PRACTICE KEY CLINICAL HM20 VIRTUAL October 2020 MANAGEMENT QUESTION CONFERENCE Volume 24 No. 10 p10 Unit-based p12 How to manage p18 Complete assignments oncologic emergencies coverage

Dr. Venkatrao Medarametla, medical director of hospital medicine, Baystate Medical Center, Springfield, Mass.

The ally in the waiting room Improving communication with patients’ loved ones

By Eric Butterman

e think of a patient’s recovery happening in multiple locations – in a hospital room or a rehabilitation facility, for example. But many clinicians may not consider the opportunity to aid healing that lies in the waiting room. The waiting room is where a patient’s loved ones often are, and they, some- timesW more than anyone, can unlock the path to a patient’s quicker recovery. Friends and

EALTH family can offer encouragement, as they have an existing bond of trust that can help if a pa- H tient needs reinforcement to take their medications or follow other health care advice. AYSTATE , B

AJOIE Continued on page 16 L ODD T

® the-hospitalist.org

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01_2_16_17_HOSP20_10.indd 1 9/22/20 2:44 PM COMMENTARY October 2020 Volume 24 No. 10

Physicians, make a plan PHYSICIAN EDITOR THE SOCIETY OF HOSPITAL MEDICINE Weijen W. Chang, MD, SFHM, FAAP Phone: 800-843-3360 [email protected] Fax: 267-702-2690 Website: www.HospitalMedicine.org to vote PEDIATRIC EDITOR Anika Kumar, MD, FHM, FAAP Chief Executive Of cer [email protected] Eric E. Howell, MD, MHM By Anika Kumar, MD, FHM, COORDINATING EDITORS FAAP Alan Hall, MD Marketing Communications Manager

THE FUTURE HOSPITALIST Brett Radler [email protected] n March 2020, following the an- Keri Holmes-Maybank, MD, FHM nouncement of the United States’ INTERPRETING DIAGNOSTIC TESTS Marketing Communications Specialist CONTRIBUTING WRITERS Caitlin Cowan first death related to COVID-19, [email protected] many physicians began using Eric Butterman; Krishna A. Chokshi, MD; Itheir voices to discuss the shortage Thomas R. Collins; SHM BOARD OF DIRECTORS of personal protective equipment Vignesh Doraiswamy, MD; President (PPE). Many physicians, myself in- Bruce Jancin; Danielle Scheurer, MD, MSCR, SFHM Anika Kumar, MD, FHM, FAAP; President-Elect cluded, petitioned elected leaders at Thomas McIlraith, MD, SFHM, CLHM; Jerome C. Siy, MD, SFHM the community, state, and federal Damian McNamara; Treasurer levels to address the PPE shortage. Isha Puri, MD, MPH, FHM; Rachel Thompson, MD, MPH, SFHM Secretary Historically, physicians have ad- Patrick Rendon, MD; Danielle Scheurer, MD, MSCR, SFHM; Kris Rehm, MD, SFHM Immediate Past President vocated for improved public health. Dr. Kumar is the pediatric editor Cardinale Smith, MD, PhD; From seat belt laws in the 1980s and of The Hospitalist. She is clinical Christopher Frost, MD, SFHM Ann-Marie Tantoco, MD, FAAP, FHM; Board of Directors 1990s to the Affordable Care Act in assistant professor of pediatrics Jessica Zimmerberg-Helms, MD Tracy Cardin, ACNP-BC, SFHM the 2000s, physicians have testified at the Cleveland Clinic Lerner Steven B. Deitelzweig, MD, at the community, state, and federal College of Medicine at Case FRONTLINE MEDICAL MMM, FACC, SFHM COMMUNICATIONS EDITORIAL STAFF Bryce Gartland, MD, FHM levels to advocate for the health and Western Reserve University and a Executive Editor Kathy Scarbeck, MA Flora Kisuule, MD, MPH, SFHM safety of our patients and the pub- pediatric hospitalist at Cleveland Editor Richard Pizzi Mark W. Shen, MD, SFHM lic. Yet while we have been making Clinic Children’s. Creative Director Louise A. Koenig Darlene Tad-y, MD, SFHM Director, Production/Manufacturing Chad T. Whelan, MD, FACP, FHM our voices heard, we are often silent Rebecca Slebodnik at the ballot box. EDITORIAL ADVISORY BOARD FRONTLINE MEDICAL In the 1996 and 2000 elections, phy- election. The organization called on Hyung (Harry) Cho, MD, SFHM; COMMUNICATIONS ADVERTISING STAFF sicians voted 9% less often than the all health care providers and provid- Marina S. Farah, MD, MHA; Senior Director Business Development general public, and compared with ers in training to pledge to vote in Ilaria Gadalla, DMSc, PA-C; Angelique Ricci, 973-206-2335 James Kim, MD; 4 cell 917-526-0383 [email protected] lawyers – professionals with similar the election. They are continuing Ponon Dileep Kumar, MD, FACP, CPE; Classi ed Sales Representative educational attainment and financ- these efforts for the 2020 elections. Shyam Odeti, MD, MS, FHM; Heather Gonroski, 973-290-8259 es – physicians voted 22% less often.1 We should join our nation’s medi- Venkataraman Palabindala, MD, SFHM; [email protected] Tiffani M. Panek, MA, SFHM, CLHM; It is unclear why physicians are less cal students by also pledging to vote. Linda Wilson, 973-290-8243 Adhikari Ramesh, MD, MS; [email protected] Raj Sehgal, MD, FHM; likely to vote. In a 2016 article, David To begin, we can all Make A Plan To Senior Director of Classi ed Sales Grande, MD, and Katrina Armstrong, Vote. Each plan should include the Kranthi Sitammagari, MD; Amith Skandhan, MD, FHM; Tim LaPella, 484-921-5001 MD, postulated that physicians may following: Lonika Sood, MD, FACP, FHM; cell 610-506-3474 [email protected] not vote because our work hours cre- • Register to vote: In many states Amit Vashist, MD, FACP Advertising Of ces 7 Century Drive, ate barriers to visiting polls.2 eligible voters can register online. Suite 302, Parsippany, NJ 07054-4609 Despite our lack of engagement at • Request an absentee ballot: Many 973-206-3434, fax 973-206-9378 the ballot box, voting is important to states require registered voters to improving our patients’ social deter- request absentee ballots online or THE HOSPITALIST is the official newspaper of the THE HOSPITALIST (ISSN 1553-085X) is published Society of Hospital Medicine, reporting on issues monthly for the Society of Hospital Medicine by minants of health. In a recently pub- by mail. and trends in hospital medicine. THE HOSPITALIST Frontline Medical Communications Inc., 7 Century lished systematic review, the authors • Vote: Submit an absentee ballot reaches more than 35,000 hospitalists, physician Drive, Suite 302, Parsippany, NJ 07054-4609. Print assistants, nurse practitioners, medical residents, and subscriptions are free for Society of Hospital Medi- found several studies supporting the prior to election or vote in-person health care administrators interested in the practice cine members. Annual paid subscriptions are avail- association between voting and social on election day. Some counties al- and business of hospital medicine. Content for able to all others for the following rates: THE HOSPITALIST is provided by Frontline Medical determinants of health. Their review low voting early in person. Communications. Content for the Society Pages is Individual: Domestic – $195 (One Year), found that, when large numbers of In practice, our plans will differ provided by the Society of Hospital Medicine. $360 (Two Years), $520 (Three Years), Canada/Mexico – $285 (One Year), $525 (Two Years), people from communities participat- slightly because each state has its Copyright 2020 Society of Hospital Medicine. All $790 (Three Years), Other Nations - Surface – $350 ed in voting, it translated into greater own election laws. rights reserved. No part of this publication may be (One Year), $680 (Two Years), $995 (Three Years), reproduced, stored, or transmitted in any form or by Other Nations - Air – $450 (One Year), $875 (Two influence over determining who held This election season let us ensure any means and without the prior permission in writing Years), $1,325 (Three Years) political power in that community. all physician voices are heard. Make from the copyright holder. The ideas and opinions expressed in The Hospitalist do not necessarily Institution: United States – $400; Those with power introduced and A Plan To Vote for your patients and reflect those of the Society or the Publisher. The Canada/Mexico – $485 All Other Nations – $565 supported policies responding to communities. Society of Hospital Medicine and Frontline Medical Student/Resident: $55 Communications will not assume responsibility for their constituents’ needs, ultimately damages, loss, or claims of any kind arising from Single Issue: Current – $35 (US), $45 (Canada/ influencing their constituents’ social References or related to the information contained in this Mexico), $60 (All Other Nations) Back Issue – $45 publication, including any claims related to the (US), $60 (Canada/Mexico), $70 (All Other Nations) 3 determinants of health. By voting, 1. Grande D et al. Do doctorsvote? J Gen Intern products, drugs, or services mentioned herein. Med. 2007 May;22(5):585-9. POSTMASTER: Send changes of address (with old we as physicians are helping to 2. Grande D, Armstrong K. Will physicians vote? Letters to the Editor: [email protected] mailing label) to THE HOSPITALIST, Subscription Services, P.O. Box 3000, Denville, NJ 07834-3000. address the social determinants of Ann Intern Med. 2016;165:814-5. The Society of Hospital Medicine’s headquarters health in our communities. 3. Brown CL et al. Voting, health and interven- is located at 1500 Spring Garden, Suite 501, RECIPIENT: To subscribe, change your address, purchase a single issue, file a missing issue claim, Many medical students have been tions in healthcare settings: A scoping review. Philadelphia, PA 19130. Public Health Rev. 2020 Jul. doi: 10.1186/s40985- or have any questions or changes related to your doing their part to improve the so- Editorial Offices: 2275 Research Blvd, Suite 400, subscription, call Subscription Services at 1-833-836- 020-00133-6. Rockville, MD 20850, 240-221-2400, fax 240-221-2548 2705 or e-mail [email protected]. cial determinants of health in their 4. American Medical Student Association. communities by pledging to vote. In AMSA launches Med Out the Vote campaign, BPA Worldwide is a global industry call to action. 2018 Jul 29. Accessed 2020 Sep resource for verified audience data and 2018, the American Medical Student The Hospitalist is a member. 14. https://www.amsa.org/about/amsa-press- Association launched their “Med room/amsa-launches-med-out-the-vote-cam- To learn more about SHM’s relationship with industry partners, visit www.hospitalmedicine.com/industry. Out the Vote” initiative prior to the paign-call-to-action/. October 2020 | 2 | The Hospitalist

01_2_16_17_HOSP20_10.indd 2 9/25/20 11:26 AM HOSP_03.indd 1 9/21/2020 2:38:30 PM

ELUH20CDNY0675_M3_NVAF_Hosp_JrnlAd_TABLOID_FM.indd 1 9/18/20 6:55 PM LEADERSHIP The Authority/Accountability balance Evaluating your career trajectory

By Thomas McIlraith, MD, dinates, through mentoring and sup- reported HMG updates and issues to SFHM, CLHM port, will add to your success. There the board of directors and the CEO. is another, more cynical view of A common reporting structure have had the pleasure of work- subordinates that can be identified in the early days was that a senior ing on the Society of Hospital using the Authority/Accountability member of the medical staff, or Medicine’s signature Leadership balance, which I will address. group, had once worked in the hos- Academies since 2010, and I enjoy pital and therefore “understood” Iworking with hospital medicine Authority the issues and challenges that the leaders from around the country In this construct, “Authority” has a hospitalists were facing. It was up every year. I started as a hospital much broader meaning than just to this physician with seniority and medicine leader in 2000 and served the ability to tell people what to do. connections to advocate for the hos- during the unprecedented growth of The ability to tell people what to do pitalists as they saw fit. The prob- the field when it was “the most rap- is important but not sufficient for lem was that the hospital landscape idly growing specialty in the history success in hospital politics. was, and is, constantly evolving of medicine.” Financial resources are essential in innumerable ways. These “once Most businesses dream of having for a successful Authority/Account- removed” reporting structures for a year of double-digit growth; my ability balance – not only the hard- HMGs failed to get the required in- Dr. McIlraith is the founding department grew an average of 15% ware such as computers, telephones, formation on the rapidly changing, chairman of the Hospital Medicine annually for more than 10 years. pagers, and so on, but also clerical and evolving, hospitalist landscape Department at Mercy Medical These unique experiences have support, technical support, and ana- to the desks of executives who had Group in Sacramento. He received taught me many lessons and af- lytic support so that you are getting the financial and structural control the SHM Award for Outstanding forded me the opportunity to watch high-quality data on the perfor- to address the challenges that the Service in Hospital Medicine in many stars of hospital medicine mance of the members of your hos- hospitalists in the trenches were 2016 and is currently a member rise, as well as to learn from several pital medicine group (HMG). These facing. of the SHM Practice Management Numerous HMGs failed in the and Awards Committees, as well Long-term goals, such as taking on a new hospital early days of hospital medicine as the SHM Critical Care Task because of this type of misaligned Force. contract,“ are the big-picture stuff that can make or reporting structure. This is a lesson break the career of an HMG leader. Long-term goals also that should not be forgotten: Make need to be delineated in the job description, along with sure your HMG leader has a seat at all the hospitalists are meeting the the table where executive decisions geometric mean length of stay, and specific time stamps and the resources you need. are made, including but not limited that all the physicians are having ” to the board of directors. To be in 15 encounters per day doesn’t hap- less-scrupulous leaders about the “soft” resources (clerical, technical, balance, you have to be “in the room pen immediately. Long-term goals, darker side of hospital politics. and analytical) are often overlooked where it happens.” such as taking on a new hospital One of the lessons I learned the as needs that HMG leaders must contract, are the big-picture stuff hard way about hospital politics is advocate for; I speak with many Accountability that can make or break the career striking the “Authority/Accountabil- HMG leaders who remain under-re- The outcomes that you are respon- of an HMG leader. Long-term goals ity balance” in your career. I shared sourced with “soft” assets. However, sible for need to be explicit, appro- also need to be delineated in the job this perspective at the SHM annu- being appropriately resourced in priately resourced with Authority, description, along with specific time al conference in 2018, at speaking these areas can be transformational and clearly spelled out in your job stamps and the resources you need engagements on the West Coast, for a group. Hospitalists don’t like description. Your job description is to accomplish big-ticket items – and with my leadership group at doing clerical work, and if you don’t a document you should know, own, which are spelled out in the Author- the academies. I am sharing it with like a menial job assigned to you, and revisit regularly with whomev- ity side (that is, physician recruiter, you because the feedback I have re- you probably won’t do it very well. er you report to, in order to ensure secretary, background checks, and ceived has been very positive. Having an unlicensed person dedi- success. so on). The Authority/Accountability cated to these clerical activities not Once you have the Authority One of the classic misuses of balance is a tool for evaluating only will cost less, but will ensure side of the equation appropriately Accountability is the “Fall Guy” sce- your current career trajectory and the job is done better. resourced, setting outcomes that nario. The Fall Guy scenario is often measuring if it is set up for success Reporting structure is critically are a stretch, but still realistic and used by cynical hospital and medical or failure. The essence is that your important, often overlooked, and his- achievable within the scope of your group executives to expand their in- Authority and Accountability need torically misaligned in HMGs. When position, is critical to your success. fluence while limiting their liability. to be balanced for you to be suc- hospital medicine was starting in the It is good to think about short-, In the Fall Guy scenario, the execu- cessful in your career, regardless of late 1990s and early 2000s, rapidly medium-, and long-term goals, espe- tive is surrounded with junior part- your station. Everybody from the growing hospitalist groups were cially if you are in a leadership role. ners who are underpowered with hospitalist fresh out of residency typically led by young, early-career For example, one expectation you Authority, and then the executive to the CEO needs to have Authority physicians who had chosen hospital will have, regardless of your station, makes decisions for which the ju- and Accountability in balance to be medicine as a career. The problem is that you keep up on your email nior partners are Accountable. This successful. And as you use the tool was that they often lacked the se- and answer your phone. These are allows the senior executive to make to measure your own potential for niority and connections at the execu- short-term goals that will often be risky decisions on behalf of the hos- success or failure, learn to apply it to tive level to advocate for their HMG. included in your job description. pital or medical group without the those who report to you. All too often the hospitalist group However, taking on a new hospital liability of being held accountable I believe the rising tide lifts all was tucked in under another de- contract and making sure that it when the decision-making process boats and the success of your subor- partment or division which, in turn, has 24/7 hospitalist coverage, that fails. When the risky, and often October 2020 | 8 | The Hospitalist

