March 2021 COMMENTARY IN THE LITERATURE COMMENTARY Volume 25 No. 3 Hospital-level care Morphine safe for Hospitalists prepare for p10 provided at home p23 COPD patients p30 X’ing of the X Waiver

Dr. Sareer Zia, hospitalist and physician advisor Inpatient telemedicine can help address hospitalist pain points COVID-19 has increased confidence in the technology

By Sareer Zia, MD, MBA Scenario 1 A patient presents to an emergency department of a ince the advent of COVID-19, health care has small community hospital. He needs to be seen by a spe- seen an unprecedented rise in virtual health. cialist, but (s)he is not available, so patient gets trans- com . Telemedicine has come to the forefront of our ferred out to the ED of a different hospital several miles conversations, and there are many speculations away from his hometown. hotoGraPhy

P Saround its future state. One such discussion is around He is evaluated in the second ED by the specialist, the sustainability and expansion of inpatient telemedi- has repeat testing done – some of those tests were al- reGory G cine programs post COVID, and if – and how – it is going ready completed at the first hospital. After evaluating

® teven to be helpful for health care. him, the specialist recommends that he does not need .S the-hospitalist.org Continued on page 18 www Consider the following scenarios:

SURVEY INSIGHTS PHM FELLOWS Andrew White, Catherine Ezzio, MD, SFHM MD

HM groups are getting Inclusivity needed in

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Hospitalist PHYSICIAN EDITOR THE SOCIETY OF HOSPITAL MEDICINE Weijen W. Chang, MD, SFHM, FAAP Phone: 800-843-3360 Movers and Shakers [email protected] Fax: 267-702-2690 Website: www.HospitalMedicine.org PEDIATRIC EDITOR By Matt Pesyna and its Informatics Committee for Anika Kumar, MD, FHM, FAAP Chief Executive Officer Impatient and Outpatient Electronic [email protected] Eric E. Howell, MD, MHM Vivek H. Murthy, MD, was named Health Records. COORDINATING EDITORS by President Biden as his selection Alan Hall, MD Director of Communications

