Wilson • 973-290-8243 • [email protected]

September 2019 | 24 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

TOWER HEALTH IS HIRING HOSPITALISTS

Tower Health is a regional, integrated healthcare system comprised of six acute-care hospitals and a network of outpatient facilities providing leading-edge, compassionate healthcare and wellness services to a population of 2.5 million people across southeastern Pennsylvania.

We are continuing to expand and are hiring Hospitalists for Reading Hospital (West Reading, PA), Brandywine Hospital (Coatesville, PA), and Phoenixville Hospital (Phoenixville, PA).

n Board-Certified or Board-Eligible in Internal Medicine n H1b Visa Candidates Accepted n 14 Shifts/Month for Daytime Hospitalists; 12 Shifts/Month for Nocturnists n EMR is EPIC

What We Offer: n Competitive Salary with Highly Obtainable Incentive Bonus n Generous CME Stipend n Educational Loan and Relocation Assistance n Comprehensive Health Benefits n 403(b) and 457(b) Retirement Plans n Claims-Made Malpractice Insurance with Tail Coverage n Spousal/Domestic Partner Job Search Support

For more information, contact: Carrie Moore, Physician Recruiter Phone: 484-628-8153 • [email protected]

EOECareers.TowerHealth.org EOE

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

LET YOUR STRENGTHS SHINE

Expand your horizons as a member of the special ops physician team

New for hospital medicine clinicians

n First-classexperiencewithfirst-classpay n Excellentalternativetolocumswithguaranteedshifts/hours n Supportofnationalnetworkofhospitalistexperts n Practiceacrossyourregionbutlivewhereyouwant n Variouspracticesettingswithappropriatepatientcensus n Reimbursementforlicensure,certificationsandtravel n IndependentContractorstatus n Professionalliabilityinsurancewithtailcoverage n LiveWellWorkLifeservicesincludesanassociateassistance programandotheremotionalwellbeinginitiatives n Full-timeposition n Outstandingriskmanagementprogram

Join our team teamhealth.com/special-operations or call 855.879.3153

Hospitalist & Nocturnist Opportunities in SW Virginia & NE Tennessee

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

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

Please Contact: Tina McLaughlin, CMSR Ballad Health Senior Physician Recruiter O) 276-258-4580 [email protected]

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

Now Hiring at Accuity Delivery Systems Medical Director Full Time Position Location: Remote

Job Responsibilities What We Do

• Lead the Accuity MD Tower to capture the accurate representation Accuity Delivery Systems helps of a patient’s clinical status hospitals capture complete and accurate clinical documentation • Perform DRG validation and confirm the principle diagnosis of of inpatient visits. Our MD Review every case Program provides a physician-led • Identify the clinical indicators for every query that is generated, secondary review of every patient’s following all regulatory requirements medical record. • Undergo robust training upon on-boarding at Accuity

With our proven success, we are rapidly expanding operations and are actively on-boarding new health systems across the country. For more information about our current career opportunities, please call #646.568.2840 or email [email protected]

810 7th Avenue, Suite 1110, New York, NY 10019 | 646.568.2840 | www.ACCDS.com the-hospitalist.org | 27 | September 2019 Make your next smart move. Visit shmcareercenter.org.

Join our Academic Hospital Medicine Program with one of the Premier Public Hospitals in the South

The Division of Hospital Medicine at the Emory University School of Medicine is currently seeking exceptional individuals to join our academic hospital medicine program at Atlanta’s Grady Memorial Hospital. Ideal candidates will be BC/BE internists who possess outstanding clinical and interpersonal skills and who envision a fulfilling career in academic hospital medicine. Emory hospitalists have opportunities to A position with our program includes: be involved in teaching, quality improvement, patient safety, health services research, and other professional • Generous salary and benefits activities. Our hospitalists have access to faculty development programs within the Division and work with • Flexible scheduling and time off leaders focused on mentoring, medical education, and fostering research. • Teaching opportunities (day and night) • On-site medical director and Sr. Clinical Advisor • Broad range of clinical, academic, innovation, and We are recruiting now for both Nocturnist and Daytime positions, so apply today. Applications will be research experiences considered as soon as they are received. Emory University is an Equal Opportunity Employer. • Faculty appointments commensurate with experience • Full malpractice and tail coverage