08thru11_HOSP20_10.indd 8 9/22/20 2:51 PM ill-informed, decision fails, the junior partner who lacked the Authority to make the decision – but held the Ac- countability for it – becomes the Fall Guy for the failed endeavor. This is a critical outcome that the Authority/ Accountability balance can help you avoid, if you use it wisely and prop- erly. If you find yourself in the Fall Guy position, it is time for a change. The Authority, the Accountability, or both need to change so that they are in better balance. Or your employer needs to change. Changing employ- ers is an outcome worth avoiding, if at all possible. I have scrutinized thousands of resumes in my career, and frequent job changes always wave a red flag to prospective em- ployers. However, changing jobs remains a crucial option if you are

being set up for failure when Au- MAGES I

thority and Accountability are out ETTY of balance. 123/G

If you are unable to negotiate for FTER A R the balance that will allow you to be D successful with your current group, remember that HMG leaders are a quires taking decisive and strategic el position, but that is an entirely and provides strategies for staying prized commodity and in short sup- action, or you will suffer as did Gen- different discussion. I like to think up on short-term goals while con- ply. Leaving a group that has been eral McClellan. Failing to act when of a well-written job description as tinually moving long-term goals your career is hard, but it is better to you are appropriately resourced can including short-term and long-term forward. leave than stay in a position where be just as damaging to your career goals. Short-term goals are usually If you show up at your review you are set up for failure as the Fall and credibility as allowing yourself the daily stuff that keeps operations with a list of accomplishments as Guy. Further, the most effective time to become the Fall Guy. running smoothly but garners little well as an understanding of how the to expand your Authority is when attention. Examples would include “time management matrix” affects you are negotiating the terms of a Job description staying current on your emails, your responsibilities, your boss new position. Changing positions Everybody has somebody that they answering your phone, organizing will be impressed. It is also worth is the nuclear option. However, it is report to, no matter how high up meetings, and regularly attending mentioning that Covey’s first habit better than becoming the Fall Guy, on the executive ladder they have various committees. Even some of is “Proactivity.” He uses the term and a change can create opportuni- climbed. Even the CEO must report these short-term goals can and will Proactivity in a much more nuanced ties that will accelerate your career to the board of directors. And that change over time. I always enjoyed form than we typically think of, and influence, if done right. reporting structure usually involves quality oversight in my depart- however. Simply put, Proactivity is When I talk about Authority/Ac- periodic formal reviews. Your for- ment, but as the department and the opposite of Reactivity, and it is countability balance, I always count- my responsibilities grew, I realized I another invaluable tool for success er the Fall Guy with an ignominious Despite my cynicism couldn’t do everything that I want- with those long-term goals that will historical figure: General George B. ed to do. I needed to focus on the help you make a name for yourself. McClellan. General McClellan was toward“ executives in the things only I could do and delegate When you show up for your the commander of the Army of the medical field, I personally those things that could be done by review, be it annual, biannual, or Potomac during the early years of someone else, even though I wanted other, be prepared. Not only should the American Civil War. General Mc- advocate for supporting to continue doing them myself. I cre- you bring your job description and Clellan had the industrial might of the career development ated a position for a clinical quality recommendations for how it should the Union north at his beck and call, of those around you and officer, and quality oversight moved be adapted in the changing environ- as well as extraordinary resources off of my job description. ment, but also bring examples of for recruiting and retaining soldiers advise against furthering Long-term goals are the aspira- your accomplishments since the last for his army. At every encounter your career at the expense tional items, such as increasing mar- review. with General Robert E. Lee’s Army of ket share, decreasing readmissions, I talk with leaders frequently Northern Virginia, General McClel- of others. improving patient satisfaction, and who are hardworking and diligent lan outnumbered them, sometimes ” the like. Effective leaders are of- and hate bragging about their by more than two to one. Yet Gener- mal review is a good time to go over ten focused on these aspirational, achievements; I get that. At the al McClellan was outfoxed repeated- your job description, note what is long-term goals, but they still must same time, if you don’t inform your ly for the same reason: He failed to relevant, remove what is irrelevant, effectively execute their short-term superiors about your successes, take decisive action. and add new elements that have goals. Stephen Covey outlines the there is no guarantee that they will Every time that McClellan failed, evolved in importance since your dilemma with the “time manage- hear about them or understand he blamed insufficient resources last review. ment matrix” in his seminal work them in the appropriate context. and told President Lincoln that Job descriptions take many forms, “The 7 Habits of Highly Effective Bragging about how great you are he needed more troops and more but they always include a list of People.” An in-depth discussion is in the physician’s lounge is annoy- equipment to be successful. In sum- qualifications. If you have the job, beyond the scope of this article, but ing; telling your boss about your mary, while the Fall Guy scenario you have the qualifications, so that the time management matrix places accomplishments since the last needs to be avoided, once you are is not likely to change. You may be- tasks into one of four categories review is critical to maintaining adequately resourced, success re- come more qualified for a higher-lev- based on urgency and importance, Continued on following page the-hospitalist.org | 9 | October 2020

08thru11_HOSP20_10.indd 9 9/22/20 2:51 PM PRACTICE MANAGEMENT Hospitalists and unit-based assignments

By Isha Puri, MD, MPH, FHM uates performance on domains such as clinical quality and safety, financial stability, HCAHPS, hat seems like a usual day to a sea- and operational effectiveness (length of stay and soned hospitalist can be a daunting readmission rates). In my experience, effective task for a new hospitalist. A routine unit-based rounding positively influences all the day as a hospitalist begins with pre- measures of the balanced score card. Wrounding, organizing, familiarizing, and gathering Multidisciplinary roundings (MDRs) provide a data on the list of patients, and most importantly platform where “the team” meets every morning prioritizing the tasks for the day. I have experi- to discuss the daily plan of care, everyone gets on enced both traditional and unit-based rounding the same page, and unit-based assignments fa- models, and the geographic (unit-based) rounding cilitate hospitalist participation in MDRs. MDRs model stands out for me. typically are a collaborative effort between care The push for geographic rounding comes from team members, such as a case manager, nurse, the need to achieve excellence in patient care, and hospitalist, physical therapist, and pharma- coordination with nursing staff, higher HCAHPS cist. Each team member provides a precise input. (Hospital Consumer Assess- Team members feel account- ment of Healthcare Providers able and are better prepared and Systems) scores, better for the day. It’s easier to devel- provider satisfaction, and ef- op a rapport with your patient Dr. Puri is a hospitalist at Lahey Hospital and ficiency in work flow and in when the same organized, com- Medical Center in Burlington, Mass., and is a documentation. The goal is prehensive plan of care gets member of SHM’s Practice Analysis Committee. typically to use this well-established tool to pro- communicated to the patient. vide quality care to acutely ill patients admitted It is important that each team member is pre- to the hospital, creating an environment of im- pared prior to the rounds. The total time for the ployed HMGs and only 32% for HMGs employed proved communication with the staff. It’s a “pa- rounds is often tightly controlled, as a fundamen- by multistate management companies. In HMGs tient-centered care” model – if the patient wants tal concern is that MDRs can take up too much that served pediatric patients only, 27% utilized to see a physician, it’s quicker to get to the patient time. Use of a checklist or whiteboard during the unit-based assignments. and provides more visibility for the physician. unit-based rounds can improve efficiency. Mid- Undoubtedly geographic rounding has its own These encounters result in improved patient-pro- day MDRs are another gem in patient care, where challenges. The pros and cons and the feasibility vider relationships, which in turn influences the team proactively addresses early barriers in needs to be determined by each HMG. It’s often HCAHPS scores. Proximity encourages empathy, patient care and discharge plans for the next day. best to conduct the unit-based rounds on a few better work flow, and productivity. The 2020 State of Hospital Medicine report units and then roll it out to all the floors. The American health care system is intense and highlights utilization of unit-based rounding, in- An important prerequisite to establishing a complex, and effective hospital medicine groups cluding breakdowns based on employment mod- unit-based model for rounding is a detailed data (HMGs) strive to provide quality care. Perfor- el. In groups serving adults patients only, 43% of analysis of total number of patients in various mance of an effective HMG is often scored on a university/medical school practices utilized unit- units to ensure there is adequate staffing. It “balanced score card.” The “balanced score” eval- based assignments versus 48% for hospital-em- Continued on following page

Continued from previous page reers to last decades. The average to assess your chances of success strongly believe that you can’t build the momentum of past accomplish- hospital CEO has a tenure of less and to advocate for yourself so that up your group, and our profession, ments. If you are not willing to toot than 3.5 years, however, and when you and your group can be success- just by tearing people down. Lend- your own horn, there is a very good a new CEO is hired, almost half ful. ing a helping hand may bring you chance that your horn will remain of chief financial, chief operating, Despite my cynicism toward ex- less attention in the short term, but silent. I don’t think self-promotion and chief information officers are ecutives in the medical field, I per- such action raises your stature, cre- comes easily to anyone, and it has fired within 9 months. You may be sonally advocate for supporting the ates loyalty, and leads to sustainable to be done with a degree of humil- focused on the long-term success career development of those around success for the long run. ity and sensitivity; but it has to be of your organization as you plan you and advise against furthering done, so prepare for it. your career, but many hospital your career at the expense of oth- Sources administrators are interested only ers. Many unscrupulous executives Quinn R. HM turns 20: A look at the Importance of teamwork in short-term gains. It is similar to will use this approach, surrounding evolution of hospital medicine. The We talk about teamwork and collab- some members of Congress who are themselves with Fall Guys, but my Hospitalist. 2016 August. https:// oration as hospitalists, and SHM is interested only in what they need to experience shows that this is not www.the-hospitalist.org/hospitalist/ always underscoring the importance do now to win the next election and a sustainable strategy for success. article/121525/hm-turns-20-look-evo- of teamwork and highlighting ex- not in the long-term needs of the It can lead to short-term gains, but lution-hospital-medicine. amples of successful teamwork in country. You should understand this eventually the piper must be paid. Stephen R. Covey. The 7 Habits of its many conferences and publica- disconnect when dealing with hos- Moreover, the most successful med- Highly Effective People: Powerful tions. Most hospital executives are pital executives, and how you and ical executives and leaders that I Lessons in Personal Change. Simon focused on their own careers, how- your credibility can become cannon have encountered have been those & Schuster. 1989. ever, and many have no reservations fodder in their quest for short-term who genuinely cared about their 10 statistics on CEO turnover, about damaging your career (your self-preservation. subordinates, looked out for them, recruitment. Becker’s Hospi- brand) if they think it will promote You have to look out for and take and selflessly promoted their ca- tal Review. 2020. https://www. theirs. You have to look out for your- care of yourself as you promote reers. beckershospitalreview.com/ self and size up every leadership your group. With a better under- In the age of social media, tearing hospital-management-adminis- position you get into. standing of the Authority/Account- others down seems to be the fastest tration/10-statistics-on-ceo-turn- Physicians can expect their ca- ability balance, you have new tools way to get more “likes.” However, I over-recruitment.html. October 2020 | 10 | The Hospitalist

08thru11_HOSP20_10.indd 10 9/22/20 2:51 PM PRACTICE MANAGEMENT

Continued from previous page must be practical to localize providers to differ- ent units, and complexity of various units can differ. At Lahey Hospital and Medical Center in Burlington, Mass., an efficient unit-based model has been achieved with complex units typically assigned two providers. Units including oncology and the progressive care unit can be a challenge, because of higher intensity and patient turnover. Each unit is tagged to another unit in the same geographical area; these units are designated “sis- ter pods.” The intention of these units is to strike a balance and level off patient load when needed. This process helps with standardization of the work between the providers. A big challenge of the unit-based model is to understand that it’s not always feasible to maintain consistency in patient assignments. Some patients can get transferred to a different unit because of limited telemetry and specialty units. At Lahey the provider manages their own patient as “patient drift” happens, in an attempt to maintain continuity of care. The ultimate goal of unit-based assignments is to improve quality, financial, and operational metrics for the organization and take a deeper dive into provider and staff satisfaction. The sim- plest benefit for a hospitalist is to reduce travel time while rounding. Education and teaching opportunities during the daily MDRs are still debatable. Another big step in this area may be a “resident-centered MDR” with the dual goals of improving both quality of care and resident education by focus- ing on evidence-based medicine.

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the-hospitalist.org | 11 | October 2020

08thru11_HOSP20_10.indd 11 9/22/20 2:51 PM CLINICAL

Key Clinical Question How do you manage common inpatient oncologic emergencies? Three routinely encountered emergencies in the inpatient setting

By Krishna A. Chokshi, MD; and Cardinale Smith, MD, PhD

Key takeaways Dexamthasone 10 mg oral or IV fol- lowed by 4 mg every 4-6 hours until Case definitive treatment is started is as- Mr. Williams is a 56-year-old man with newly diagnosed metastatic sociated with improved neurologic prostate cancer, diabetes mellitus, peptic ulcer disease, and hyper- outcomes and minimal adverse side tension. He is admitted with back pain and lower extremity weak- effects. Higher doses of steroids are ness worsening over 2 weeks. He denies loss of sensation or bowel unlikely to offer more benefit. In pa- and bladder incontinence and can walk. MRI confirms cord compres- tients with paraplegia or autonomic

sion at T10. What initial and subsequent steroid doses would be of MAGES dysfunction, the ability to restore

I Dr. Chokshi Dr. Smith

most benefit to administer? ETTY neurologic function is reduced and /G the burdens of steroid treatment may outweigh its benefits.5 Dr. Chokshi is assistant professor ISPANOLISTIC

H in the division of hospital medicine Case continued at Mount Sinai Hospital, New York. n 2016, there were an estimated at 10 mg followed by 4 mg every 4-6 Mr. Williams completed treatment Dr. Smith is associate professor 15,338,988 people living with can- hours.5 The use of higher doses of for MSCC but was still complaining in the division of hematology/ cer in the United States.1 As such, dexamethasone may result in im- of extreme lethargy and noticed oncology at Mount Sinai Hospital. it is important that hospitalists provement in neurologic deficits, an increase in thirst and no bowel Ibe proficient in managing oncologic but has higher risks for toxicity and movement in 5 days. His serum cal- emergencies that can arise during is not universally supported in the cium was 14 mg/dL. and renal failure. Bradycardia and the natural history of cancer or literature. shortened QT interval are seen more from its treatment. This article will A study conducted by Vecht and Hypercalcemia of malignancy with severe hypercalcemia. review three emergencies that are colleagues demonstrated few differ- HCM is the most common paraneo- routinely encountered in the inpa- ences between initial high-dose and plastic syndrome, observed in near- Management of hypercalcemia of tient setting: malignant spinal cord low-dose dexamethasone.6 Intrave- ly 30% of patients with advanced malignancy compression (MSCC), hypercalcemia nous administration of either 10 mg cancer. It is a poor prognostic Management of HCM depends on of malignancy (HCM), and febrile or 100 mg dexamethasone, both fol- indicator, and approximately half corrected calcium or ionized cal- neutropenia (FN). lowed by total 16 mg of dexameth- of all patients with HCM will die cium levels, chronicity, degree of asone orally per day, showed no within 30 days.8 Cancer is the most symptoms, and presence of renal Malignant spinal cord significant difference in mobility or common reason for hypercalcemia failure. In general, mild asymptom- compression survival between the groups. in the inpatient setting9 and is most atic hypercalcemia can be managed Treatment of MSCC usually aims In a prospective study by Heim- often associated with multiple my- with outpatient care. Serum calci- to preserve function rather than dal and colleagues that evaluated eloma, non–small cell lung cancer, um greater than 14 mg/dL should TABLE 1 reverse established deficits. MSCC the relationship between dexa- breast cancer, renal cell carcinoma, be treated regardless of symptoms from epidural tumor metastasis methasone dose and toxicity, Managementnon-Hodgkins lymphoma,of hypercalcemia and leu- of malignancy(Table 1). develops in 5%-14% of all cancer higher doses of steroids had no kemia. For mild to moderate HCM, man- cases,2 with back pain as the most meaningful impact on neurological Hypercalcemia most often pres- agement involves TABLE saline 3 adminis- common symptom. Nearly 60%-85% symptoms and resulted in more ents with cognitive changes and tration to achieveMultinational euvolemia and Association for Supportive Care in Cancer index of patients have weakness at the severe side effects.7 Patients were lethargy, anorexia, nausea, consti- calcitonin, which has temporizing time of diagnosis,3 and unfortu- either given a 96-mg IV loading pation, polyuria and polydipsia, effects. Early administration of IV nately, nearly two-thirds of patients dose, gradually tapered over 2 will be nonambulatory at presen- weeks, or enrolled in the low-dose TABLE 1 tation. group in which they received 4 mg Management of hypercalcemia of malignancy While timely steroid administra- IV dexamethasone four times per tion in addition to definitive treat- day with a taper over 2 weeks. The Serum calcium Severity Management approach ment may maintain ambulatory high-dose group experienced side 10.5-11.9 mg/dL Mild If the patient is asymptomatic and hypercalcemia capacity at 1 year after therapy,4 effects in 28.6% of patients, with developed chronically, it may not require urgent there is no consensus on the opti- 14.3% experiencing serious side treatment; can usually treat with isotonic uids. mal loading and maintenance dose effects. 12.0-13.9 mg/dL Moderate Isotonic uids alone are usually insufcient; and duration of steroids. Meanwhile, 7.9% of the low-dose can use calcitriol with bisphosphonate therapy. group exhibited some side effects, >14 mg/dL Severe Should be treated even in patients without Overview of the data with none experiencing serious symptoms. Management is similar to moderate

Although there are no formal guide- adverse effects. The high-dose hypercalcemia. If >18 mg/dL, worsening renal EWS N lines on optimal steroid dosing for group did not experience a signifi- failure, or inability to tolerate IV uid, may need to consider dialysis. EDGE MSCC, it is common practice for cant increase in mobility (57.1% vs. MD dexamethasone to be initially dosed 57.9%). Source: Dr. Chokshi, Dr. Smith October 2020 | 12 | The Hospitalist

12thru15_HOSP20_10.indd 12 9/22/20 3:11 PM TABLE 3 Multinational Association for Supportive Care in Cancer index