The FuTure hospiTalisT Brett Radler for Surgeon General of the United Lyon County Kansas recently an- [email protected] States. Dr. Murthy filled the same nounced that Ladun Oyenuga, MD, Keri Holmes-Maybank, MD, FhM role from 2014 to has been appointed as public health inTerpreTing DiagnosTic TesTs Communications Specialist CONTRIBUTING WRITERS Caitlin Cowan 2017 during Pres- officer for the county. She began her [email protected] ident Obama’s tenure on Jan. 1. Debra L. Beck; Larry Beresford; Richard Bottner, DHA, PA-C; Haley Briggs, PA-C; administration. Dr. Oyenuga is a hospitalist at Eric Butterman; Victoria Cooremans, MD; SHM BOARD OF DIRECTORS Dr. Murthy Newman Regional Health (Emporia, Khooshbu Dayton, MD; Randy Dotinga; President was a hospitalist Kan.). She is a native of Nigeria and Catherine Ezzio, MD; Marina S. Farah, MD, Danielle Scheurer, MD, MSCR, SFHM President-Elect and an instructor did her residency at Harlem (N.Y.) MHA; Marcia Frellick; Reem Hanna, MD; Clarissa Johnston MD, FACP; Mark Kissler, Jerome C. Siy, MD, SFHM at Brigham and Hospital Center. She has been with MD; Maria Klimenko, MD; Mark S. Lesney, Treasurer Women’s Hospi- Newman since 2017. PhD; Chandra S. Lingisetty, MD, MBA, Rachel Thompson, MD, MPH, SFHM Secretary MHCM; Marlene Martin, MD; Jordan tal at Harvard Dr. Murthy Kris Rehm, MD, SFHM Messler, MD, SFHM; Robert Metter, Immediate Past President Medical School, Cherese Mari Laulhere BirthCare MD; Kirsten Nieto, MD; Venkataraman Boston, prior to becoming surgeon Center (Long Beach, Calif.) recent- Christopher Frost, MD, SFHM Palabindala, MD, MBA, FACP, SFHM; Board of Directors general the first time. ly announced the addition of an Snehal Patel, MD, FACP; Matt Pesyna Tracy Cardin, ACNP-BC, SFHM OB hospitalist program at Miller Rupesh Prasad, MD, MPH, CPE, SFHM; Steven B. Deitelzweig, MD, Joshua Raines, MD; Sherine Salib, MD, FACP; David Tupponce, MD, recently was Children’s & Women’s Hospital. OB MMM, FACC, SFHM Allison Shelley; Alexander Sun, MD; Bryce Gartland, MD, FHM named the new president of Allegh- hospitalists, or laborists, care for Michael Tozier, MD; Patrice Wendling Flora Kisuule, MD, MPH, SFHM eny Health Network’s Grove City women with obstetrical issues while Andrew White, MD, SFHM; Bethany Mark W. Shen, MD, SFHM (Pa.) Medical Center. He takes over in the hospital. Zablotsky, PA-C; Sareer Zia, MD, MBA Darlene Tad-y, MD, SFHM Chad T. Whelan, MD, FACP, FHM for interim president Allan Klapper, At Cherese Mari Laulhere, OB hos- FRONTLINE MEDICAL MD, who filled the position since pitalists will be on hand 24 hours a COMMUNICATIONS EDITORIAL STAFF Executive Editor Kathy Scarbeck, MA FRONTLINE MEDICAL August 2020. day to assist patients’ OB/GYNs or to Editor Richard Pizzi COMMUNICATIONS ADVERTISING STAFF Dr. Tupponce fill in if the personal physician can- Creative Director Louise A. Koenig Senior Director Business Development comes to Grove not get to the hospital quickly. Director, Production/Manufacturing Angelique Ricci, 973-206-2335 Rebecca Slebodnik cell 917-526-0383 [email protected] City Medical Classified Sales Representative EDITORIAL ADVISORY BOARD Center after a Hospitalists at Nationwide Chil- Heather Gonroski, 973-290-8259 Hyung (Harry) Cho, MD, SFHM; Marina [email protected] successful tenure dren’s (Columbus, Ohio) are now S. Farah, MD, MHA; Ilaria Gadalla, DMSc, as president of providing care for children who are PA-C; James Kim, MD; Ponon Dileep Linda Wilson, 973-290-8243 Kumar, MD, FACP, CPE; Shyam Odeti, MD, [email protected] Central Maine hospitalized at Adena Regional Med- Senior Director of Classified Sales Medical Center, ical Center (Chillicothe, Ohio). MS, FHM; Venkataraman Palabindala, MD, SFHM; Tiffani M. Panek, MA, SFHM, CLHM; Tim LaPella, 484-921-5001 cell 610-506-3474 [email protected] Lewiston, where It is an expansion of an ongoing Adhikari Ramesh, MD, MS; Raj Sehgal, he grew its phy- Dr. Tupponce partnership between the two hos- MD, FHM; Kranthi Sitammagari, MD; Amith Advertising Offices 7 Century Drive, sician group and pitals. Adena and Nationwide Chil- Skandhan, MD, FHM; Lonika Sood, MD, Suite 302, Parsippany, NJ 07054-4609 fine-tuned the hospital quality pro- dren’s have been working together