Apply now for immediate openings! Email your cover letter and CV to: Dr. Joanna Bonsall, Director c/o Danielle Moses, Physician Services Coordinator/Recruiter for Medicine Phone: 404-778-7726 [email protected]

www.medicine.emory.edu/hospital-medicine

Med/Peds Hospitalist Opportuniti es Available Hospitalist/Nocturnist Join the Healthcare Team at Cambridge Health Alliance Berkshire Health Systems Cambridge Health Alliance (CHA), a well-respected, nationally recognized and award-winning public healthcare system, is Berkshire Health Systems is currently seeking BC/BE Med/Peds recruiting for part time and full time hospitalists and nocturnists. physicians to join our comprehensive Hospitalist Department CHA is a teaching affiliate of both Harvard Medical School (HMS) • Day and Nocturnist positions and Tufts University School of Medicine. Our system is comprised • Previous Med/Peds Hospitalist experience is preferred of three campuses and an integrated network of both primary and • Leadership opportunities available specialty outpatient care practices in Cambridge, Somerville and Located in Western Massachusetts Berkshire Medical Center is the Boston’s Metro North Region. region’s leading provider of comprehensive health care services • Full time and part time opportunities available • Comprehensive care for all newborns and pediatric inpatients including: o Level Ib nursery • Schedule will consist of daytime and nighttime shifts, noctur- o 7 bed pediatrics unit nist positions are available o Care for pediatric patients admitted to the hospital • Academic Appointment at Harvard Medical School • Comprehensive adult medicine service including: • Opportunity to teach medical students and residents o 302-bed community teaching hospital with residency programs • Two coverage locations approximately 5 miles apart o Geographic rounding model To advertise in • Physician assistant support at both locations o A closed ICU/CCU The Hospitalist or the • CHA’s hospitalist department consists of 25+ clinicians o A full spectrum of Specialties to support the team Ideal candidates will be Board Certified, patient centered and o A major teaching affi liate of the University of Massachusetts Medical Journal of Hospital Medicine demonstrate a strong commitment to work with a multicultural, School and University of New England College of Osteopathic Medicine underserved patient population. Experience and interest in perform- • 7 on/7 off 12 hour shift schedule ing procedures and community ICU coverage preferred. At CHA we We understand the importance of balancing work with a healthy offer a supportive and collegial environment, a strong infrastructure, personal lifestyle a fully integrated electronic medical record system (EPIC) and com- • Located just 2½ hours from Boston and New York City CONTACT: • Small town New England charm petitive salary/benefits package. • Excellent public and private schools Heather Gonroski Please visit www.CHAproviders.org to learn more and apply through • World renowned music, art, theater, and museums 973.290.8259 our secure candidate portal. CVs may be sent directly to Kasie Marchini • Year round recreational activities from skiing to kayaking, this is an ideal at [email protected]. CHA’s Department of Provider family location. [email protected] Recruitment may be reached by phone at (617) 665-3555 or by fax at Berkshire Health Systems offers a competitive or (617) 665-3553. salary and benefi ts package, including relocation. Linda Wilson We are an equal opportunity employer and all qualified applicants will Interested candidates are invited to contact: 973.290.8243 receive consideration for employment without regard to race, color, Liz Mahan, Physician Recruitment Specialist, Berkshire Health Systems [email protected] religion, sex, sexual orientation, gender identity, national origin, disability 725 North St. • Pittsfield, MA 01201 • (413) 395-7866. status, protected veteran status, or any other characteristic protected Applications accepted online at www.berkshirehealthsystems.org by law. September 2019 | 28 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

Live. Hospitalists and Nocturnists Opportunities Available

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

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

Schedule a call with our recruiter today! Wayne Saxton, FASPR Physician Recruiter 717-231-8383 [email protected] UPMCPinnacle.com/Providers

UPMC Pinnacle is an Equal Opportunity Employer. EOE

Hospitalist Opportunities with Penn State Health

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

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

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

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

Make it part of your career. Berkshire Health Systems is currently seeking BC/BE Internal Medicine physicians to join our comprehensive Hospitalist Department Vituity provides the support and resources • Day, Evening and Nocturnist positions you need to focus on the joy of healing. • Previous Hospitalist experience is preferred We currently have opportunities for hospitalists and Located in Western Massachusetts Berkshire intensivists at hospitals and skilled nursing practices across Medical Center is the region’s leading provider of the country. Some with sign-on bonuses up to $100,000! comprehensive health care services • 302-bed community teaching hospital with residency programs • A major teaching affiliate of the University of Massachusetts Medical School and UNECOM • Geographic rounding model To advertise in • A closed ICU/CCU The Hospitalist or the • A full spectrum of Specialties to support the team • 7 on/7 off 10 hour shift schedule Journal of Hospital Medicine We understand the importance of balancing work with a healthy personal lifestyle • Located just 2½ hours from Boston and New York City • Small town New England charm • Excellent public and private schools CONTACT: • World renowned music, art, theater, and museums Heather Gonroski • Year round recreational activities from skiing to kayaking, 973.290.8259 this is an ideal family location. [email protected] Berkshire Health Systems offers a competitive salary and benefits or package, including relocation. Linda Wilson Interested candidates are invited to contact: 973.290.8243 Liz Mahan, Physician Recruitment Specialist, Berkshire Health Systems [email protected] 725 North St. • Pittsfield, MA 01201 • (413) 395-7866. Applications accepted online at www.berkshirehealthsystems.org

Self Regional Healthcare, an 11-time Gallop Great Workplace award recipient, is seeking BE/BC Internal Medicine physicians. We currently have opportunities in both outpatient clinics as well as the Hospitalist department.