TABLE 2 CLINICAL Agents used for the treatment of hypercalcemia of malignancy

Agent Indication Mechanism of Dosing Onset of Duration Adverse effects hour period.13 Up to 30% of patients action activity with solid tumors develop febrile Normal saline All severity of HCM. Goal Volume expansion; 200-300 mL/hr 6 hours Hours Hypervolemia. Caution neutropenia after chemotherapy, is to achieve euvolemia. increases renal with goal urinary in oliguria or heart and nearly 80% of patients with excretion of Ca. output >100-150 failure. mL/hr hematologic malignancy or after hematopoietic stem cell therapy Calcitonin Temporizes hypercalcemia. Inhibits osteoclast 4-8 units/kg 2 hours 6-8 hours Nausea, ushing, Reduces serum calcium activity; increases IM or hypersensitivity, local (HSCT) experience it. by roughly 1 mg/dL. To renal excretion of subcutaneously reaction symptoms, Even though an infectious etiolo- be given concurrent Ca; inhibits GI hypophosphatemia, gy is identified in only 30%-40% of to bisphosphonates. absorption of Ca. nephrotoxicity. cases, all patients with febrile neu- Pamidronate Moderate to severe HCM. Inhibits osteoclast 60-90 mg IV <24 hours 7-14 days Osteonecrosis of jaw tropenia should initially receive at activity. administered with long-term use. least empiric gram-negative cover- over 2-6 hours age. The mortality rate is nearly 70% Zoledronic acid Superior to pamidronate Inhibits osteoclast 4-8 mg IV 24-48 2-3 days Same as pamidronate. in neutropenic patients who do not in moderate to severe activity. administered hours Has been used with hypercalcemia. over 15 minutes creatinine >4.5 mg/dL receive empiric antibiotics and is re- 14 with dose reduction. duced to 4%-20% with antibiotics. Denosumab HCM refractory to IV Inhibits RANKL binding 120 mg 9 days 1-4 days Fatigue, nausea, bisphosphonates. HCM to RANK, inhibiting subcutaneously dermatitis, hypocalcemia Risk stratification for febrile neu- in advanced renal osteoclast formation. every 4 weeks w/ hypophosphatemia, tropenia and early discharge failure. loading doses worsened in renal failure. Talcott’s Rules, the Multinational on days 8, 15 Association for Supportive Care Glucocorticoids Can be useful for Reduces hypercalcemia 60 mg by mouth 2-5 days Days to Hyperglycemia, myopathy, in Cancer (MASCC) score, and the

lymphomas that produce from calcitriol prednisone; weeks GI bleed. EWS 1,25-dihydroxyvitamin D. overproduction. hydrocortisone N Clinical Index of Stable Febrile 100 mg every 6 hr EDGE Neutropenia (CISNE) are validated MD tools to determine low-risk febrile Source: Dr. Chokshi, Dr. Smith neutropenia patients (Tables 3 and bisphosphonates for moderate to ability to tolerate IV fluids, dialysis maintain that pamidronate, which is 4). The Infectious Diseases Society severe HCM is beneficial because with a low-calcium bath should be less expensive, is of similar clinical of America guidelines validated the onset of action is 24-48 hours. Fu- considered (Table 2). efficacy to zoledronic acid.12 use of MASCC in 2002 but found rosemide for management of HCM that CISNE had better performance has fallen out of favor unless the Zoledronic acid versus pamidronate Key takeaways than other tools. Coyne and col- patient develops hypervolemia. De- A single dose of zoledronic acid nor- Management of HCM should be de- leagues conducted a retrospective nosumab has been Food and Drug malizes the serum calcium concen- termined by the severity of the calci- cohort study to assess these two Administration approved for HCM tration in 88% of patients, compared um level. The mainstay of treatment risk stratification tools in the ED refractory to bisphosphonate ther- with 70% of those who received includes hydration with normal sa- and found that the CISNE was apy and can manage HCM in 64% pamidronate, in a pooled analysis of line, calcitonin ,and bisphosphonate 98.3% specific for identifying ad- of patients who did not respond two phase 3 trials.11 The median du- therapy; zoledronic acid is preferred verse outcomes, whereas the MAS- adequately to bisphosphonate ther- ration of normocalcemia was longer over pamidronate. For patients CC was 54.2% specific.15 apy. 10 Because it can be used in ad- for those receiving zoledronic acid refractory to bisphosphonates or A study by Talcott and colleagues vanced renal failure without dose (32-43 days vs. 18 days). The efficacy patients with renal insufficiency, used Talcott’s Rules to identify low- TABLE adjustment,2 it is first-line therapy of the 4-mg and 8-mg zoledronic denosumab should be used. risk febrile neutropenia patients, Agentsin thisused population, for the treatment although theof hypercalcemiaacid doses wereof malignancy similar, but the 4-mg who were randomized to early risk for hypocalcemia is increased dose was recommended because of Case continued: Febrile discharge with home intravenous in renal failure. For patients with renal toxicity and increased mortal- neutropenia antibiotics versus continued in- serum calcium greater than 18 mg/ ity associated with the higher dose. Febrile neutropenia is defined as a patient management. There were dL, worsening renal failure, or in- Despite these data, many specialists single oral temperature of 100.9° F no significant differences in the or a temperature of 100.4° F sus- primary outcomes, defined as any TABLE 3 tained over a 1-hour period in a change in clinical status requiring Multinational Association for Supportive Care in Cancer index patient with absolute neutrophil medical evaluation.16 Another study count (ANC) less than 1,000 cells/ suggested that discharge after 24 Characteristic Weight mL or ANC expected to decrease to hours based on clinical stability Burden of febrile neutropenia with no or mild symptoms1 5 less than 500 cells/mL within a 48- Continued on following page No hypotension (systolic BP >90 mmHg) 5 TABLE 4 No chronic obstructive pulmonary disease2 4 Solid tumor or hematological malignancy with no previous fungal infection3 4 Clinical Index of Stable Febrile Neutropenia No dehydration requiring parenteral uids 3 Characteristic Points Burden of febrile neutropenia with moderate symptoms4 3 Eastern Cooperative Oncology Group performance score ≥2 2

EWS Stress-induced hyperglycemia (initial blood glucose ≥121 mg/dL, 2 Outpatient status 3 N

EDGE or ≥250 mg/dL in diabetic patients or those on steroids) Age <60 years 2 MD Chronic obstructive pulmonary disease 1 1. Burden of febrile neutropenia refers to general clinical status as in uenced by the febrile neutropenic episode. It is evaluated in accordance with the following scale: no symptoms (5), Chronic cardiovascular disease 1 mild symptoms (5), moderate symptoms (3), severe symptoms (0), moribund (0). Mucositis grade ≥2 1 2. Chronic obstructive pulmonary disease means active chronic bronchitis, emphysema, Monocytes <200 cells/mcL 1 decrease in FEVs, need for oxygen therapy and/or steroids and/or bronchodilators. 3. Previous fungal infection means demonstrated fungal infection or empirically treated Scoring Interpretation suspected fungal infection. Low risk = 0 1.1%-1.5% risk of complication within 7 days 4. Points attributed to the variable “burden of febrile neutropenia” are not cumulative. Thus, the EWS N maximum theoretical score is therefore 26. A score of ≥21 is considered low risk and a score Intermediate risk = 1-2 4%-6.2% risk of complication within 7 days of <21 as high risk (positive predictive value of 91%, speci’city of 68%, and sensitivity of 71%). High risk = ≥3 34%-95% risk of complication within 7 days EDGE MD Source: Ann Emerg Med. 2017;69(6):755-64. doi: 10.1016/j.annemergmed.2016.11.007 Source: Ann Emerg Med. 2017;69(6):755-64. doi: 10.1016/j.annemergmed.2016.11.007

the-hospitalist.org 13 October 2020 TABLE 1 Management| | of hypercalcemia of malignancy 12thru15_HOSP20_10.indd 13 9/22/20 3:11 PM CLINICAL

Continued from previous page 7. Heimdal K et al. High incidence of serious side effects of high- dose dexamethasone treatment in patients with epidural spinal Quiz with outpatient oral antibiotics was noninferior cord compression. J Neurooncol. 1992;12(2):141-4. to standard inpatient and intravenous antibiotic 8. Ralston S et al. Cancer-associated hypercalcemia: Morbidity and rs. Smith is a 64-year-old woman therapy.17 A Cochrane review in 2013 of 22 random- mortality. Clinical experience in 126 treated patients. Ann Intern with endometrial cancer with Med. 1990;112(7):499-504. ized controlled trials determined that oral antibi- temperature of 100.4° F at home. 9. Lindner G et al. Hypercalcemia in the ED: Prevalence, etiology, M otics were an acceptable treatment for low-risk and outcome. Am J Emerg Med. 2013;31(4):657-60. She takes no antibiotics, has no other 18 patients. 10. Hu M et al. Denosumab for patients with persistent or relapsed medical history, and was sent in from clin- hypercalcemia of malignancy despite recent bisphosphonate treat- ic and admitted for further management. Key takeaways ment. J Natl Cancer Inst. 2013;105(18):1417-20. She feels well, and preliminary infectious Though the MASCC is highly sensitive in identify- 11. Major P et al. Zoledronic acid is superior to pamidronate in workup is negative. She has been afebrile the treatment of hypercalcemia of malignancy: A pooled anal- ing low-risk febrile neutropenia patients, it should ysis of two randomized, controlled clinical trials. J Clin Oncol. for more than 24 hours, and her ANC is be used with clinical caution because up to 11% of 2001;19(2):558-67. 600 cells/mL. patients characterized as low risk developed se- 12. Stewart A. Clinical practice. Hypercalcemia associated with Her son’s soccer game is tomorrow, and vere complications.19 If a low-risk patient with sol- cancer. N Engl J Med. 2005;352(4):373-9. she would like to be present. Her family id tumor malignancy has adequate home support, 13. Freifeld A et al. Executive summary: Clinical practice guideline is involved in her care. Under what condi- for the use of antimicrobial agents in neutropenic patients with lives within an hour of the hospital, and has access cancer: 2010 update by the Infectious Diseases Society of America. tions can she be discharged? to follow-up within 72 hours, oral antibiotics and Clin Infect Dis. 2011;52(4):427-31. early discharge can be considered. 14. Baden L et al. Prevention and treatment of cancer-related infec- A. She should not be discharged until full tions, version 2.2016, NCCN clinical practice guidelines in oncol- course of empiric intravenous antibiot- ogy. J Natl Compr Canc Netw. 2016;14(7):882-913. References ics is completed. 15. Coyne C et al. Application of the MASCC and CISNE risk-strat- 1. SEER. Cancer of Any Site - Cancer Stat Facts. https://seer.cancer. ification scores to identify low-risk febrile neutropenic patients in B. Consider discharge in another 24 hours gov/statfacts/html/all.html. Accessed 2019 Jul 17. the emergency department. Ann Emerg Med. 2017;69(6):755-64. if she remains afebrile. 2. Kwok Y et al. Clinical approach to metastatic epidural spinal cord 16. Talcott J et al. Safety of early discharge for low-risk patients with C. Discharge if low risk by MASCC or compression. Hematol Oncol Clin North Am. 2006;20(6):1297-305. febrile neutropenia: a multicenter randomized controlled trial. J CISNE, with oral doses of levofloxacin 3. Helweg-Larsen S et al. Prognostic factors in metastatic spinal Clin Oncol. 2011;29:3977-83. or moxifloxacin or oral ciprofloxacin cord compression: A prospective study using multivariate analysis 17. Innes H et al. Oral antibiotics with early hospital discharge of variables influencing survival and gait function in 153 patients. compared with in-patient intravenous antibiotics for low-risk febrile and amoxicillin/clavulanic acid. Int J Radiat Oncol Biol Phys. 2000;46(5):1163-9. neutropenia in patients with cancer: A prospective randomised 4. Sørensen P et al. Effect of high-dose dexamethasone in carcino- controlled single centre study. Br J Cancer. 2003;89(1):43-9. Answer: C. The patient has a solid tumor matous metastatic spinal cord compression treated with radiother- 18. Vidal L et al. Oral versus intravenous antibiotic treatment for malignancy, is low risk by both MASCC apy: A randomised trial. Eur J Cancer. 1994;30(1):22-7. febrile neutropenia in cancer patients. Cochrane Database Syst. 5. Skeoch G et al. Corticosteroid treatment for metastatic spinal Rev. 2013. and CISNE, and can most likely be dis- cord compression: A review. Global Spine J. 2017;7(3):272-9. 19. Taplitz RA et al. Outpatient management of fever and neutro- charged if she is clinically stable or im- 6. Vecht C et al. Initial bolus of conventional versus high-dose penia in adults treated for malignancy: American Society of Clinical proved. A 7-day course of antibiotics is dexamethasone in metastatic spinal cord compression. Neurol- Oncology and Infectious Diseases Society of America clinical prac- recommended with close follow-up. ogy. 1989;39(9):1255-7. tice guideline update. J Clin Oncol. 2018;36(14):1443-53.

Unexpected results in COVID-19 cytokine data

By Damian McNamara intensive care medicine at Radboud University Medical Center in Nijme- he immune system overacti- gen, the Netherlands. SHM provides hospital-based vation known as a “cytokine The team’s research was published providers with a platform to learn Tstorm” does not play a major online on Sept. 3 in a letter in JAMA. from, network through and make role in more severe COVID-19 out- comes, according to unexpected Cytokines lower than expected our voices and needs heard. findings in new research. The Normally, cytokines trigger inflamma- findings stand in direct contrast to tion and promote healing after trau- Suj Sundararaj, MD, MBA many previous reports. ma, infection, or other conditions. “We were indeed surprised by the Although a cytokine storm re- results of our study,” senior study mains ill defined, the authors noted, author Peter Pickkers, MD, PhD, said many researchers have implicated in an interview. a hyperinflammatory response in- If I had one regret, it’s not joining as soon as In a unique approach, Dr. Pickkers volving these small proteins in the and colleagues compared cytokine pathophysiology of COVID-19. I became a hospitalist. levels in critically ill people with The question remains, however, Ilya Yepishin, DO COVID-19 with those in patients whether all cytokine storms strike with bacterial sepsis, trauma, and people with different conditions the after cardiac arrest. same way. “For the first time, we measured Dr. Pickkers, lead author Matthijs the cytokines in different diseases Kox, PhD, and colleagues studied 46 using the same methods. Our results people with COVID-19 and acute re- Our focus is your future. convincingly show that the circulat- spiratory distress syndrome (ARDS) Not a member? Don’t wait. ing cytokine concentrations are not who were admitted to the ICU at Join today at hospitalmedicine.org/join higher, but lower, compared to other Radboud University Medical Center. diseases,” said Dr. Pickkers, who is All participants underwent mechan- affiliated with the department of Continued on following page October 2020 | 14 | The Hospitalist

12thru15_HOSP20_10.indd 14 9/25/20 11:37 AM COMMENTARY 2020 has been quite a year

By Danielle Scheurer, MD, MSCR, SFHM to improve upon how we care for all patients, despite COVID-19. What I couldn’t have known remember New Year’s Day 2020, full of hope and is how hospitalists would pivot to new arenas of wonderment of what the year would bring. I care settings, including the EDs, ICUs, “COVID was coming into the Society of Hospital Medi- units,” and telehealth – flawlessly and seamlessly cine as the incoming President, taking the 2020 filling care gaps that would otherwise be cata- Ireins in the organization’s 20th year. It would be a strophically unfilled. year of transitioning to a new CEO, reinvigorating What I couldn’t have known is how we would be our membership engagement efforts, and renew- willing to come back into work, day after day, to ing a strategic plan for forward progress into the care for our patients, despite the risks to ourselves next decade. It would be a year chock full of travel, and our families. What I couldn’t have known is speaking engagements, and meetings with thou- how hospitalists would come together as a com- sands of hospitalists around the globe. munity to network and share knowledge in un- What I didn’t know is that we would soon face precedented ways, both humbly and proactively the grim reality that the long-voiced concern of – knowing that we would not have all the answers infectious disease experts and epidemiologists but that we probably had better answers than would come true. That our colleagues and friends most. What I couldn’t have known is that the SHM and families would be infected, hospitalized, and staff would pivot our entire SHM team away from Dr. Scheurer is chief quality officer and professor die from this new disease, for which there were no previous “staple” offerings (e.g., live meetings) to of medicine at the Medical University of South good, effective treatments. That our ability to come virtual learning and network opportunities, which Carolina, Charleston. She is president of SHM. together as a nation to implement basic infection would be attended at rates higher than ever seen control and epidemiologic practices would be frac- before, including live webinars, HMX exchanges, tured, uncoordinated, and ineffective. That within 6 and e-learnings. What I couldn’t have known is So, is 2020 shaping up as expected? Absolutely months of the first case on U.S. soil, we would wit- that we would figure out, in a matter of weeks, not! But I am more inspired, humbled, and mo- ness 5,270,000 people being infected from the dis- what treatments were and were not effective for tivated than ever to proudly serve SHM with ease, and about 200,000 dying from it. And that the our patients and get those treatments to them more energy and enthusiasm than I would have stunning toll of the disease would ripple into every despite the difficulties. And what I couldn’t have dreamed on New Year’s Day. And even if we nook and cranny of our society, from the economy known is how much prouder I would be, more can’t see each other in person (as we so naively to the fabric of our families and to the mental and than ever before, to tell people: “I am a hospitalist.” planned), through virtual meetings (national, re- physical health of all of our citizens. I took my son to the dentist recently, and when gional, and chapter), webinars, social media, and However, what I couldn’t have known on this we were just about to leave, the dentist asked: other listening modes, we will still be able to con- past New Year’s Day is how incredibly resilient “What do you do for a living?” and I stated: “I am nect as a community and share ideas and issues as and innovative our hospital medicine society and a hospitalist.” He slowly breathed in and replied: we muddle through the remainder of 2020 and be- community would be not only to endure this new “Oh … wow … you have really seen things …” Yes, yond. We need each other more than ever before, way of working and living, but also to find ways we have. and I am so proud to be a part of this SHM family.