FACP, FHM; Amit Vashist, MD, FACP 973-206-3434, fax 973-206-9378 gram. Prior to that, he was chief ex- in helping to care for children in the ecutive officer at Tenet Healthcare’s south central and southern Ohio 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 Abrazo Scottsdale (Ariz.) Campus region since 2011. Nationwide Chil- and trends in hospital medicine. THE HOSPITALIST Frontline Medical Communications Inc., 7 Century and CEO at Paradise Valley Hospital, dren’s hospitalists will round in spe- 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- Phoenix,. cial care and the well-baby nursery health care administrators interested in the practice cine members. Annual paid subscriptions are avail- Dr. Tupponce is familiar with at Adena, as well as provide educa- and business of hospital medicine. Content for able to all others for the following rates: THE HOSPITALIST is provided by Frontline Medical western Pennsylvania, having tion programs for Adena providers Communications. Content for the Society Pages is Individual: Domestic – $195 (One Year), earned a master’s degree in medical and staff. provided by the Society of Hospital Medicine. $360 (Two Years), $520 (Three Years), Canada/Mexico – $285 (One Year), $525 (Two Years), management from Carnegie Mellon Copyright 2021 Society of Hospital Medicine. All $790 (Three Years), Other Nations - Surface – $350 University in Pittsburgh. He also MultiCare Health System (Tacoma, 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 was chief resident at the University Wash.) has announced that it will any means and without the prior permission in writing Years), $1,325 (Three Years) of Pittsburgh Medical Center. expand its hospitalist program part- from the copyright holder. The ideas and opinions expressed in The Hospitalist do not necessarily Institution: United States – $400; nership with Sound Physicians, also reflect those of the Society or the Publisher. The Canada/Mexico – $485 All Other Nations – $565 Malcolm Mar Fan, MD, has been based in Tacoma, to create a region- Society of Hospital Medicine and Frontline Medical Student/Resident: $55 Communications will not assume responsibility for elevated to medical director of the wide, cohesive group of providers. damages, loss, or claims of any kind arising from Single Issue: Current – $35 (US), $45 (Canada/ Hospitalist Group at Evangelical The goal is to help ensure efficient 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) Community Hospital (Lewisburg, management of inpatient popula- products, drugs, or services mentioned herein. POSTMASTER: Send changes of address (with old Pa.). In this new position, Dr. Mar tions as a region instead of at the Letters to the Editor: [email protected] mailing label) to THE HOSPITALIST, Subscription Services, P.O. Box 3000, Denville, NJ 07834-3000. Fan will oversee all operations for individual hospital level, and will The Society of Hospital Medicine’s headquarters the facility’s hospitalist program. allow MultiCare to implement stan- is located at 1500 Spring Garden, Suite 501, RECIPIENT: To subscribe, change your address, Philadelphia, PA 19130. purchase a single issue, file a missing issue claim, Dr. Mar Fan has been a hospital- dard tools, processes and regionwide or have any questions or changes related to your ist at Evangelical since 2014 after best practices. Editorial Offices: 2275 Research Blvd, Suite 400, subscription, call Subscription Services at 1-833-836- Rockville, MD 20850, 240-221-2400, fax 240-221-2548 2705 or e-mail [email protected]. completing his internist residency The hospitalist programs at Ta- at Albert Einstein Medical Center in coma General Hospital, Allenmore BPA Worldwide is a global industry resource for verified audience data and Philadelphia. He has played a major Hospital, and Covington Medical The Hospitalist is a member. role on Evangelical’s Peri-Operative Center will transition to Sound Phy- To learn more about SHM’s relationship with industry partners, visit www.hospitalmedicine.com/industry. Glucose Management Committee sicians on April 5. March 2021 | 2 | The Hospitalist FROM THE SOCIETY SHM CEO Eric E. Howell likes to fix things Engineering provided a foundation for hospital medicine