California Outpatient Only: • Fresno • Redding • San Jose You will provide medical services consistent in quality with the community standards • Modesto • San Diego • San Mateo and the standards set forth by Self Regional Healthcare. Internal Medicine physician Illinois Missouri Oregon will engage in direct patient care activities and medical/clinical practices as the principle • Belleville • St. Louis • Eugene component of his/her overall professional responsibilities with the group and practice. • Greenville Hospitalist Only: • Work a 7on/7off, 12-hour schedule with NO call. Interested in travel? • Check out our Reserves Program. Excellent work-life balance with comfortable patient volumes • Competitive salary package and benefits, including student loan assistance • Future leader? EPIC EMR • Apply for our Administrative Fellowship. Intensivist provides majority ICU care

Hybrid Model: We proudly sponsor visa candidates! Enjoy the best of both worlds. This will allow a physician to work both inpatient and outpatient. The ideal candidate would provide inpatient coverage 1 in every 4 weeks. For more information, please contact us at [email protected]. About Greenwood, S.C.: Just an hour from Columbia and Greenville, Greenwood, or “Emerald City,” as it is known by the Please Contact: locals, offers a temperate climate, year-round golf and recreation and lakeside living at pristine Lake Twyla Camp, Physician Recruiter, Greenwood. It is also home to the S.C. Festival of at (864) 725-7029 or Flowers, a celebration of flora that features larger- [email protected] than-life topiaries during the month of June. September 2019 | 30 | The Hospitalist HOSPITALIST INSIGHT Reversal agents for direct-acting oral anticoagulants Summary of guidelines published in the Journal of Hospital Medicine

By Matthew Tuck, MD, MEd, risk of major bleeding with DOACs cizumab for patients on dabigatran FACP over warfarin but no difference in and use of prothrombin complex con- overall mortality when used to treat centrate (PCC) or recombinant coag- hen on call for admis- venous thromboembolism (see Ta- ulation factor Xa (andexanet alfa) for sions, a hospitalist ble 2). Because of these combined patients on apixaban or rivaroxaban receives a request advantages, DOACs are increasingly for the treatment of life-threatening from a colleague to prescribed, accounting for approxi- bleeding (see Table 3). Wadmit an octogenarian man with mately half of all oral anticoagulant Idarucizumab is a monoclonal anti- an acute uncomplicated deep vein prescriptions in 2014. body developed to reverse the effects thrombosis to start heparin, bridg- Although DOACs have been shown of dabigatran, the only DOAC that ing to warfarin. The patient has no to be as good if not superior to VKAs directly inhibits thrombin. In 2017, evidence of postphlebitic syndrome, and heparins in these circumstances, researchers reported on a cohort of pulmonary embolism, or right-sided there are situations where a DOAC subjects receiving idarucizumab for heart strain. The hospitalist asks her should not be used. There are limited uncontrolled bleeding or who were colleague if he had considered treat- data on the safety of DOACs in pa- on dabigatran and about to undergo ing the patient in the ambulatory tients with mechanical heart valves, an urgent procedure. Of those with Dr. Tuck is associate section setting using a direct-acting oral liver failure, and chronic kidney dis- uncontrolled bleeding, two-thirds chief for hospital medicine at the anticoagulant (DOAC). After all, this ease with a creatinine clearance less had confirmed bleeding cessation Veterans Affairs Medical Center in would save the patient an unneces- than 30 mL/min. Therefore, warfarin within 24 hours. Periprocedural he- Washington, D.C. sary hospitalization, weekly interna- is still the preferred agent in these mostasis was achieved in 93.4% of pa- tional normalized ratio checks, and settings. There are some data that tients undergoing urgent procedures. other important lifestyle changes. In apixaban may be safe in patients However, it should be noted that use to betrixaban and edoxaban is con- response, the colleague voices con- with a creatinine clearance of greater of idarucizumab conferred an in- sidered off label but is recommended crease risk (6.3%) of thrombosis with- by guidelines. Studies on investiga- Table 1. Comparison of mortality and bleeding-related mortality in 90 days. Based on these findings, tional reversal agents for betrixaban in patients with atrial fibrillation on DOACs or warfarin guidelines recommend use of idaru- and edoxaban are ongoing. cizumab in patients experiencing Both unactivated and activated life-threatening bleeding, balanced PCC contain clotting factor X. Their Outcome Event rates per year Risk ratio NNT/NNH* against the risk of thrombosis. use to control bleeding related to