Continued from previous page The researchers likewise found analysis suggest COVID-19 may not regulation at the Immunology Fron- ical ventilation and were treated be- lower concentrations of IL-8 in be characterized by cytokine storm,” tier Research Center at Osaka (Japan) tween March 11 and April 27, 2020. patients with COVID-19, compared the researchers noted. However, University, said in an interview. The investigators measured plasma with the out-of-hospital cardiac they added, “whether anticytokine His study, published online Aug. levels of cytokines, including tumor arrest patients. IL-8 levels did not therapies will benefit patients with 21 in PNAS, also revealed lower se- necrosis factor (TNF), interleukin-6, COVID-19 remains to be deter- rum IL-6 levels among people with and IL-8. They compared results in mined.” COVID-19, compared with patients this group with those in 51 patients The findings of this Going forward, Dr. Pickkers and with bacterial ARDS or sepsis. who experienced septic shock and preliminary“ analysis colleagues are investigating the ef- Dr. Kishimoto drew a distinction, ARDS, 15 patients with septic shock fectiveness of different treatments however: COVID-19 patients can without ARDS, 30 people with suggest COVID-19 may to lower cytokine levels. They are develop severe respiratory failure, out-of-hospital cardiac arrest, and not be characterized by treating people with COVID-19, for suggesting a distinct immune reac- 62 people who experienced multiple cytokine storm. example, with the IL-1 cytokine in- tion, compared with patients with traumas. They used historical data hibitor anakinra and steroids. bacterial sepsis. SARS-CoV-2 directly for the non–COVID-19 cohorts. ” They also plan to assess the infects and activates endothelial differ between the COVID-19 and long-term effects of COVID-19 on cells rather than macrophages, as Conditional findings assessed trauma groups. the immune system. “Following an occurs in sepsis. Compared with patients with sep- Furthermore, the researchers infection, it is known that the im- For this reason, Dr. Kishimoto said, tic shock and ARDS, the COVID-19 found no differences in IL-6 con- mune system may be suppressed for “SARS-CoV-2 infection causes crit- cohort had lower levels of TNF, centrations between patients with a longer period of time, and we are ical illness and severe dysfunction IL-6, and IL-8. The differences were COVID-19 and those who experi- determining to what extent this is in respiratory organs and induces a statistically significant for TNF (P < enced out-of-hospital cardiac arrest also present in COVID-19 patients,” cytokine storm,” even in the setting .01), as well as for IL-6 and IL-8 con- or trauma. Dr. Pickkers said. of lower but still elevated serum centrations (for both, P < .001). However, levels of TNF in people IL-6 levels. In addition, the COVID-19 group with COVID-19 were higher than in Enough to cause a storm? Dr. Pickkers and Dr. Kishimoto had significantly lower IL-6 and IL-8 trauma patients. The study “is quite interesting, and reported no relevant financial rela- concentrations compared with the The small sample sizes and single- data in this paper are consistent with tionships. patients who had septic shock with- center study design are limitations. our data,” Tadamitsu Kishimoto, MD, A version of this story originally out ARDS. “The findings of this preliminary PhD, of the department of immune appeared on Medscape.com. the-hospitalist.org | 15 | October 2020

12thru15_HOSP20_10.indd 15 9/22/20 3:11 PM Improving communication Continued from page 1

But if loved ones are going to help patients, they Dr. Esbensen said it is critical to start off on do not realize it is possible to receive phone calls need help from clinicians. Beyond being potential the right foot when communicating with a pa- from hospitalists. “We need to remind them that allies, they are also hurting, experiencing worry tient’s loved one, especially during the current they can get in touch with us. We have to remem- or confusion in a world of medical jargon. pandemic. ber how helpless they can feel and how they The coronavirus changes the relationship of “With COVID-19, the most important thing is to want to understand what is happening in the patients and their loved ones, as patients are speak honestly, to say hope for the best but pre- hospital.” often isolated or limited in the number of visi- pare for the worst-case scenario,” Dr. Esbensen For medical adherence issues, sometimes it is tors they are allowed to see. A smartphone re- said. “We’ve seen that conditions can shift dra- best to communicate with the patient and loved places the smiling faces of friends and relatives matically in short periods of time. The loved one at their bedside, and a text is a poor substitute needs to have a sense of the positive and negative for a hug. possibilities. Families tend to lack understanding The Hospitalist asked some experienced hos- of the changes in the patient that are caused by pitalists for insight on how best to communicate COVID-19. The patient can come out of the hos- with patients’ loved ones to improve outcomes pital debilitated, very different than when they for all, medically and emotionally. entered the hospital, and we need to warn people close to them about this. Unrealistic expectations Team approach need to be guarded against if a patient’s loved “Patients feel isolated, terrified, and vulnerable ones are going to help.” but still need an advocate in the hospital, so daily Perhaps the best form of communication with communication with a patient’s loved one is im- a patient’s loved ones is an often-forgotten skill: portant to give a sense that the patient is looked listening. after,” said Kari Esbensen, MD, PhD, a hospitalist “Get an idea from the patient’s loved ones of and palliative care expert at Emory University what the issues are, as well as their idea of what Hospital Midtown, Atlanta. they think of the disease and how it spreads,” Dr. Glenn Rosenbluth, MD, a pediatric hospitalist Esbensen said. “Sometimes they are right on tar-

and director, quality and safety programs, at get but sometimes there are misinterpretations , the University of California, San Francisco, Be- and we need to help them understand it better. OSENBLUTH

nioff Children’s Hospital, agreed. He said that It’s not a ‘one-size-fits-all’ speech that we should R

the most important thing is to communicate, give, but try to say, ‘tell me what you think is LENN . G period. going on, what you think you’ve heard, and what R D “We fall into this pattern of ‘out of sight, out of you’re worried about,’ and learn what is most im- OURTESY

mind,’‹” he said. “We need to take the extra step portant to the patient. Start on those terms and C to find out who a patient’s loved ones are. If it is adapt; this way you can correct and address what Dr. Rosenbluth a clinical visit, ask the patient, or maybe get the makes them most fearful, which can be different information from a caseworker, or just pay atten- for each loved one. For some, the concern could We have to remember that tion to who is dropping in to see the patient. Hav- be that they have children or other vulnerable ing a second person available to jot down notes, people in the house. Finding out these other is- a“ loved one is important to or having a handy list of questions – it all helps sues is important.” a patient’s care team and we the patient. We forget that sometimes it can seem Venkatrao Medarametla, MD, SFHM, medical like a whirlwind for the patient when they are director for hospital medicine at Baystate Medi- need to include them, empower hurting. We have to remember that a loved one is cal Center, Springfield, Mass., emphasized that, in them, and show that we want important to a patient’s care team and we need to a time when hospitalists are being pulled in every to hear their voices. include them, empower them, and show that we direction, it is easy to lose your attention. want to hear their voices.” “It’s very important that family members know ” you’re present with them,” he said. “This can be one at the same time, Dr. Hodo advised. “Wheth- an emotional time and they need empathy. It’s er it’s for medication or postdischarge exercises, Quick takeaways very easy for our list of tasks to get in the way if they both receive the information together of communicating, including with our body lan- it can reinforce adherence. But you also need • Get beyond personal protective equipment. guage.” to remember that the patient may only want a A conversation with a patient’s loved one Dr. Medarametla said one of the reasons to loved one told about certain things, or possibly might be easier to achieve via phone, with- communicate with patients’ loved ones is to calm nothing at all. We need to make sure we under- out all the protective gear in the way. them – a patient’s relatives or their friends may stand the patient’s wishes, regardless of wheth- • Encourage adherence. Speaking with pa- not be under your medical care, but they are still er we think a person close to them can be an tients and loved ones together may be more human beings. ally or not.” effective. They may reach agreement quicker “A lot of people just want information and Dr. Esbensen also noted that a loved one can on how best to adhere to medical advice. want to be helpful, but we also need to realize give hospitalists important clues to the emotion- • Accept clues from loved ones. They might that, while we are caring for many patients, al components of a patient’s care. give you a better sense of a patient’s worries, this one person is the patient they are focused “I remember a patient whose wife told me how or help you to connect better with those in on,” said Laura Nell Hodo, MD, a pediatric hos- he worked in a garage, how he was strong and your care. pitalist at Kravis Children’s Hospital at Mount did not want people to think he was a weak guy • Be present. You have a long to-do list but do Sinai in New York. “Don’t rush, and if you know just because of what was happening to him,” not let empathy fall off it, even if you feel that a patient’s loved one needs more time, Dr. Esbensen said. “I didn’t know that he felt he overwhelmed. make sure it can be found – if not then, at least might be perceived in this way. I mentioned to • Listen. By finding out what a patient’s loved later on the phone. Fifteen to 20 minutes may him how I learned he was a good mechanic and ones know, you can figure out what they be what’s needed, and you can’t shortchange he perked up and felt seen in a different light. don’t know – and need to. them.” These things make a difference.” Dr. Hodo said that a patient’s loved ones often But when is the best time to speak with a October 2020 | 16 | The Hospitalist

01_2_16_17_HOSP20_10.indd 16 9/22/20 2:44 PM patient’s loved ones? Since “It’s not just in the hos- much communication is pital but after discharge,” done via phone during the she said. “A person offering pandemic, there are differ- support can really help ent philosophies. patients throughout their “We had a debate among journey, and much success colleagues to see how each in recovering from illness of us did it,” Dr. Rosenbluth occurs after the transition said. “Some try to call after home. Having the support each patient encounter, of that one person a patient while they are outside the trusts can be critical.” room and it’s fresh in their Dr. Hodo believes that mind, but others find it the coronavirus pandemic

better to make the call after ODO could forever change the H

their rounds, to give the ELL way hospitalists communi- N

person their full attention. AURA cate with patients and their . L Most of the time I try to do R loved ones. D it that way.” “I work in pediatrics and OURTESY

Dr. Rosenbluth noted that, C we know serious medical in the current environment, a Dr. Hodo decisions can’t be made phone call may be better than without guardians or a face-to-face conversation parents,” she said. “But in with patients’ loved ones. My experience from working in adult coronavirus units is adult medicine doctors “We’re covered in so much that“ the thinking about the loved ones’ role in patient care – and may not automatically ask gear to protect us from the communication with them – might just change. the patient about calling coronavirus that it can feel someone for input on deci- like a great distance exists ” sion-making. With COVID, between us and the person with whom we’re all aspects of care. Long after a patient returns you cannot assume a patient is on their own, speaking,” he said. “It’s strange, but the phone can home, the support of loved ones can have a pro- because there are protocols keeping people make the conversation seem more relaxed and found impact in speeding healing and improving from physically being present in the patient’s may get people to open up more.” long-term outcomes. room. My experience from working in adult Dr. Esbensen said COVID-19 and other serious coronavirus units is that the thinking about Even when they leave illnesses can leave a patient needing support, the loved ones’ role in patient care – and com- All the hospitalists affirmed that loved ones can and maybe a “push” when feeling low keeps them munication with them – might just change. … At make a big difference for the patient through from adhering to medical advice. least, I hope so.”

SoHM Report Sneak Peek More than half of Adult HMGs continue to operate on a 7 days on/7 days off schedule, while Pediatric HMGs use more variable scheduling for their practice.

Figure 1.14 Predominant Scheduling Patterns in HMGs

Stay updated with the latest trends in hospital medicine! Order your copy today! hospitalmedicine.org/SoHM

the-hospitalist.org | 17 | October 2020

01_2_16_17_HOSP20_10.indd 17 9/22/20 2:44 PM HM20 VIRTUAL CONFERENCE

A ‘foolproof’ way to diagnose narrow complex tachycardias on EKGs

By Bruce Jancin their cell phone or in a notebook. leads are the best identifiers of atri- And then it will similarly ramp back MDedge News “If it’s irregular I’m going down al flutter?’ And the answer is the down in stages, with the up/down the right column; if it’s regular I’m inferior leads II, III, and aVF,” she pattern being repeated. hospitalist looking at an going down the left. And then I’m said. Sinus tachycardia is generally a EKG showing a narrow systematically running the drill,” she Another classic feature of atrial reflection of underlying significant complex tachycardia explained. flutter with variable conduction systemic illness, such as sepsis, hy- needs to be able to come is cluster beating attributable to a potension, or anemia. 147996.graphic IMNG Print Colors Headline for a Bar Graphic Aup with an accurate diagnosis of 3) Are upright p waves present be- varied ventricular response. This Atrial tachycardia: The heart the rhythm pronto. And hospitalist fore each QRS complex in leads II If a deck headline is needed, use this style. and V1? Meghan Mary Walsh, MD, MPH, has Label style and size developed a simple and efficient This information rules out some Narrow complex tachycardias: Here’s the breakdown method for doing so within a min- of the eight items in the differential Axes number style and size ute or two that she’s used with great diagnosis and rules in others. The differential diagnosis Note: Trade Gothic Medium, 8/11 ush left success on the wards and in teach- ing medical students and residents Narrow complex tachycardias Regular rhythm Irregular rhythm Source: Trade Gothic Medium, 8/11 ush left for nearly a decade. with an irregular rhythm 1) Sinus tachycardia 1) Atrial brillation Style Guide: “You’re busy on the wards. You There are only three: 2) Atrial tachycardia 2) Multifocal atrial tachycardia Keep the background white. may have a patient who’s unstable. Atrial fibrillation: The heart rate 3) Atrial utter 3) Atrial utter with variable conduction You need to make diagnostic de- is typically 110-160 bpm, although Use the IMNG colors. cisions very rapidly. And this is a it can occasionally go higher. The 4) AV reentrant tachycardias Move the entire graph to align the bar labels left at the blue guide bar. foolproof way to make the correct rhythm is irregularly irregular: No 5) Accelerated junctional rhythm (Resizing may need to be done on the graph to €t in the space.) diagnosis every time,” she promised two RR intervals on the EKG are MDedge News If a deeper or shorter template is needed, adjust in Window > Artboards. at HM20 Virtual, hosted by the Soci- exactly the same. And there are no Source: Dr. Walsh (Standard, as shown here, is 28 picas x 20 picas.) ety of Hospital Medicine. p waves. To create the dotted lines if they change, use the clear arrow tool, click Her method involves asking three “If it’s faster than 100 bpm, irreg- results in a repeated pattern of ir- rate is generally 100-140 bpm, and on the line that needs to be changed, use the eyedropper tool, then questions about the 12-lead EKG: ularly irregular, and no p waves, the regular RR intervals: There might p waves are present. But unlike in click on the dotted rule provided on the side of the template. conclusion is very simple: It’s AFib,” be a 2:1 block in AV conduction for sinus tachycardia, the patient with 1) What’s the rate? Dr. Walsh said. several beats, then maybe a 4:1 block atrial tachycardia lying in bed with A narrow complex tachycardia by Multifocal atrial tachycardia for several more, with resultant a heart rate of 140 bpm is not in a definition needs to be both narrow (MAT): The heart rate is generally lengthening of the RR interval, then state of profound neurohormon- and fast, with 100-150 bpm 3:1, with shortening of RR. This reg- al activation and is not all that a QRS complex but can some- ularly irregular sequence is repeated sick. of less than 0.12 times climb to throughout the EKG. Another diagnostic clue is seconds and about 180 bpm. “Look for a pattern amidst the provided by a look at the tele- a heart rate The PP, PR, and chaos,” the hospitalist advised. monitoring strip. Unlike in sinus above 100 bpm. RR intervals The heart rate might be roughly tachycardia, where the heart rate Knowing how far above 100 bpm the are varied, inconsistent, and don’t 150 bpm with a 2:1 block, or 100 bpm ramps up and then back down re- rate is will help with the differential repeat. Most importantly, there are with a 3:1 block. The p waves in atri- peatedly, in atrial tachycardia the diagnosis. three or more different p-wave mor- al flutter with variable conduction heart rate very quickly ramps up phologies in the same lead. One p can be either negatively or positive- in stages to, say, 140 bpm, and then 2) Is the rhythm regular or irregular? wave might look like a tall mountain ly deflected. hangs there. “If I put the EKG 10 feet away peak, another could be short and Atrial flutter: This is the only from you, you should still be able to flat, and perhaps the next is big and Narrow complex tachycardias narrow complex tachycardia that look at it and say the QRS is either broad. with a regular rhythm appears in both the regular and ir- systematically marching out – boom, MAT often occurs in patients with Sinus tachycardia: The heart rate is regular rhythm columns. It belongs boom, boom – or there is an irregu- a structurally abnormal atrium – for typically less than 160 bpm, the QRS in the irregular rhythm column lar sea of QRS complexes where the example, in the setting of pulmo- complexes show a regular pattern, when there is variable conduction RR intervals are variable and incon- nary hypertension leading to right and upright p waves are clearly visi- and cluster beating, with a regularly sistent,” said Dr. Walsh, a hospitalist atrial enlargement, with resultant ble in leads II and V1. irregular pattern of RR intervals. In at the University of Minnesota, depolarization occurring all over the The distinguishing feature of this contrast, when atrial flutter is in the Minneapolis, and chief academic of- atrium. arrhythmia is the ramping up and regular rhythm column, it’s because ficer at Hennepin Healthcare, where “Don’t confuse MAT with AFib: ramping down of the heart rate. The the atrioventricular node is steadily she oversees all medical students One has p waves, one does not. Oth- tachycardia is typically less than 160 conducting the atrial depolariza- and residents training in the health erwise they can look very similar,” bpm. But the rate doesn’t suddenly tions at a rate of about 300 bpm. So system. she said. jump from, say, 70 to 140 bpm in a there’s no cluster beating. As in atri- This distinction between a regu- Atrial flutter with variable con- flash while the patient is lying in al flutter with variable conduction, lar and irregular rhythm immedi- duction: A hallmark of this reen- the hospital bed. A trip to the telem- the flutter waves are visible most ately narrows the differential by trant tachycardia is the atrial flutter etry room for a look at the teleme- often in leads II, III, and aVF, where dividing the diagnostic possibilities waves occurring at about 300 bpm try strip will tell the tale: The heart they can be either positively or neg- into two columns (see chart). She between each QRS complex. rate will have progressively ramped atively deflected. urged her audience to commit the “On board renewal exams, the up from 70, to 80, then 90, then 100, AV reentrant tachycardias: These list to memory or keep it handy on question is often asked, ‘Which 110, 120, 130, to perhaps 140 bpm. Continued on following page October 2020 | 18 | The Hospitalist