Editor’s note: This profile is part of medicine came about by a lucky SHM’s celebration of National Hos- chance, following residency and a pitalist Day on March 4. Visit the year as chief resident at Johns Hop- website of The Hospitalist for more kins Bayview Medical Center in Bal- hospitalist profiles. timore. “One of my duties as chief resident was taking care of hospital- By Larry Beresford ized patients. I didn’t know it but I owell H

was becoming a de facto hospitalist,” . E

c

or Eric E. Howell, MD, MHM, he recalled. ri E

. At the time, he thought he might r CEO since July 2020 for the D Society of Hospital Medicine, end up choosing to specialize in ourtesy

an undergraduate degree in something like cardiology or critical C Felectrical engineering and a lifelong care medicine, but in 2000 he was Dr. Eric E. Howell was raised on the shores of the Chesapeake Bay in Mary- proclivity for figuring out puzzles, invited to join the new “non-house- land and continues to spend time on the water. staff” medical service at Bayview. Also called a general medicine inpa- Seeing new job opportunities with SHM, which he had joined as tient service, it eventually evolved Dr. Howell describes his career path a member early in his career and into the hospitalist service. as a new job focus opening up ev- for which he had previously served His residency program director, ery 5 years or so, redefining what as president. He became SHM’s Roy Ziegelstein, MD, a cardiologist he does and trying something new quality improvement liaison and a and now the vice dean of education and exciting with better pay. His co–principal investigator on Proj- at Johns Hopkins, created a job for first was a focus on clinical hospi- ect BOOST (Better Outcomes for him. “I was one of the first four doc- tal medicine and learning how to Older Adults Through Safe Transi- tors hired. I thought I’d just do it for be a better doctor. Then in 2005 he tions), SHM’s pioneering, national a year, but I loved inpatient work, began work as a teacher at Johns mentored-implementation model so I stayed,” Dr. Howell said. “Roy Hopkins School of Medicine. There aimed at improving transitions of mentored me for the next 20 years he mastered the teaching of medical care from participating hospitals and helped me to become an above trainees, winning awards as an in- to reduce readmissions. “BOOST average hospitalist.” structor, including SHM’s award for really established SHM’s reputation Early on, Dr. Howell’s department excellence in teaching. as a quality improvement–oriented chair, David Hellman, MD, who had In 2010 he again changed his focus organization. It was a stake in the worked at the University of Cali- to program building, leading the ex- ground for quality and led to SHM fornia–San Francisco with hospital pansion of the hospitalist service for receiving the Joint Commission’s Dr. Eric E. Howell medicine pioneer Robert Wachter, Bayview and three other hospitals 2011 John M. Eisenberg Award for MD, MHM, sent Dr. Howell to San in the Johns Hopkins system. Dr. Innovation in Patient Safety and solving problems, and taking things Francisco to be mentored by Dr. Howell helped grow the service to Quality,” he said. apart to see how they fit back to- Wachter, since there were few hos- nearly 200 clinicians while becoming Dr. Howell’s fifth career phase, gether were building blocks for an pital mentors on skilled at operational and program medical society management, exemplary career as a hospitalist, the East Coast at development. emerged when he was recruited to group administrator, and medical that time. His fourth job incarnation, apply for the SHM chief executive educator. “What I took starting in 2015, was the obsessive position – held since its inception by When he was growing up in his- away from that pursuit of quality improvement, retiring CEO Larry Wellikson, MD, toric Annapolis, Md., near the shores experience was marshaling data to measure and MHM. Dr. Howell started work at of the Chesapeake Bay, things to put how important it improve clinical and other outcomes SHM in the midst of the pandemic, back together included remote- was to profession- on the quality dashboard – mortali- spending much of his time work- control airplanes, small boat en- alize hospital med- ty, length of stay, readmissions, rates ing from home – especially when gines, and cars. As a hospitalist, his icine – in order to Dr. Ziegelstein of adverse events – and putting Philadelphia implemented stricter interest in solving problems and fa- develop special- quality improvement strategies in COVID-19 restrictions. Once pan- cility with numbers and systems led ized expertise,” Dr. Howell recalled. place. demic restrictions are loosened, he him to become an expert on quality “Dr. Wachter taught me that hospital- “Our mortality rates at Bayview expects to do a lot of traveling. But improvement, transitions of care, ists need to have a professional focus. were well below national standards. for now, the external-facing part of and conflict management. Quality improvement, systems-based We came up with an amazing pro- his job is mainly on Zoom. “One thing about engineering: improvement, and value all became gram. A lot of hospital medicine pro- You’re always having to fix things. part of that,” he said. grams pursue improvement, but we Making the world a better place It helps you learn to assess complex “Many people thought to be a hos- really measured it. We benchmarked Dr. Howell said he has held fast to situations,” said Dr. Howell, who is pitalist all you had to know was basic ourselves against other programs three mottos in life, which have 52. “It was helpful for me to bring an medicine. But it turns out medicine at Hopkins,” he said. “I set up a ded- guided his career path as well as his engineering approach into the hospi- in the hospital is just as specialized icated conference room, as many personal life: (1) to make the world tal. One of my earliest successes was as any other specialty. The hospital QI programs do. We called it True a better place; (2) to be ethical and reengineering admissions processes itself requires specialized knowl- North, and each wall had a different transparent; and (3) to invest in to dramatically reduce the amount of edge that didn’t even exist 20 years QI focus, with updates on the re- people. His wife of 19 years, Heather time patients were spending in the ago.” Because of complicated disease ported metrics. Every other week we Howell, an Annapolis realtor, says emergency room before they could states and clinical systems, hospital- met there to talk about the metrics,” making the world a better place is be admitted to the hospital.” ists have to be better at navigating he said. what they taught their children, But his career path in hospital the software of today’s hospital. That experience led to working Continued on following page the-hospitalist.org | 3 | March 2021