Warfarin DOACs DOAC vs. VKA per year ews

n In 2018, the Food and Drug Ad- DOAC use is based on observational All-cause mortality 4.87% 4.46% 0.90 (P <.0001) 244 ministration approved recombinant studies. In a systematic review of the edge Fatal hemorrhage 0.38% 0.19% 0.49 (P <.00001) 526 coagulation factor Xa for treatment nonrandomized studies, the efficacy Md of life-threatening or uncontrolled of PCC to stem major bleeding was *Number needed to treat/number needed to harm bleeding in patients on apixaban 69% and the risk for thromboem- Source: J Am Coll Cardiol. 2016;68:2508-21 or rivaroxaban. The approval came bolism was 4%. There are no head- after a study by the ANNEXA-4 to-head studies comparing use of cern that the “new drugs don’t have than 10 mL/min, but long-term safety investigators showed that recombi- recombinant coagulation factor Xa antidotes.” studies have not been performed in nant coagulation factor Xa quickly and PCC. Therefore, guidelines are to DOACs have several benefits patients with end-stage renal disease and effectively achieved hemostasis. use either recombinant factor Xa or over vitamin K antagonists (VKAs) on hemodialysis. Finally, in patients Full study results were published PCC for the treatment of life-threat- and heparins. DOACs have quicker requiring concomitant inducers or in April 2019, demonstrating 82% of ening bleeding related to DOAC use. onset of action, can be taken by inhibitors of the P-glycoprotein or patients receiving the drug attained As thrombosis risk heightens after mouth, in general do not require cytochrome P450 enzymes like an- clinical hemostasis. However, as with use of any reversal agent, the recom- dosage adjustment, and have fewer tiepileptics and protease inhibitors, idarucizumab, up to 10% of patients mendations are to resume anticoag- VKAs and hepa- had a thrombotic event in the fol- ulation within 90 days if the patient Table 2. Mortality, major bleeding compared for rins are favored. low-up period. Use of recombinant is at moderate or high risk for recur- DOACs or warfarin in venous thromboembolism Notwithstand- coagulation factor Xa for treatment rent thromboembolism. ing their ad- of life-threatening bleeding related After discussion with the hospi- vantages, when talist about the new agents avail- Outcome Hazard ratio Confidence interval ews DOACs first hit able to reverse anticoagulation, n Table 3. Reversal agent(s) for All-cause mortality 0.99 0.84-1.16 the market there the colleague decided to place the

edge direct oral anticoagulants Major bleeding 0.92 0.82-1.03 were concerns patient on a DOAC and keep him in Md that reversal Anticoagulant Reversal Agent(s) his nursing home. The patient did Source: BMJ. 2017;359:j4323 agents were not Apixaban not thereafter experience sustained available. In the Betrixaban* PCC or recombinant bleeding necessitating use of these dietary and lifestyle modifications, August issue of the Journal of Hos- reversal agents. More importantly

Edoxaban* coagulation factor Xa ews n compared with VKAs and heparins. pital Medicine’s Clinical Guideline Rivaroxaban for the patient, he was able to stay

In atrial fibrillation, DOACs have Highlights for the Hospitalist, Emily edge in the comfort of his home. Dabigatran Idarucizumab been shown to have lower all-cause Gottenborg, MD, and Gregory Misky, Md and bleeding-related mortality MD, summarized guideline recom- *Off-label recommendation to use recombinant For a complete list of references, see than warfarin (see Table 1). Obser- mendations for reversal of the newer coagulation factor Xa in these drugs the online version of this article at vational studies also suggest less agents. This includes use of idaru- Source: Dr. Tuck www.the-hospitalist.org. the-hospitalist.org | 31 | September 2019 As a physician-owned group, we protect each other.

As a hospitalist, the possibility of medical malpractice suits can weigh heavy on your mind. When you join US Acute Care Solutions, the scales are tipped in your favor. Every full-time HM and EM physician becomes an owner in our group, giving us the power to reduce risk and protect our own. In fact, our continuing education and risk management programs cut lawsuits to less than half the national average. If a case is ever brought against you, we’ll have your back with our legendary Litigation Stress Support Team and the best medical malpractice insurance. It’s one more reason to weigh the importance of physician ownership. It matters.

Discover the benfits of physician ownership at USACS.com.

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

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