18thru21_HOSP20_10.indd 18 9/22/20 4:24 PM HM20 VIRTUAL CONFERENCE

Risk stratification key in acute pulmonary embolism

By Bruce Jancin Dr. Tapson said it’s worthwhile for hospi- “If the heart rate is 70, the patient is probably MDedge News talists to take a close look at these Europe- very stable. Of course, that might not hold up in an guidelines (Eur Respir J. 2019 Oct 9. doi: a patient with conduction problems or who is ll intermediate-risk pulmonary embo- 10.1183/13993003.01647-2019). on a beta-blocker, but in general if I see someone lism is not the same, Victor F. Tapson, “I think our Europeans friends did a really nice who looks good, has a relatively small pulmonary MD, declared at HM20 Virtual, hosted job with those guidelines. They’re great guide- embolism, and a low heart rate, it makes me feel by the Society of Hospital Medicine. lines, better than many of the others out there. much better. If the heart rate is 130 or 120, I’m AThe best current guidelines on the manage- I think they’re very, very usable,” he said. “I took much more concerned.” ment of acute pulmonary embolism (PE) recom- part in the ACCP [American College of Chest Both the European guidelines and the mend a risk stratification strategy that involves Physicians] guidelines for years. I think they’re PERT Consortium guidelines on the diag- further subdivision of intermediate-risk PE into very rigorous in terms of the evidence base, but nosis, treatment, and follow-up of acute PE intermediate to low or intermediate to high risk. because they’re so rigorous there’s just tons of 2C This additional classification is worthwhile be- recommendations, which are basically sugges- cause it has important treatment implications. tions. The ESC guidelines are more robust.” AND

Patients with intermediate- to low-risk PE,

along with those who have truly low-risk PE, Risk stratification EVERBERI R require anticoagulation only. In contrast, pa- Once anticoagulation is on board, the next task LAUDIO

tients with intermediate- to high-risk PE are at is risk stratification to determine the need for , C ACO

increased risk of decompensation. They have a more aggressive therapy. A high-risk PE is best I E much higher in-hospital mortality than those defined hemodynamically as one causing a sys- D OMMONS with intermediate- to low-risk PE. So hospitalists tolic blood pressure below 90 mm Hg for at least IUSEPPE C may want to consult their hospitals’ PE response 15 minutes. The term “high risk” is increasingly , G ERRA IKIMEDIA team (PERT), if there is one, or whoever on staff replacing “massive” PE, because the size of the S /W ALTER HERLI

is involved in helping make decisions about the clot doesn’t necessarily correlate with its hemo- W appropriateness of more aggressive interven- dynamic impact. G OURTESY IZIANO T tions, such as catheter-directed thrombolysis or An intermediate-risk PE is marked by a simpli- C catheter-directed clot extraction, said Dr. Tapson, fied Pulmonary Embolism Severity Index (sPESI) Patients with intermediate- to high-risk PE are at director of the venous thromboembolism and score of 1 or more, right ventricular dysfunction increased risk of decompensation. pulmonary vascular disease research program at on echocardiography or CT angiography, or an Cedars-Sinai Medical Center in Los Angeles. elevated cardiac troponin level. (Clin Appl Thromb Hemost. 2019 Jun 17. doi: “We don’t have evidence of any real proven The sPESI is a validated, user-friendly tool that 10.1177/1076029619853037), which Dr. Tapson mortality difference yet in the intermediate- to grants 1 point each for age over 80, background coauthored, recommend substratifying inter- high-risk PE group by being more aggressive. cardiopulmonary disease, a systolic blood pres- mediate-risk PE into intermediate to low or I think if the right patients were studied we sure below 100 mm Hg, cancer, a heart rate of intermediate to high risk. It’s a straightforward could see a mortality difference. But one thing 110 bpm or more, and an oxygen saturation level matter: If a patient has either right ventricular I’ve noted is that by being more aggressive – in a below 90%. dysfunction on imaging or an elevated cardiac cautious manner, in selected patients – we clear- “All you really need to know about a patient’s troponin, that’s an intermediate- to low-risk PE ly shorten the hospital stay by doing catheter-di- sPESI score is: Is it more than zero?” he explained. warranting anticoagulation only. On the other rected therapy in some of these folks. It saves Indeed, patients with an sPESI score of 0 have a hand, if both right ventricular dysfunction and money,” he observed. 30-day mortality of 1%. With a score of 1 or more, an elevated troponin are present, the patient has Once the diagnosis of PE is confirmed, the first however, that risk jumps to 10.9%. an intermediate- to high-risk PE. Since this dis- priority is to get anticoagulation started in all No scoring system is 100% accurate, though, tinction translates to a difference in outcome, a patients with an acceptable bleeding risk, since and Dr. Tapson emphasized that clinician gestalt consultation with PERT or an experienced PE in- there is convincing evidence that anticoagula- plays an important role in PE risk stratification. terventionalist is in order for the intermediate- to tion reduces mortality in PE. The 2019 European In terms of clinical indicators of risk, he pays spe- high-risk PE, he said. Society of Cardiology guidelines recommend a cial attention to heart rate. Dr. Tapson reported receiving research funding direct-acting oral anticoagulant over warfarin on “I think if I had to pick the one thing that from Bayer, Bristol-Myers Squibb, Janssen, BiO2, the basis of persuasive evidence of lower risk of drives my decision the most about whether EKOS/BTG, and Daiichi. He is also a consultant to major bleeding coupled with equal or better ef- someone needs more aggressive therapy than Janssen and BiO2, and on speakers’ bureaus for fectiveness in preventing recurrent PE. anticoagulation, it’s probably heart rate,” he said. EKOS/BTG and Janssen.

Continued from previous page atrial flutter, there is no ramp up in dias the p waves are often buried in “In the case of accelerated junc- reentrant tachycardias can take heart rate. Patients will be lying in the QRS complex and can be tough tional tachycardia, think slow, think two forms. In atrioventricular nodal their hospital bed with a heart rate to see. It’s very difficult to differen- ‘regular,’ think of a rate often just reentrant tachycardia (AVnRT), the of, say, 80 bpm, and then suddenly it tiate AVnRT from AVRT except by over 100, usually with p waves after aberrant pathway is found entire- jumps to 180, 200, or even as high as an electrophysiologic study. the QRS that are inverted because ly within the AV node, whereas in 240 bpm “almost in a split second,” Accelerated junctional tachy- there’s retrograde conduction,” she atrioventricular reentrant tachycar- Dr. Walsh said. cardia: This is most commonly the advised. dia (AVRT) the aberrant pathway is No other narrow complex tachy- slowest of the narrow complex Dr. Walsh reported having no found outside the AV node. AVnRT cardia reaches so high a heart rate. tachycardias, with a heart rate of financial conflicts of interest regard- is more common than AVRT. As in In both of these reentrant tachycar- less than 120 bpm. ing her presentation. the-hospitalist.org | 19 | October 2020

18thru21_HOSP20_10.indd 19 9/22/20 4:24 PM HM20 VIRTUAL CONFERENCE

Batten down the hatches for thyroid storm

By Bruce Jancin Endocrine Society, in Dr. Mayer’s view. As a pre- 37% iodine by weight, can also fan thyrotoxicosis MDedge News requisite to the diagnosis a patient must have into thyroid storm. Abrupt discontinuation of an- thyrotoxicosis as evidenced by elevated free thy- tithyroid medication is another common cause. hyroid storm is a life-threatening endo- roxine (free T4) and free or total triiodothyronine Fluid and electrolyte replacement, oxygen if ap- crine emergency for which, remarkably, (T3), which in the vast majority of cases, is ac- propriate, cooling blankets, and other supportive there are no definitive diagnostic tests, companied by low thyroid-stimulating hormone measures are also important. and the management of which is sup- (TSH). Medical management targets multiple steps in Tported by a startlingly weak evidence base. The Japanese diagnostic system for thyroid thyroid hormone production and action to quell “What’s tricky is there really are no specific bio- storm relies on five categories of organ system– thyroid storm. The first order of business is to chemical level cutoffs for thyroid storm, and also no based clinical features. This approach places inhibit synthesis of new thyroid hormone by unique laboratory abnormalities. So in the end, it’s greater weight on disturbances of consciousness prescribing a thioamide. Dr. Mayer favors prop- a clinical diagnosis and a clinical judgment,” Stepha- – restlessness, delerium, agitation, psychosis, ylthiouracil over methimazole for this purpose nie B. Mayer, MD, MHSc, observed at HM20 Virtual, because, not only does it block the thyroid gland hosted by the Society of Hospital Medicine. from synthesizing new hormone, it also reduces Moreover, there are no prospective clinical conversion of T4 to T3. Propylthiouracil is usually trials addressing the treatment of thyroid storm, given orally as a 500- to 1,000-mg loading dose, and the 2016 American Thyroid Association clin- then 250 mg every 4 hours. The drug can also be ical practice guidelines on the topic are based given rectally or by nasogastric tube. upon low-quality evidence from case reports and One hour or more after starting the thioamide, studies dating back to the 1970s and 1980s. UpTo- inorganic iodine is started to inhibit release of Date reached the same conclusion in 2020, noted preformed hormone from the thyroid gland. Five Dr. Mayer, an endocrinologist at Virginia Com- drops of saturated solution of potassium iodide monwealth University, Richmond. given every 6 hours is the recommended dose; it Thinking that perhaps the guideline writing provides 764 mg of iodide per day. Lugol’s solution MAGES panel had missed something, she asked a univer- I dosed at four to eight drops every 6-8 hours is an ETTY

sity medical research librarian to custom-build /G effective alternative. a comprehensive search for studies on thyroid Simultaneous with starting the patient on

storm management. The search proved unre- MAGICMINE inorganic iodine, a low-dose beta-blocker is intro- warding, she said. duced to control adrenergic symptoms. “The evidence is, unfortunately, a little disap- lethargy, coma – than the other four components, “Propranolol is first line because it also decreas- pointing,” Dr. Mayer explained. which consist of fever of at least 100.4° F, tachy- es T4 to T3 conversion and it’s noncardioselective, Thyroid storm is a rare condition, but one that cardia of 130 or more beats per minute, heart so it’s better than a cardioselective beta-blocker hospitalists must be ready for. Dr. Mayer high- failure signs and symptoms, and gastrointestinal/ at reducing sympathetic tone–related symptoms, lighted current best practices in diagnosis and hepatic involvement as evidenced by nausea, such as agitation, fever, and psychosis,” the endo- management. vomiting, hyperdefecation, and/or a total biliru- crinologist explained. bin level of 3.0 mg/dL or more. At the same time that propranolol at 60-80 mg A high-mortality emergency The Japanese approach offers two paths to a is given orally every 4 hours and iodine are start- Thyroid storm is an extreme manifestation of definite diagnosis of thyroid storm. One requires ed, the patient is placed on glucocorticoids as thyrotoxicosis, which is marked by multiorgan at least one CNS manifestation plus symptoms another means of reducing peripheral conversion dysfunction and rapid decompensation. In a drawn from any one of the other four categories. of T4 to T3. The options are intravenous hydro- large, first-of-its-kind, national retrospective U.S. The other route, for patients without evident cortisone at 100-300 mg/day in divided doses or study, the incidence of thyroid storm was 0.57-0.76 CNS symptoms, requires the presence of symp- dexamethasone at 2 mg every 6 hours. cases per 100,000 persons per year. Thyroid storm toms from at least three of the other four catego- Aspirin and NSAIDs should be avoided as an- accounted for 16% of the more than 121,000 hos- ries, Dr. Mayer said. tipyretics because they can actually raise T3 and pital discharges featuring a primary diagnosis of A patient is categorized as having suspected T4 levels. Acetaminophen is the right fever-lower- thyrotoxicosis. The in-hospital mortality rate for rather than definite thyroid storm if the CNS ing agent in the setting of thyroid storm. patients with thyroid storm was 1.2%-3.6% during criterion isn’t met but any two of the others are. Dr. Mayer has occasionally had to reach for one the 10-year study period, a rate 12-fold higher than A patient also qualifies for suspected thyroid of several backup therapies. Prescribing a bile that among patients with thyrotoxicosis without storm when CNS manifestations plus symptoms acid sequestrant – 20-30 g/day of cholestyramine thyroid storm (Thyroid. 2019 Jan;29[1]:36-43). from at least one other category are present, but or colestipol – will trap thyroid hormone in the Dr. Mayer highlighted a multicenter French thyroid hormone levels aren’t available (Endocr J. intestine, preventing it from recirculating. study that underscored the current hefty morbid- 2016 Dec 30;63[12]:1025-64). “Be careful to dose it away from the other med- ity and mortality associated with thyroid storm. ications,” she cautioned. Among 92 patients admitted to the ICU for thy- Management of thyroid storm Also, therapeutic plasmapheresis is effective at roid storm, the in-ICU mortality rate was 17%, and There is usually a precipitating event that drives rapidly removing circulating thyroid hormone in the mortality rate 6 months after admission was the transition from smoldering thyrotoxicosis to patients who don’t show early clinical improve- 22%. Independent risk factors for in-ICU mortali- thyroid storm. ment in response to multipronged medical ther- ty were multiorgan failure and the occurrence of “The big thing is to look for and treat the un- apy. cardiogenic shock within the first 48 hours in the derlying precipitating event,” the endocrinologist Dr. Mayer offered a couple of final tips to hospi- ICU (Crit Care Med. 2020 Jan;48[1]:83-90). stressed. talists regarding thyroid storm: Know who directs It’s often a systemic insult: severe infection, plasmapheresis at your hospital, and keep the Diagnosis of thyroid storm trauma, surgery, an acute MI, diabetic ketoacidosis, American Thyroid Association management guide- The most user-friendly system for assistance in pulmonary embolism, or perhaps having just gone lines handy (Thyroid. 2016 Oct;26[10]:1343-421). diagnosing thyroid storm is the one put forth through labor. Iodine exposure in the form of IV She reported receiving funding from both No- by the Japan Thyroid Association and the Japan contrast or taking amiodarone, which contains voNordisk and Astra Zeneca. October 2020 | 20 | The Hospitalist

18thru21_HOSP20_10.indd 20 9/22/20 4:24 PM HM20 VIRTUAL CONFERENCE

Developing COVID-19 hospital protocols during the pandemic

By Thomas R. Collins What Dr. Brode and Dr. Busch de- page summary of protocols – much with COVID and COVID patients MDedge News scribed was in large part a fine-tun- more, they said, and it could feel that some of those markers were ing of communication – being overwhelming. not really informing any of our clin- s hospitalists and other available to communicate in real time Dr. Busch and Dr. Brode were ical decisions,” she said. “Obviously, physicians at the Univer- and being aware of when certain asked how standardized order as literature comes out we may sity of Texas at Austin specialists should be contacted – for sets for COVID patients could be reevaluate what goes into that stan- considered how to treat instance, to determine at what oxy- justified without comparison to a dard order set and how frequently ACOVID-19 patients in the early we follow labs.” weeks of the pandemic, one ques- Dr. Brode said the context – a pan- tion they had to consider was: What It’s all about teamwork. The interprofessional demic – has to be considered. about convalescent plasma? team“ members know their roles and have shared “In an ideal world, we could show All they had to go on were small that the intervention is superior case series in Ebola, SARS, and expectations because they have a common through a randomized fashion MERS and a few small, nonrandom- understanding of the protocol. with a control group, but really ized COVID-19 studies showing a ” our thought process behind it is possible benefit and minimal risk, just, what is the default?” he said. but the evidence was only “toward genation level internal medicine staff control group that didn’t use the “I looked at the order sets [as] not the middle or bottom” of the evi- should get in touch with the pulmo- standard order set. that they’re going to be dictating dence pyramid, said Johanna Busch, nary–critical care team. Dr. Busch responded that, while care, but it’s really like the guard- MD, of the department of internal Dr. Brode said that the ground- there was no controlled trial, the or- rails of what’s reasonable. And medicine at Dell Medical Center at work is laid for productive meetings, der sets they use have evolved based when you’re in the middle of a the university. with agendas announced ahead on experience. surge, what is usually reasonable The center’s COVID-19 committee of time and readings assigned and “At the beginning, we were fol- and easiest is what is going to be asked a few of its members – infec- presenters ready with near-finished lowing every inflammatory marker done.” tious disease and internal medicine products at meeting time, “with a known to mankind, and then we re- Dr. Busch and Dr. Brode reported physicians – to analyze the literature clear path for operationalizing it.” alized as we gained more experience no relevant financial relationships. and other factors. In the end, the “We don’t want people kind of committee – which meets regularly riffing off the top of their heads,” he and also includes pulmonology–crit- said. ical care experts, nursing experts, Committee members are encour- and others – recommended using aged to be as specific as possible convalescent plasma because of the when giving input into COVID-19 evidence and the available supply. care decisions, he said. But in subsequent meetings, as the “We’re so used to dealing with pandemic surged in the South and uncertainty, but that doesn’t really the supply dwindled, the committee help when we’re trying to make changed its recommendation for con- tough decisions,” Dr. Brode said. valescent plasma to more limited use, They might be asked, “What are you she said during HM20 Virtual, hosted going to write in your consult note by the Society of Hospital Medicine. template?” or “It’s 1:00 a.m. and your Dell’s experience with the therapy intern’s panicked and calling you – is one example of how the center what are you going to tell them to had to quickly develop protocols do over the phone?” Leaders for managing a pandemic with es- The recommendations have to go sentially no solid evidence for treat- into writing and are incorporated ment and a system that had never into the electronic medical record, been challenged before to the same a process that required some work- Wanted degree. arounds, he said. He also noted that “It’s all about teamwork,” said the committee learned early on that W. Michael Brode, MD, of the de- they should assume that no one SHM is now recruiting for partment of internal medicine at reads the e-mails – especially after Dell. “The interprofessional team being off for a period of time – so the Board of Directors. members know their roles and have they likely won’t digest updates on Nominate yourself or a colleague to serve a shared expectations because they an email-by-email basis. have a common understanding of “We quickly learned,” Dr. Brode three-year term beginning in May 2021. the protocol.” It’s okay to deviate said, “that this information needs from the protocol, he said, as long as to live on a Web site or [be] linked Deadline: October 31, 2020 the language exists to communicate to the most up-to-date version in a these deviations. cloud-sharing platform.” Submit your nomination: “Maybe the approach is more im- In a question-and-answer dis- hospitalmedicine.org/boardnominations portant than the actual content,” he cussion, session viewers expressed said. enthusiasm for the presenters’ one- the-hospitalist.org | 21 | October 2020