02_3_4_5_6_THN21_3.indd 3 2/19/2021 10:02:14 AM FROM THE SOCIETY

Survey Insights Hospital medicine groups are getting larger What are the implications for your workplace?

By Andrew White, MD, SFHM these large groups employ NP/PA hos- HMGs are most likely to offer some- pitalists as well. Second, these HMGs thing flexible that might enhance lthough readers will be typically employ some part-time and career sustainability for hospitalists. forgiven for missing the contracted PRN physicians in this Second, large groups are the most subtle change, the tables FTE count. In combination, these two likely to employ hospitalists with in the 2020 State of Hospi- factors mean that large HMGs often extra training, whether that be geri- Atal Medicine (SoHM) Report under- employ many more than 50 individual atrics, palliative care, pediatrics, or went a landmark structural change clinicians. In fact, the average number a medicine subspecialty. Working in that echoes the growth of our field. a large group means you can ask for In the latest SoHM Report, the hos- curbside consults from a diverse and pital medicine group (HMG) size well-trained bunch of colleagues. categories all increased significantly Third, large groups were most like- to reflect the fact that hospitalist ly to employ nocturnists, meaning groups have grown from a median fewer night shifts are allocated to of 9 physician full-time equivalents the hospitalists who want to focus (FTE) in 2016 to a median of 15.2 em- of physicians in this cohort was 72.3 on daytime work. From an individ- ployed/contracted FTE (excluding before counting NP/PAs and locums. ual perspective, there is a lot to like Dr. White is associate professor FTE provided by locum tenens pro- Third, do not interpret the portion about working in a large HMG. of medicine at the University of viders) in 2020. of large groups in the survey (12.7%) There are some drawbacks to larg- Washington, Seattle. He is the For many years, the Report con- as insignificant. Because each one er groups, of course. Large groups chair of SHM’s Practice Analysis sidered “large” adult HMGs to be employs so many total hospitalists, can be less socially cohesive and Committee. those with 30 or more FTE of phy- large HMGs collectively represent a the costs of managing 70-100 hospi- sicians, and smaller groups were common work environment for many talists typically grow well past the organized by FTE categories of <5, hospitalists in the United States. capacity of a single group leader. case management physician adviser 5-9, 10-19, and 20-29. Now the SoHM Lastly, although pediatric HMGs have My personal belief is that these roles, or IT expertise. Report describes a large HMG as 50 grown, far fewer (3.1%) have over 50 downsides can be solved through Ultimately, large groups typical- employed/contracted FTE or great- FTE, so this column focuses on HMGs economies of scale and skilled ly represent the maturation of an er, a category that represents 12.7% serving adults. management teams. In addition, a HMG within a large hospital – it of HMGs serving adults. The other Why does it matter that groups large group can afford to dedicate signifies that the hospital relies on categories expanded to <5, 5-14, 15- are growing in size? The SoHM Re- leadership FTE to niche hospitalist that group to deliver great patient 29, and 30-49, respectively. Overall, port offers extensive data to answer needs, such as career development outcomes in every corner of the hos- HMGs are growing in size, and the this question. Here are a couple of and coaching, which are difficult pital. Where you practice remains a SoHM displays new data slices that highlights but consider buying the to fund in small practices. This also personal choice, but the emergence help leaders to compare their group report to dig deeper. First, large provides more opportunities for of large groups hints at the clout to modern peers. groups are far more likely to offer staff hospitalists to begin taking on and sophistication hospitalists can There are some caveats to consider. variable scheduling. Although the some leadership or administrative build by banding together. Learn First, these figures represent only 7-on, 7-off scheduling pattern is still duties or branch out into related more about the full 2020 SoHM Re- physician FTE, and essentially all the norm in all group sizes, large areas such as quality improvement, port at hospitalmedicine.org/sohm.