18thru21_HOSP20_10.indd 21 9/22/20 4:24 PM HM20 VIRTUAL CONFERENCE

Performance status, molecular testing key to metastatic cancer prognosis

By Bruce Jancin how long they have to live. For one static cancer and poor performance ic cytotoxic cancer-directed therapy MDedge News thing, the national average 5-year status by determining whether that is appropriate for patients with poor overall survival figure is hardly an status is caused by the cancer itself performance status who have one erformance status and mo- individualized assessment. Plus, or some other cause that’s not easily of several specific relatively nonche- lecular testing results are oncology is a fast-moving field in reversible, such as liver failure. moresponsive types of metastatic key tools in prognosticating which important treatment advanc- Take, for example, the inpatient cancer. These include esophageal, for patients with newly di- es occur all the time, and the SEER with advanced SCLC. This is an gastric, and head and neck cancers. Pagnosed metastatic solid tumors, data lag far behind. For example, aggressive and chemosensitive can- On the other hand, advanced according to Sam Brondfield, MD, when Dr. Brondfield recently looked cer. Dr. Brondfield said he is among SCLC isn’t the only type of metastat- MA, an inpatient medical oncologist up the current SEER 5-year survival many medical oncologists who are ic cancer that’s so chemosensitive at the University of California, San for patients diagnosed with met- convinced that, if 148071.graphicpoor performance that he and many other oncologists Francisco. astatic non–small cell lung cancer status in a patient with advanced believe aggressive chemotherapy Oncologists have at their finger- (NSCLC), the figure quoted was less SCLC is caused by the cancer itself, should beIMNG offered Print even Colors in the face Headline for a Bar Graphic tips a voluminous and ever-growing of poor patient performance statusIf a deck headline is needed, use this style. body of clinical trials data to draw ECOG performance status attributable to the cancer itself. on for prognostication. Yet many Take, for example, colorectal can-Label style and size hospitalists will be surprised to Grade Description of patient cer with no more than five metas- Axes number style and size learn that this wealth of informa- 0 Fully active, able to carry on all predisease performance without restriction tases to the lung or liver, provided tion is of little value in the inpatient those metastases are treatable withNote: Trade Gothic Medium, 8/11 ush left 1 Restricted in physically strenuous activity but ambulatory and able to carry settings where they work, he said at resection or radiation. “Those pa- out work of a light or sedentary nature, e.g., light housework, of ce work Source: Trade Gothic Medium, 8/11 ush left HM20 Virtual, hosted by the Society tients are actually curable at a high of Hospital Medicine. 2 Ambulatory and capable of all self-care but unable to carry out any work rate. They have about a 30%-40% Style Guide: activities; up and about more than 50% of waking hours “The applicability of clinical tri- cure rate. So those patients, even ifKeep the background white. als data to hospitalized patients is 3 Capable of only limited self-care; con ned to bed or chair more than 50% they have poor performance status,Use the IMNG colors. of waking hours generally poor. That’s an important if we can get them up for surgery orMove the entire graph to align the bar labels left at the blue guide bar. 4 Completely disabled; cannot carry on any self-care; totally con ned to bed caveat to keep in mind,” Dr. Brond- radiation, we usually do try to treat (Resizing may need to be done on the graph to €t in the space.) field said. or chair them aggressively,” Dr. Brondfield If a deeper or shorter template is needed, adjust in Window > Artboards. Enrollment in clinical trials is 5 Dead said. MDedge News (Standard, as shown here, is 28 picas x 20 picas.) usually restricted to patients with a There are other often chemore- To create the dotted lines if they change, use the clear arrow tool, click score of 0 or 1 on the Eastern Clin- Source: Eastern Clinical Oncology Group sponsive metastatic cancers for ical Oncology Group performance which oncologists frequently rec- on the line that needs to be changed, use the eyedropper tool, then status, meaning their cancer is than 6%, and it was drawn from prompt initiation of inpatient che- ommend aggressive treatment to click on the dotted rule provided on the side of the template. causing minimal or no disruption to data accrued in 2009-2015. That motherapy should be recommended improve quality of life in patients their life (see graphic). Sometimes simply doesn’t reflect contemporary to elicit a response that improves with poor performance status. trials will include patients with practice. quality of life and performance These cancers include aggressive a performance status of 2 on the Indeed, it’s no longer true that status in the short term. If, on the lymphomas, which are actually ECOG scale, a tool developed nearly the average survival of patients other hand, the poor performance often curable; multiple myeloma; 40 years ago, but clinical trials vir- with metastatic NSCLC is less than status is caused by organ failure or testicular and germ cell cancers; tually never enroll those with an a year. In the practice-changing some other issue that can’t easily NSCLC with a targetable muta- ECOG status of 3 or 4. Yet most hos- KEYNOTE-189 randomized trial, be improved, hospice may be more tion, which is often responsive to pitalized patients with metastatic which accrued participants in 2016- appropriate. oral medications; and prostate and cancer have an ECOG performance 2017, the median overall survival of “The contour of SCLC over time is well-differentiated thyroid cancers, status of 3 or worse. Thus, the clin- patients randomized to pembroli- that despite its treatment respon- which can usually be treated with ical trials outcome data are of little zumab (Keytruda) plus standard siveness it inevitably recurs. But hormone- or iodine-based therapies relevance. cytotoxic chemotherapy was 22 with chemotherapy you can give rather than more toxic intravenous “In oncology the distinction be- months, compared with 11 months people in this situation months of cytotoxic chemotherapy. tween ECOG 2 and 3 is very import- with chemotherapy plus placebo (J quality time, so we generally try to The impact of inpatient palli- ant,” Dr. Brondfield emphasized. Clin Oncol. 2020 May 10. doi: 10.1200/ treat these sorts of patients,” Dr. ative chemotherapy in patients When he talks about treatment JCO.19.03136). As a result, immuno- Brondfield explained. with poor performance status and options with hospitalized patients therapy with a programmed death–1 The National Comprehensive advanced solid cancers not on the who have metastatic cancer and inhibitor such as pembrolizumab in Cancer Network guidelines upon short list of highly chemosensitive poor performance status – that is, combination with chemotherapy is which oncologists rely leave lots of cancers has not been well studied. ECOG 3 or 4 – he’ll often say: “Assum- now standard practice in patients room for interpretation regarding A recent retrospective study of 228 ing you feel better and can go home, with metastatic NSCLC without tar- the appropriateness of inpatient such patients who received inpa- that’s when these clinical trial data getable mutations. chemotherapy in patients with tient palliative chemotherapy at a may apply better to you.” advanced cancer and poor patient large Brazilian academic medical Dr. Brondfield cautioned against Performance status guides performance status. Citing “knowl- center provided little reason for quoting the National Cancer Insti- treatment decision-making edge that’s been passed down enthusiasm regarding the practice. tute’s Surveillance, Epidemiology Hospitalists can help oncologists in across oncology generations,” Dr. Survival was short, with 30- and 60- and End Results (SEER) 5-year over- decision-making regarding whether Brondfield said he and many of his day survival rates of 56% and 39%, all survival data when hospitalized to offer palliative systemic therapy colleagues believe early palliative respectively. Plus, 30% of patients patients with advanced cancer ask to patients with advanced meta- supportive care rather than system- Continued on following page October 2020 | 22 | The Hospitalist

22thru25_HOSP20_10.indd 22 9/22/20 4:21 PM HM20 VIRTUAL CONFERENCE

Population health can improve postdischarge care

By Thomas R. Collins tient care that is less centralized, fees based on and a 49% decrease in hospital days for “superuti- MDedge News outcomes and patient experience rather than lizers” of the ED, Dr. Myers said. simply volume of services, team approaches Postdischarge clinics – where patients can be ith the United States spending rather than single-provider care, and a general seen for the first few visits after hospitalization the most per capita on health care attention to preserving health rather than treat- – have also been valuable for many health sys- among industrialized nations but ing sickness. tems, because they are closely in tune with what having the worst aggregate health At Cleveland Clinic, care teams try to under- happened during the inpatient stay. These clin- outcomes,W there’s a stark need for improvement, stand not just the care that is medically neces- ics are staffed by hospitalists, interns, residents, according to an expert at HM20 Virtual, hosted by sary, but what is wanted and justified, as well as or ambulatory clinicians. Dr. Myers said hos- the Society of Hospital Medicine. how to deliver that care safely, pitalists tend to have an improved perspective Broadening the focus beyond the four walls of reliably, and affordably with after working in a discharge clinic, with more the hospital can bring better results while also outcomes that patients and concern about a patient’s needs once they leave saving money, said Adam Myers, MD, chief of families desire. the hospital bed. population health at Cleveland Clinic. Dr. Myers The results are striking. Af- “Those hospitalists that I know who have par- described the way his health system has begun to ter increasing the number of ticipated in programs like this start to act a bit pay more careful attention to the needs of specif- ambulatory patient “touches” more like primary care physicians,” he said. ic kinds of patients and tailoring posthospitaliza- for those with chronic disease, In a Q&A session after Dr. Myers’ presentation, tion care accordingly, with in-person and virtual inpatient care – disliked by he discussed how hospitalists can affect the home visits, and postdischarge clinics. Dr. Myers patients and costly to health many layers of health care policy, factors that of- With an increasing attention to value, health centers – decreased. From the ten overlap with population health. care organizations have to change their structure first quarter of 2018, outpatient visits increased He noted that medical care accounts for only or risk going the way of the Choluteca Bridge in 9%, while inpatient visits dropped 7.4%, Dr. Myers about 20% of patient outcomes – the rest involve Honduras, Dr. Myers said. The Choluteca Bridge said. social and environmental factors. was built to be hurricane proof, but was none- “As we managed patients more effectively on “I don’t know about you , but I’m not satisfied theless rendered useless in 1998 after Hurricane an outpatient basis, their need for inpatient care only impacting 20% of health outcomes,” he said. Mitch shifted the very course of the river be- diminished,” he said. “It works.” First, physicians need to understand what is neath it. Cleveland Clinic has also made changes de- happening in their communities, and the health Similarly, the way health care is delivered often signed to reduce costly readmissions, using vir- policies that are preventing improvement. Then, does not meet the needs of the population. tual visits, house calls, time reserved for team build partnerships to help fix these problems. He “Our national system has been focused almost meetings to identify patients with gaps in their pointed to lead poisoning as an example. entirely on inpatient care,” Dr. Myers said. “A lot care, and attention to nonmedical determinants “If you think about it, lead poisoning is a social of the transition in care is outside of facilities and of health, such as assessing fall risk at home and housing problem that shows up as a health care outside the walls of our inpatient settings.” addressing lack of nutritious food options in a issue. Unless we are getting out into the com- Instead, he said a focus on population health community. munity and mitigating the root problem, we will – understanding and tending to the needs of The health system has seen a 28% reduction in have to treat it over and over again,” he said. people rather than just treating them when they the cost of care attributed to house calls, 12% cost Dr. Myers reported no relevant financial disclo- show up at clinics – should involve more outpa- reduction attributed to better care coordination, sures.

Continued from previous page disagreement between the oncolo- and the palliative care team will in before trying to prognosticate in were admitted to the ICU, where gist wanting to be aggressive for a have perspectives of their own. patients with a metastatic cancer for they received aggressive and costly sick inpatient and the hospitalist or which targetable mutations might be end-of-life care. The investigators generalist provider thinking: ‘This Molecular testing is now the present. Survival rates can vary sub- found these results suggestive of person looks way too sick for che- norm in metastatic cancers stantially depending upon those test overprescribing of inpatient palli- motherapy.’•” These days oncologists order molec- results. Take, for example, metastatic ative chemotherapy (BMC Palliat For this reason he is a firm be- ular testing for most patients with NSCLC: Just within the past year, Care. 2019 May 20;18[1]:42. doi: 10.1186/ liever in having multidisciplinary metastatic carcinomas to determine clinical trials have been published s12904-019-0427-4). conversations regarding prognosis eligibility for targeted therapy, suit- reporting overall survival rates of 39 Of note, the investigators found in in challenging situations involving ability for participation in clinical months in patients with treatable a multivariate analysis that an ele- hospitalized patients with advanced trials, prognostication, and/or as- mutations in epidermal growth vated bilirubin was associated with cancer. An oncologist can bring to sistance in determining the site of factor receptor, 42 months with ana- a 217% increased risk of 30-day mor- such discussions a detailed under- origin if that’s unclear. plastic lymphoma kinase mutations, tality, and hypercalcemia was associ- standing of clinical trial and mo- A single-pass fine-needle aspiration and 51 months in patients whose ated with a 119% increased risk. lecular data as well as information biopsy doesn’t provide enough tissue tumor signature features mutations “That’s something to take into about the patient’s response to the for molecular testing. It’s therefore in c-ros oncogene 1, as compared with account when these decisions are first round of therapy. But lots of important to order initially a multi- 22 months with no targetable muta- being made,” Dr. Brondfield advised. other factors are relevant to prog- pass fine-needle aspiration to avoid tions in the KEYNOTE-189 trial. In response to an audience com- nosis, including nutritional status, the need for a repeat biopsy, which “There’s a lot of heterogeneity ment that oncologists often seem comorbidities, and the intuitive eye- is uncomfortable for the patient and around how metastatic tumors be- overly optimistic about prognosis, ball test of how a patient might do. can delay diagnosis and treatment. have and respond to therapy. Not Dr. Brondfield observed, “I think The patient’s family, primary care Dr. Brondfield advised waiting for all metastatic cancers are the same,” it’s very common for there to be a provider, oncologist, the hospitalist, molecular testing results to come the oncologist emphasized. the-hospitalist.org | 23 | October 2020

22thru25_HOSP20_10.indd 23 9/22/20 4:21 PM HM20 VIRTUAL CONFERENCE

Drug allergy in the chart? Ask patients for specifics

By Thomas R. Collins These questions can help deter- billiform rash without a fever can symptoms, and the timing – an im- MDedge News mine the next steps. For sulfa-based be done on an outpatient basis. But mediate reaction is much different antibiotics, hospitalists can often if the patient had hives, or became than a symptom that showed up aige Wickner, MD, MPH, desensitize patients with certain short of breath or anaphylactic, it days later. medical director for quality reaction characteristics using wide- needs to be done as an inpatient by “Sometimes they’ll say they’re al- and safety at Brigham and ly studied protocols to allow the an allergist, she said. lergic to penicillin, but will tell you Women’s Hospital and assis- patient to temporarily take a sulfa- they’ve taken Augmentin or amox- Ptant professor at Harvard Medical containing medication. icillin, so you can take that allergy School, both in Boston, described a The dominant message of Dr. off the list,” Dr. Wickner said. scenario that might sound familiar Wickner’s talk on drug allergies Often, skin testing At Brigham and Women’s Hos- to hospitalists. was to get clear details on the al- and/or“ challenge pital and Massachusetts General A 72-year-old man is admitted to lergic reaction – it can help guide testing can help Hospital, Boston, physicians have the hospital for a lung transplant, clinicians through a path forward, developed protocols for assessing and has a listed allergy to “sulfa,” either finding an alternative drug or patients receive and managing suspected allergies to contained in antibiotics and other performing further evaluation and first-line therapy. penicillin, aspirin and NSAIDs, and medications. His medical records say perhaps continuing with the drug in trimethoprim/sulfamethoxazole – his reaction was “rash.” question if the allergy turns out not ” helpful tools, she said, because the What do you do? to be a major concern. nature and context of the reaction The answer, Dr. Wickner said, “Please, for all of your patients, can matter a great deal in how to re-

speaking at HM20 Virtual, spon- take an allergy history on every HINKSTOCK spond to the listed allergy. /T sored by the Society of Hospital listed medication; often you will be If someone has a reaction, and you AFFORD