Continued from previous page “Why do I still see patients? I find it so reward- Mason, 18, who starts college at Rice University ing. And I get to teach, which I love,” he said. “To in fall 2021 with an interest in premed, and Anna, be honest, I don’t think you truly need to see pa- Dr. Eric E. 16, a competitive sailor. “We always had a poster tients to be head of a professional medical society Howell was hanging in our house extolling that message,” Ms. like SHM. Maybe someday I’ll give that up. But chief medical Howell said. only if it’s necessary to make the society more officer for the Dr. Howell grew up in a nautical family, with successful.” Joint Commis- many of his relatives working in the maritime Half of Dr. Howell’s Society work now is sion–accredited business. His kids grew up on the water, learn- planned and half is “putting out fires” – while Baltimore Civic ing to pilot a powerboat before driving a car, as learning members’ needs in real time. “Right now, owell Center Field e. H

he did. “We boat all the time on the bay” in his we’re worried about burnout and PTSD, because riC Hospital for . e r

lobster boat, which he often works on to keep it frankly it’s stressful to take care of COVID pa- D COVID-19 pa- seaworthy, Ms. Howell said. tients. It’s scary for a lot of clinicians. I’m working tients, opened ourtesy “There’s nothing like taking care of hospital- with our members to make sure they have what C in March 2020. ized patients to make you feel you’re making the they need to be clinically prepared, including re- world a better place,” Dr. Howell observed. “Very sources to be more resilient professionally.” “SHM has such a powerful mission – it’s about often you can make a huge difference for the Every step of his career, Dr. Howell said, has making patient care better, and making hospital- patients you do care for, and that is incredibly seemed like the best job he ever had. “Making the ists better clinicians. I know the Society is having rewarding.” Although the demands of his SHM world a better place is still important to me. I tell a powerful impact, and that’s good enough for leadership position required relinquishing most SHM members that it’s important to know they me. I’m into teams. Hospital medicine is a team of his responsibilities at Johns Hopkins, he con- are making a difference. What they’re doing is sport, but so is SHM, interacting with its mem- tinues to see patients and teach residents there really important, especially with COVID, and it bers, staff, and board.” 2-4 weeks a year on a teaching service. needs to be sustainable,” he said. Continued on following page March 2021 | 4 | The Hospitalist

02_3_4_5_6_THN21_3.indd 4 2/19/2021 10:02:22 AM LEADERSHIP Do you want to become a hospitalist leader? Learn how or even whether you should