Medicine, is to first ask more ques- able to remove or clarify the medical M think it might be anaphylaxis, don’t PIKE

tions for clarification. How bad was record and the changes can be life S spend time pondering it, Dr. Wick- the rash? Was it blistering? To what saving,” she said. ner said. “If that thought crosses type of sulfa did the patient have a For instance, desensitization to The question of drug allergies is your mind, treat it like anaphylaxis, reaction? sulfa for patients who’ve had a mor- substantial. About 35% of patients then analyze after the fact.” Most have at least one listed drug allergy, patients with anaphylaxis have with penicillin, NSAIDs, and CT some cutaneous sign, even if it’s just contrast agents topping the list, Dr. flushing. Wickner said. Although 10% of the Dr. Wickner said that, if an aller- general population and 15% of inpa- gist is available, take advantage of tients have a listed penicillin allergy, that. “If allergy is available in-house, more than 90% of listed penicillin utilize them. Often, skin testing and/ allergies turn out not to actually be or challenge testing can help pa- allergic, in part because penicillin al- tients receive first-line therapy.” lergies are often diagnosed in child- In a question-and-answer session hood and are frequently outgrown after her presentation, Dr. Wickner over time. Having a listed allergy said that hospitalists “have a huge can impact treatment, Dr. Wickner role to play” in drug allergy delabeling. said, with alternatives not always “We would love to have a more clear-cut. standard practice of allergy reconcil- She described one patient she saw iation, just like we do with medica- who had 62 listed drug allergies, tion reconciliation,” she said. Asking prompting her clinicians to wonder, questions to get more specifics is “what can I safely give this patient?” essential – and simply asking direct- Physicians, she said, subject to drug ly about each listed allergen is “step allergy “alert fatigue,” tend to over- one, and you’ll really find it’s going ride about 80% of allergy alerts, but to broaden the things that you can this can sometimes have serious do for your patients.” consequences. Asked about whether reactions “The best time to clarify is when listed as allergies are frequently a patient is healthy and well,” said just adverse effects, Dr. Wickner Dr. Wickner, not when they are an said that patients who say they SHM’s Virtual Leadership Capstone inpatient and sick. It is much more are frequently nauseous – rather difficult to test for an allergy, and than breaking out into a rash, for Take your leadership skills to the next level to treat an allergic reaction, than example – might not be having a from the comfort of your home. when someone’s health is quickly true allergic reaction. After careful April 5 –7, 2021 | 1:00 – 5:00 p.m. EST (each day) declining. consideration, they might be better Learn more: hospitalmedicine.org/capstone She urged physicians to ask pa- managed with antinausea medica- tients to be specific about the name tion than avoidance of the drug. of a drug they suspect they’re al- Dr. Wickner reported no relevant lergic to, about the indications, the financial disclosures. October 2020 | 24 | The Hospitalist

22thru25_HOSP20_10.indd 24 9/25/20 11:42 AM HM20 VIRTUAL CONFERENCE

Hospitalists balance work, family as pandemic boosts stress

By Thomas R. Collins Dr. Alfandre said etching out time MDedge News for yourself must be “a priority, or it won’t happen.” Doing so, he said, n a Q&A session at HM20 Virtual, “feels indulgent but it’s not. It’s cen- hosted by the Society of Hospital tral to being able to do the kind of Medicine, Heather Nye, MD, PhD, work you do when you’re at the hos- SFHM, professor of medicine at pital, at the office, and when you’re Ithe University of California, San back home again.” Francisco, and David J. Alfandre, MD, Dr. Nye observed that, while work- MPH, associate professor of medicine ing from home on nonclinical work, at New York University Langone, “recognizing how little I got done was discussed strategies to help hospital- a big surprise,” and she had to “grow ists tend to their personal wellness comfortable with that” and learn to during the COVID-19 pandemic. live with the uncertainty about when HINKSTOCK The speakers described the com- that was going to change. /T plicated logistics and emotional and Both physicians described the psychological strain that has come emotional toll of worrying about their children

if they have to MONKEYBUSINESSIMAGES We empathize with continue distance “our patients, and we learning. and scared and need her help. and be frightened about – but [that Dr. Alfandre “I feel like sharing that part of knowledge] just gives them a little empathize with our said that a shared our job [with] our kids helps them perspective.” children and what Google calen- understand that there are very, very Dr. Nye and Dr. Alfandre said dar for his wife big problems out there – that they they had no financial conflicts of their experience is. and him – with don’t have to know too much about interest. ” Dr. Alfandre appointments, work obligations, from working during the pandemic, children’s doctor’s appointments, while balancing home responsibili- recitals – has been helpful, removing ties and parenting. The session was the strain of having to remind each an opportunity to humanize hospi- other. He said that there are skills talists’ experience as they straddle used at work that hospitalists can work and family. use at home – such as not getting Dr. Nye said she was still “warm- upset with a child for crying about a ing up to personal wellness” because spilled drink – in the same way that there have been so many other de- a physician wouldn’t get upset with On Demand mands over the past several months, a patient concerned about a test. but that taking the time to go for I feel like sharing that Secure your CME for the year. walks – to bring on HM20 Virtual On Demand offers a maximum of 40 AMA a feeling of health part“ of our job [with] PRA Category 1 Credit™ and 18.00 MOC points. Access even more than our kids helps them our most popular sessions and newly added content in the physical ben- response to COVID-19: efits – has been understand that there are helpful. Even be- very, very big problems • Updates in Heart Failure fore the pandem- out there. • Antibiotics Made Ridiculously Simple ic, she said, she Dr. Nye brought a guitar ” • New! Discharge Planning for COVID-19: Collected to the office to take a few minutes for “We empathize with our patients, Practices from Across the US a hobby for which she can’t seem to and we empathize with our chil- • New! Structural Racism and Bias in Hospital Medicine find uninterrupted time at home. dren and what their experience During Two Pandemics “Bringing a little bit of yourself is,” he said. Similarly, seeing family into your work life goes a long way members crowd around a smart- SHM members save $300 on HM20 Virtual On Demand. for a lot of people,” she said. phone video call to check in with a Child care and odd hours always COVID-19 patient can be a helpful Learn more at hospitalmedicine.org/hm20virtual have been a challenge for hospi- reminder to appreciate going home talists, the presenters said, and to family at the end of the day. for those in academia, any “wiggle When her children get upset that The Society of Hospital Medicine is accredited by the Accreditation Council for Continuing Medical room” in the schedule is often taken she has to go in to work, Dr. Nye Education (ACCME) to provide continuing education for physicians. up by education, administration, said, it has been helpful to explain and research projects. that her many patients are suffering the-hospitalist.org | 25 | October 2020

22thru25_HOSP20_10.indd 25 9/22/20 4:21 PM HM20 VIRTUAL CONFERENCE

Heart failure: Practice-changing developments for hospitalists

By Bruce Jancin 0.6% with an intermediate-risk EHMRG, 1.9% with The H2FPEF score MDedge News high risk, and 3.9% in the very-high-risk group. Diagnosis of heart failure with preserved ejection The corresponding 30-day mortality rates were fraction (HFpEF) is a challenge in euvolemic pa- recently validated, easy-to-use calcula- 0%, 1.9%, 3.9%, 5.9%, and 14.3%. tients with clear lungs and dyspnea on exertion. tor of predicted 7-day mortality risk in The University of Toronto investigators also Investigators at the Mayo Clinic have developed patients presenting with acute decom- asked participating physicians for their clinical and subsequently validated a weighted score pensated heart failure is well worth estimates of 7-day mortality risk while blinded to known as the H2FPEF score that’s of great assis- Aincorporating into hospitalist clinical practice, the EHMRG predictions. The algorithm proved tance in this task. The score is based upon a set Dustin T. Smith, MD, said at HM20 Virtual, host- more accurate than physician predictions across of six simple variables universally available in ed by the Society of Hospital Medicine. the board. Indeed, physicians consistently over- patients undergoing diagnostic work-up for the The risk prediction tool, called the Emergency estimated the mortality risk for all categories numerous potential causes for dyspnea on exer- Heart Failure Mortality Risk Grade (EHMRG), tion. Together these six variables comprise the can help guide clinical decision-making as to acronym H2FPEF: whether a patient presenting with acute heart • Heavy: One point for a body mass index greater failure is appropriate for early discharge or than 30 kg/m2. should instead be admitted for inpatient mon- • Hypertension: One point for being on two or itoring and more aggressive therapy, explained more antihypertensive drugs. Dr. Smith, a hospitalist at Emory University in • Atrial fibrillation: Three points for paroxysmal Atlanta. or persistent AF. In addition to the EHMRG, other highlights • Pulmonary hypertension: One point for having of his wide-ranging update on recent practice- a Doppler echocardiographic estimated pulmo- changing developments in heart failure directly nary artery systolic pressure greater than 35 relevant to hospitalists included the introduction mm Hg. of a simple, evidence-based tool for differenti- • Elder: One point for age greater than 60 years. ating heart failure with preserved ejection frac- • Filling pressure: One point for a Doppler echo- tion from other potential causes of unexplained cardiographic E/e’ ratio above 9. dyspnea on exertion in euvolemic patients, and a The total score can range from 0 to 9 (Circula- study debunking what has been called the potas- tion. 2018 Aug 28;138[9]:861-70). sium repletion reflex in patients with acute heart Each 1-point increase in the score essentially failure undergoing diuresis. Dr. Smith doubled a patient’s risk of having HFpEF as op- posed to pulmonary embolism or some other The ACUTE study cause for the dyspnea. Heart failure is an area of special interest for I’m sure you’ve all written orders “I really like this H2FPEF score. The score Dr. Smith. He has been surprised to find that “ works very, very well. Once you get to a score virtually no hospitalists, emergency medicine to keep the potassium greater than of 6 or above, the probability of HFpEF is more physicians, or cardiologists he has spoken with 4.0 mEq/L and the magnesium above than 90%, which is pretty powerful. I think this is have heard of the EHMRG or its validation in the 2 mEq/L about a million times, like I worthwhile,” Dr. Smith said. ACUTE (Acute Congestive Heart Failure Urgent In their derivation and validation cohorts, the Care Evaluation) study. Yet this is a very handy have. Mayo Clinic investigators used as their gold stan- tool for hospitalists, he observed. ” dard for diagnosis of HFpEF invasive hemodynamic The EHMRG algorithm utilizes nine variables exercise testing with a pulmonary artery catheter for which data are readily available for every pa- except the very-high-risk one, where they un- in place to measure pressures. A score that enables tient who arrives at the emergency department derestimated the true risk (Circulation. 2019 Feb hospitalists to lessen the need for that kind of cost- with acute heart failure. The variables are age, 26;139[9]:1146-56). ly invasive testing is most welcome. arrival by ambulance, heart rate, systolic blood Given that heart failure remains year after year “Here’s how I’d use this score: With an H2FPEF pressure, potassium level, oxygen saturation, tro- at the top of the list of most frequent causes for score of 0-1, HFpEF is unlikely. With an intermedi- ponin, serum creatine, and presence or absence hospital admission, and that there is compelling ate score of 2-5, additional testing is warranted. If of active cancer. The information is entered into a evidence that many low-risk patients get hospi- the score is high, 6-9, I think HFpEF is likely,” the cell phone app, which spits out the patient’s esti- talized while potentially unsafe early discharges hospitalist said. mated 7-day mortality risk. The algorithm divides also occur, the EHMRG score fills an important Dr. Smith isn’t the only big fan of the H2FPEF patients into one of five risk groups ranging from unmet need. score. In an editorial accompanying publication very low to very high. With the addition of data “I think this can help inform us as to who with of the score’s validation study, Walter J. Paulus, input as to the presence or absence of ST-seg- acute heart failure potentially needs to come into MD, PhD, hailed the H2FPEF score as “a unique ment depression on the 12-lead ECG, the weighted the hospital and who doesn’t,” Dr. Smith said. “I tour de force” which constitutes a major advance algorithm will simultaneously generate an esti- think the sweet spot here is that, if you’re in the beyond the confusing diagnostic recommenda- mated 30-day mortality risk. low- or very-low-risk category, your 7-day mortal- tions for HFpEF issued by the European Society ACUTE was a prospective, observational, real- ity is less than 1%; in fact, in this study it’s zero. of Cardiology and the American Society of Echo- world validation study of EHMRG involving 1,983 But once you get to category 3 – the intermediate cardiography, which he said have been “met by patients seeking emergency department care for category – you’re talking about a 7-day mortality skepticism qualifying them as overcomplicated acute heart failure at nine Canadian hospitals. of 1%-2%, which I think is high enough to warrant and even triggered disbelief in the existence of The actual 7-day mortality rate was 0% in the hospital admission for treatment and to watch HFpEF.” very-low-risk group, 0% in the low-risk group, them, not just send them home.” Continued on following page October 2020 | 26 | The Hospitalist

26_27_28_30_31_HOSP20_10.indd 26 9/22/20 4:16 PM HM20 VIRTUAL CONFERENCE

Managing acute pain in inpatients on OUD therapy

By Bruce Jancin suggest this is not the case,” Dr. patient to an outpatient provider. bleeding, ischemic cardiovascular MDedge News Vettese said. “It will not worsen ad- Misconceptions also abound events, and worsening kidney func- diction. But if we don’t aggressively about NSAIDs as a nonopioid com- tion. Dr. Vettese offered several s the opioid epidemic rolls treat these patients’ acute pain, it ponent of acute pain management risk-mitigation strategies to increase on, hospitalists can expect puts them at higher risk for bad out- in hospitalized patients. They ac- the use of NSAIDs as opioid-sparing to increasingly encounter comes.” tually are extremely effective for agents for acute pain management. the challenge of treating Another myth – this one not un- the treatment of musculoskeletal, She has changed her own clin- Aacute pain in inpatients on medica- common among hospital pharmacy ical practice with regard to using tion-assisted treatment for opioid departments – is that only physi- NSAIDs in patients with chronic use disorder. cians with a special certification can kidney disease in response to a 2019 “This is something we’re going to prescribe methadone for inpatients. systematic review by investigators see more frequently, and many of “The federal laws are clear: Any at the University of Ottawa (Curr us already have,” Theresa E. Vettese, physician who has a DEA license can Opin Nephrol Hypertens. 2019 MD, said at HM20 Virtual, hosted by prescribe methadone in the hospital Mar;28[2]:163-70). the Society of Hospital Medicine. acute care setting, not only for pain “This was a game changer for me The drastic drop in prescriptions management, but also for treatment because in this review, low-dose for opioid pain medications in the of opioid withdrawal. You can’t pre- NSAIDs were safe in that they didn’t last several years hasn’t curtailed scribe it in the outpatient setting for significantly increase the risk of the current opioid epidemic. Instead, opioid withdrawal – that has to be worsening kidney failure even in MAGES the epidemic has to a great extent dispensed through a federally reg- I patients with stage 3 chronic kidney ETTY

morphed into expanded use of il- ulated methadone outpatient treat- /G disease. So this has expanded my licit heroin and fentanyl, noted Dr. ment program. But in the hospital, use of NSAIDs in this population

Vettese, an internist, hospitalist, and we can feel safe that we can do so. SDOMINICK through stage 3 CKD. With a creat- palliative care physician at Emory You may need to educate your phar- inine clearance below 30, however, University and Grady Memorial macist about this,” she said. orthopedic, procedural, migraine, kidney failure worsened rapidly, so Hospital in Atlanta. Hospitalists also can prescribe and some types of cancer pain. The I don’t do it in patients with CKD buprenorphine in the acute care number needed to treat (NNT) for stage 4,” Dr. Vettese said. Mythbusting inpatient setting, both for pain and postoperative pain relief for ibu- Gastroenterologists categorize Treatment of acute pain in hospital- treatment of opioid withdrawal, profen or celecoxib is 2.5, and when patients as being at high risk of GI ized patients on opioid agonist ther- without need for a DEA waiver. used in conjunction with acetamin- bleeding related to NSAID use if apy for opioid use disorder (OUD) is “It’s useful to get some skills in us- ophen at 325 mg every 4 hours, that they have a history of a complicat- actually pretty straightforward once ing buprenorphine in the inpatient NNT drops to 1.5, similar to the ed ulcer or they have at least three a few common myths have been dis- setting. You don’t need an X waiver, NNT of 1.7 for oxycodone at 15 mg. It of the following risk factors: age pelled, she said. but I encourage everyone to do the should be noted, however, that the above 65 years, history of an uncom- One of these myths –common X-waiver training because it’s a ter- bar defining effective pain relief in plicated ulcer, being on high-dose among both physicians and patients rific educational session. It’s 8 hours randomized studies is set rather low: NSAID therapy, or concurrent use in treatment for OUD – is that pre- for physicians and well worth it,” Dr. a 50% greater reduction in pain than of aspirin, glucocorticoids, or anti- scribing opioids for management of Vettese noted. achieved with placebo. coagulants. Patients are considered acute pain will place such patients By federal law the inpatient physi- Many hospitalists would like to at moderate risk if they have one or at risk for OUD relapse. cian also can prescribe 3 days of bu- use NSAIDs more often, but they’re two of the risk factors, and low risk “In fact, the data really strongly prenorphine at discharge to get the leery of the associated risks of GI Continued on following page

Continued from previous page But it turns out this traditional practice, which and hospital length of stay. After statistical ad- Particularly interesting were the variables re- involves a huge cost in terms of time, money, and justment for comorbidities, demographics, and jected for inclusion in the H2FPEF score because health care resources, is supported by weak evi- severity at admission, there was no difference they failed to achieve statistical significance as dence – and an important recent study has now between the low- and mid-normal serum potas- predictors, even though they’re often considered debunked what the investigators termed the po- sium groups in any of the three endpoints. In important in defining HFpEF, he noted. These in- tassium “repletion reflex.” contrast, the high-normal potassium group had cluded left atrial volume index, sex, and levels of The investigators at the University of Massa- a significantly longer length of stay, by a median circulating N-terminal probrain natriuretic pep- chusetts identified 4,995 patients admitted with of 0.6 extra days. The high-normal group also tide, wrote Dr. Paulus, professor of cardiac patho- exacerbation of acute heart failure and a nor- had a 78% increased likelihood of ICU transfer physiology at VU University, Amsterdam. mal admission serum potassium level of 3.5-5.0 and a 51% increased risk of in-hospital mortality, mEq/L. More than 70% received potassium reple- although neither of these differences reached Debunking the potassium repletion reflex tion at least once within a 72-hour observation statistical significance (J Hosp Med. 2019 Dec Longstanding conventional wisdom holds that window, during which 2,080 patients maintained 1;14[12]:729-36). patients hospitalized for heart failure need to a low-normal serum potassium below 4.0 mEq/L, “A potassium greater than 4.5 mEq/L may be as- maintain a serum potassium above 4.0 mEq/L. 2,326 had a mid-normal level of 4.0-4.5 mEq/L, sociated with increased risk of worse outcomes,” “I’m sure you’ve all written orders to keep the and 589 had a high-normal level of more than 4.5 Dr. Smith observed. “I think the sweet spot may potassium greater than 4.0 mEq/L and the mag- mEq/L but not more than 5.0 mEq/L. be 3.5-4.5 mEq/L based on this study.” nesium above 2mEq/L about a million times, like I The study had three endpoints: in-hospital He reported having no financial conflicts re- have,” Dr. Smith said. mortality, transfer to the intensive care unit, garding his presentation. the-hospitalist.org | 27 | October 2020

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HM20 Virtual: Improved supervision of residents

By Ann-Marie Tantoco, MD, FAAP, FHM education studies relating to supervision and fo- cused on a key question: Do you trust the resident? HM20 Virtual session title The review of medical education literature dis- Call Me Maybe: Balancing Resident Autonomy cussed the meaning and development of trust, With Sensible Supervision oral case presentations to determine trust, and the influence of supervisor experience. One study Presenter looked at the attendings’ remote access of EMR, Daniel Steinberg, MD, SFHM, FACP which allows for remote supervision as a great way to determine trust of the resident. Another Session summary study showed that attendings want more com- In this session, Dr. Steinberg, professor of med- munication than what residents provide and that icine and medical education, associate chair for the saying “Page me if you need me” does not en- education, and residency program director in the courage communication from residents as much department of medicine at Icahn School of Med- as attendings would desire. icine at Mount Sinai, New York, presented key factors, techniques, and approaches to supervis- Key takeaways ing residents. He discussed the important balance • Resident supervision is driven by what resi- of resident autonomy and supervision, especially dents need, what residents want, and what the since attendings need to focus on learner educa- supervisor can provide. tion along with patient care and safety. • Trust can be determined from direct supervi- Dr. Steinberg stated that resident supervision sion, oral presentations, and remote access of Dr. Tantoco is an academic med-peds hospitalist is driven by three factors: what residents need, EMR, but it is also influenced by attending ex- practicing at Northwestern Memorial Hospital in what residents want, and what the supervisor can perience and style. Chicago and Ann & Robert H. Lurie Children’s provide. Although data are mixed on whether su- • To increase resident communication with the Hospital of Chicago. She is an instructor of pervision improves patient outcomes, supervision attending, do not say “Page me if you need me.” medicine (hospital medicine) and pediatrics at is essential for patient care and resident education. Instead, an attending should specifically state Northwestern University, also in Chicago. Dr. Steinberg showcased several relevant medical when a call to an attending is required.

Continued from previous page tients by following a thoughtful car- know up-front that the opioids will For severe acute pain, Dr. Vettese if they have none. Dr. Vettese said diovascular risk-mitigation strategy be tapered as the acute pain im- will prescribe an immediate-release that, while NSAIDs clearly should be developed by Italian investigators proves. opioid having a high affinity to the avoided in the high-risk group, mod- (Ther Adv Drug Saf. 2017 Jun;8[6]:173- For the patient who comes into mu opioid receptor, such as oral erate-risk patients are a different 82). the hospital on buprenorphine for hydromorphone, on an as-needed matter. OUD, she immediately checks with basis. The drug has onset of effect “Many avoid the use of NSAIDs Communicating about pain the state prescription drug mon- in 30 minutes, peak effect in 1 hour, with moderate risk, but I think we management itoring program to make sure ev- and a duration of effect of 4-6 hours, can expand their use if we use the “Communication is always the key although she recommends going right NSAID and we use protective to effective pain management in with 4 hours to provide adequate strategies,” Dr. Vettese said. every situation,” Dr. Vettese empha- Many avoid the use of analgesia. Celecoxib is the safest drug in sized. NSAIDs“ with moderate “These patients will require much terms of upper GI bleeding risk, but “I talk to the patient about the higher doses than the patients who ibuprofen is close. They are associ- goals of effective pain management. risk, but I think we can are opioid naive,” she advised. ated with a 2.2-fold increased risk I’ll discourage the use of the 1-10 expand their use if we use For the patient with acute pain of bleeding when compared with pain scale, and instead, I’ll be hon- the right NSAID and we who is admitted while on metha- risk in patients not on an NSAID. est about expectations, saying, ‘You done for OUD, it’s important to call Naproxen or indeomethacin use car- have a problem that will cause acute use protective strategies. the outpatient treatment program ries a fourfold to fivefold increased pain, and it’s unlikely that I will be ” to verify the dosage. risk. able to completely relieve your pain. “You can split the dose of metha- “Celecoxib with a proton pump in- The goal is to improve your function erything is above board and there’s done to try to get better analgesia, hibitor is safest, followed by celecox- so that you can get up and go the no indication of doctor shopping although I can tell you that patients ib alone, followed by ibuprofen with bathroom by yourself, and so that for prescriptions. For in-hospital who are treated with methadone for a proton pump inhibitor. So I advo- you can sleep for a few hours. That’s acute pain, it’s safe and effective to OUD frequently don’t want to do cate using NSAIDs more frequently how we’re going to measure the continue the outpatient dose. On an that. And if they don’t want to, then in people who are at moderate risk efficacy of our pain-management outpatient basis, however, the drug I don’t,” the hospitalist said. by using them with a PPI,” she said. program.’˜” is given once daily. On that dosing As with the patient on buprenor- There is persuasive evidence of She explains to the patient that schedule both the euphoric effect as phine for OUD, she’ll use additional increased cardiovascular risk in as- she’ll be using nonopioid medica- well as the analgesic effect are lost, oral immediate-release opioids as sociation with even short-duration tions and nondrug therapies along so for acute pain management in the needed for acute severe pain in a NSAIDs, as the drugs are utilized in with oral opioid pain medications, hospital it’s recommended to split patient on methadone for medica- the treatment of acute pain in hos- which are less risky than IV opioids. the dose into twice- or thrice-daily tion-assisted OUD treatment. pitalized patients. That being said, She offers reassurance that this doses to achieve an analgesic effect. Dr. Vettese reported having no Dr. Vettese believes hospitalists can treatment strategy won’t cause an Oral NSAIDs are part of the treat- financial conflicts regarding her pre- use these drugs safely in more pa- OUD relapse. She lets the patient ment strategy whenever possible. sentation. October 2020 | 28 | The Hospitalist

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To learn more, visit www.the-hospitalist.org and click “Advertise” or contact Heather Gonroski • 973-290-8259 • [email protected] or Linda Wilson • 973-290-8243 • [email protected] 290311 October 2020 | 29 | The Hospitalist COMMENTARY

The Future Hospitalist A strong mentor/mentee relationship Establish clear expectations from the beginning

By Jessica Zimmerberg-Helms, MD, and and worked with students and residents in the Patrick Rendon, MD past. The project involves anticoagulation on the inpatient service. You are set to meet with her I. Finding a mentor next month. Case You are a 27-year-old first-year resident who is Stage 2: Establishing expectations and goals seeking mentorship. You are halfway through Now comes the hard work in establishing an ex- the year and are thinking about your goals and cellent mentor/mentee relationship. Before you future. You have a general interest in hematology/ meet with your mentor, brainstorm first. What do oncology but have limited experience and would you want out of the relationship? A publication? Dr. Zimmerberg-Helms Dr. Rendon like to gain more experience with clinically rel- Career advice? A fellowship position? You should evant scholarship. However, you do not know feel empowered in knowing that you as the men- anyone in the field and are not sure who to ask tee are in the driver seat, but this relationship Dr. Zimmerberg-Helms is a resident physician at for guidance. should be mutually beneficial. Consider basing the University of New Mexico, Albuquerque. Dr. the relationship and initial discussions on these Rendon is an attending hospitalist at the Univer- Stage 1: Seeking the right mentor key questions: sity of New Mexico. Start first with your area of interest and then 1. My goals look broadly. In this case the resident is interest- • What are my goals? It is okay not to know but ed in heme/onc. The first place to look is on the be ready to communicate some information to tionship and keep the project(s) progressing. For heme/onc department website or in the faculty your mentor. example, one goal could be to write the first draft directory. It can be helpful to look at what the po- • Remember to also ask your mentor what their of the proposal for your quality improvement tential mentor has published recently and/or look goals are for you as well. project within 3 weeks. at a version of their CV on the faculty directory 2. Outcome or website. This can help determine how produc- • What type of outcome are both you and your Stage 4: Continuing communication tive they are and help assess whether you share mentor looking for from the relationship? With any project it is important to stay on the similar interests, and whether they have worked 3. Expectations same page as your mentor and be clear to estab- with many learners in the past. • What mentorship expectations do you have? lish “who is doing what by when.” Do not expect It is also important to do some background • What are your mentor’s expectations of you? accountability to be the mentor’s job. Remember work and ask around about potential mentors. Once you feel you have a sense of what you that you are in the driver’s seat and that you Often resident colleagues and fellows have a good are looking for out of the relationship, it is im- should propose how often you need to meet and sense of current projects and which faculty work portant to communicate this with the mentor to what those meetings look like by developing an well with learners. Lastly, it is important to also establish congruent expectations of one another. agenda. You can have an open discussion and al- look at non–heme/onc physicians as there may be For example, think about asking your mentor low your mentor to help determine a reasonable internal medicine physicians or surgeons who are if the two of you can establish a mentor/men- timeline. Remember, the more you communicate doing hematology or oncology research that more tee contract. This is a written document that your goals, the better your mentor will be able to align with your interests. can be found online and establishes a mutual address them. After you have assessed whether you think agreement of roles, responsibilities, and expec- One pro tip is to always exceed your mentor’s this person would be a strong mentor for you, tations of one another for the relationship. It expectations – if you think you need 2 weeks to it is time to reach out. People are flattered to can further help to open a line for honest and complete a task, ask for 3-4 weeks. This gives you be asked and part of their promotion criteria is consistent feedback. This can also give you a extra padding in case of unforeseen circumstanc- their ability to mentor. Do not assume that a po- formalized endpoint and agreed-upon scope for es and makes you look like a “rockstar” if you hit tential mentor is too busy! Let him or her make the mentoring relationship. Having a check-in a deadline 1-2 weeks earlier than planned. that decision. Remember the worst a mentor can preestablished in a contract reduces any poten- say is “no.” Even if they do not have time or the tially awkward conversations about redefining III. Ending and/or redefining the need for a mentee at the present time, they gen- the relationship down the road. (For example, relationship erally will offer some assistance or direction on what if our case resident decides to pursue GI? Case continued who to ask. It could happen.) You are now a senior resident who’s published Start with a straightforward, but pleasant multiple articles in the past year, and have email. Waiting up to 2 weeks for a response is Stage 3: Establishing a common goal completed an anticoagulation project for inpa- reasonable. If after 2 weeks you have not received After you have determined the goals and expec- tients with pulmonary emboli. You look back word, feel free to reach out again asking politely tations of the relationship together (remember, on your experience and what stands out is the if he or she would be willing to work with you. this is a relationship), it is time to start exploring extent of your gratitude and appreciation for Do not be afraid to ask bluntly for their guidance possible projects and establishing goals for those your incredible mentor. Not only do you feel and mentorship and have a specific project or projects. Having a quality improvement or re- that your mentor has guided you in your career area of research that you would like their assis- search project will determine a common goal to and with your scholarship, but you feel that tance with. work toward and help establish and define the he or she has shaped your character and talent relationship. set. At this point your mentor is both a teacher II. Optimizing the mentor/mentee Once you have delineated broadly what the and guide, but now also a friend. While you feel relationship project(s) should be, develop smaller SMART there is always more that you can learn from Case continued (specific, measurable, achievable, relevant, time- her, you are ready to explore new interests. Success! Your email was received with interest bound) goals to move the project forward. These How do you effectively end or redefine this re- by a hematologist who has done several projects, goals determine stopping points for evaluation lationship? comes highly recommended by other residents, and feedback, which further establish the rela- Continued on following page October 2020 | 30 | The Hospitalist

26_27_28_30_31_HOSP20_10.indd 30 9/22/20 4:16 PM COMMENTARY

HM20 Virtual Key takeaways for the pediatric hospitalist

By Anika Kumar, MD, FHM, Key takeaways FAAP; Vignesh Doraiswamy, • Racial disparities are a symptom MD; Ann-Marie Tantoco, MD, of structural racism that has been FHM, FAAP propagated in medicine for centu- ries. The HM20 Virtual conference in • Addressing implicit biases at the August was filled with excellent individual level, organization level, content that can be applied by all and simultaneously at both levels hospitalists. This article summarizes can help leaders model and pro- some key concepts and takeaways mote an antiracism culture. for the pediatric hospitalist. Dr. Kumar Dr. Doraiswamy Dr. Tantoco HM20 Virtual session: When Grief Racism and bias in medicine and Crises Intersect: Perspectives HM20 Virtual session: Structural of a Black Physician in the Time of Dr. Kumar is the pediatric editor of The Hospitalist. She is clinical assistant Racism and Bias in Hospital Medi- Two Pandemics professor of pediatrics at the Cleveland Clinic Lerner College of Medicine cine During Two Pandemics Presenter: Kimberly Manning, MD, at Case Western Reserve University and a pediatric hospitalist at Cleveland Presenters: Nathan Chomilo, MD, FACP, FAAP Clinic Children’s. Dr. Doraiswamy is an assistant professor of medicine and FAAP; and Benji K. Mathews, MD, pediatrics and a med-peds hospitalist at The Ohio State University and Na- SFHM Dr. Manning, of Emory University in tionwide Children’s Hospital, both in Columbus. Dr. Tantoco is an academic Atlanta, discussed the dual pandem- med-peds hospitalist practicing in Northwestern Memorial Hospital, Chica- Dr. Chomilo, of HealthPartners in ics of COVID-19 and the racism that go, and Ann & Robert H. Lurie Children’s Hospital of Chicago. Minneapolis, explained how racial we are currently experiencing, and disparities are a symptom of racism. described the unique perspective of The presenters showed how struc- Black Americans. Though it is easy our funds of knowledge, remember 32% of hospitalists are international tural racism has been propagated in to see that COVID-19 is a pandemic, that people are grieving, explore our medical graduates. medicine with the Hospital Survey racism is not always seen in this implicit biases, be brave bystanders, The presenters revealed the struc- and Construction Act of 1964 that way. Dr. Manning demonstrated and avoid performative allyship. tural hurdles immigrant physicians allowed segregated hospitals, as well that, when a pandemic is defined face, including lack of empower- as the racism that exists within the as “that which occurs over a wide Key takeaways ment until achieving permanent “hidden curriculum.” geographic area and affects a high • Though the COVID-19 pandemic is residency status; limited leadership, Dr. Chomilo discussed how per- proportion of the population,” rac- unprecedented, the pandemic of administrative, and academic roles; sonal experiences of racism can ism is absolutely a pandemic. Black racism is not. concerns for job security and finan- lead to worse health outcomes, Americans have been dispropor- • We must “Do The Work” to combat cial stability; and experiencing mi- including depression, obesity, and tionately affected by COVID-19. Dr. everyday racism and to be cogni- cro- and macroaggressions at work. overall poor health. Dr. Mathews, Manning said we often hear that we zant of what our Black colleagues The presenters shared a framework also of HealthPartners, explained are in “unprecedented times” but as are going through every day. for a developmental orientation in- how implicit biases can be ad- far as racism is concerned, there is clined toward cultural competency dressed at the individual level, the nothing new about this. She shared Immigrant hospitalist challenges beginning with denial, followed by organizational level, and simultane- stories of personal milestones; but HM20 Virtual session: The Immi- polarization, progressing to minimi- ously at both to create an antiracist each of these instances, though grant Hospitalist: Navigating the zation, advancing to acceptance, and culture. He presented strategies to marked by beauty, was also marked Uncertain Terrain During COVID-19 culminating in adaptation. mitigate individual biases; recog- by something truly awful. Each time Presenters: Manpreet S. Malik, MD, They concluded the session by nize when biases may be triggered; she had a reason to smile, there was FHM; and Benji K. Mathews, MD, stressing the importance of advo- check biases at the door; connect something awful going on in the SFHM cacy for immigrant physicians and with others from different back- country that showed how racism encouraged colleagues to become grounds as equals; and practice was still present. Dr. Manning said Dr. Malik of Emory University in engaged in efforts within their pro- antiracism by being an active by- that, though these were her stories, Atlanta, and Dr. Mathews of Health- fessional organizations. stander. Dr. Chomilo concluded the all Black Americans can recount the Partners, opened this session by session by sharing that we can all same stories, emotions, and feelings sharing their personal stories as Key takeaway grow by addressing racism at “our of grief. immigrant physicians in the United • Immigrant physicians experience houses” (health care systems, medi- Dr. Manning concluded by sharing States. Dr. Malik noted that physi- structural challenges to their pro- cal schools, payer systems) with the how we can “Do The Work” to com- cians born outside the United States fessional advancement because of goal to create an antiracist system. bat the pandemic of racism: broaden make up 29% of U.S. physicians, and their residency status.

Continued from previous page have a change in focus (e.g., change in specialty or 3. Define your goals and discuss them with Stage 5: Redefining your mentoring relationship scholarly focus). your mentor early. (Have we mentioned the im- First, go back to the expectations or contract es- In summary, the interaction between you and portance of goals enough?) After all, your goal is tablished early in the relationship. The check-in is your mentor should be a relationship. And the the reason you started pursuing this relationship a key time in the relationship to reevaluate goals keys to a great relationship are: in the first place. and priorities. At this point you may decide to 1. Establish clear expectations from the begin- In clinical training having guidance can greatly amicably end the relationship or project, or move ning. This clarifies the relationship and helps the enhance your experience and direct your future on to a new project with a change in your role. mentee and mentor to become more successful. career in unexpected ways. We hope that using For example, the quality improvement project 2. Maintain clear and open communication these tools will guide you toward forging a strong may change to research, or you as the mentee throughout the relationship. mentor/mentee relationship. the-hospitalist.org | 31 | October 2020

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