By Eric Butterman there is a leadership “void” in the to making mistakes,” she said. “It’s ment and desire for leadership as an health system where they work, and about honing the skills that leader- early career hospitalist, how would ave you ever thought no one else wants to step up. Oth- ship requires and be open to devel- you continue down the leadership you could be a leader, in ers disconnect from the leadership opment and change.” path? your hospitalist group, in track and are happy to simply be Kierstin Cates Kennedy, MD, “A great way is to find a person hospital administration, part of a team. SFHM, chief of hospital medicine you want to be like, who could be Hor at another institution? The rea- “If you are yearning to make a dif- at the University of Alabama at a mentor. Find a successful leader sons to seek a leadership role as a ference and that’s your motivation Birmingham, said that a hospital- that you admire, and one who is hospitalist are many, but there are then you will find leadership is more ist fresh out of residency will gain willing to guide you,” Dr. Howell also many drawbacks. According to fulfilling than difficult,” she said. insight into whether leadership is said. “Books are helpful as well, and hospitalists who have reached high I still find I’m learning today – I have rungs on the leadership ladder, you Leading your peers is often one of the a list that includes Drive by Daniel will need a blend of desire, enthu- Pink and Good to Great by Jim Col- siasm, education, and experience if most“ challenging parts of leadership. I lins. There are Malcolm Gladwell you want to succeed in leadership. think taking on even just a small activity books that also have terrific knowl- like, say, working on a clinical pathway edge to impart.” What are the right reasons? Mark W. Shen, MD, SFHM, associ- “People who make good leaders for the group, will result in a lot of ate professor at Dell Medical School have a sense of purpose and want to preparation for future leadership roles. at the University of Texas at Austin make a difference,” said Eric E. How- Dr. Shen and former president of St. Louis ell, MD, MHM, CEO of the Society of ” Children’s Hospital, said potential Hospital Medicine, and former chief “But if you take a leadership role to the right path by acquiring a deeper hospitalist leaders must be aware of of medical units at Johns Hopkins fill a void or think you just want to understanding of how health care their fellow clinicians. Bayview in Baltimore. “I think most take some nonclinical time, it’s prob- institutions work. “Pay attention to the needs of the hospitalists have that sense of want- ably not a good idea. Some people “When you are new to the hospi- hospitalist group as they are artic- ing to help patients and society, so think administrative leadership is tal, you see how things work, how ulated by the lead hospitalist, the that’s a strong mission in itself. Just easier than being a hospitalist, but people interact with each other, and administration, and the patients,” he by training and the very design of it is not. Leadership should not be learn the politics,” she said. “One of said. “There are so many activities our health care system, hospitalists about getting away from something the easiest ways to do it is get in- that come up on a day-in, day-out are often natural leaders, and in else. It should be a thoughtful ca- volved in a committee and be a part basis. You should jump in and vol- leadership roles, because they run reer move, and if it is, being a leader of meetings. You can have some in- unteer to take the lead on some of teams of clinicians and train medical can be meaningful and fulfilling.” put and get exposure to other lead- those activities. Leading your peers students.” Nancy Spector, MD, the vice dean ers and they can learn more about is often one of the most challenging Danielle Scheurer, MD, MSCR, for faculty and executive director you. Once you get an organizational parts of leadership. I think taking SFHM, chief quality officer and of the Executive Leadership in Aca- understanding under your belt, then on even just a small activity like, professor of medicine at the Medical demic Medicine program at Drexel you can start taking on projects to say, working on a clinical pathway University of South Carolina, and University College of Medicine in gain even more understanding.” for the group, will result in a lot of current president of SHM, said some Philadelphia, said a willingness to preparation for future leadership hospitalists end up in leadership fail is vital for a leader. “You have to Are you still up for it? roles.” roles almost by accident – because be open to successes, yes, but also If you think you have the commit- Continued on following page

Continued from previous page hospital setting but had to do it very quickly. Initiating another new program Watching him once again do what he does best, One of Dr. Howell’s last major projects for Hop- initiating a new program, building things care- kins was to launch and be chief medical officer fully and thoughtfully, without being overly cau- for the Joint Commission–accredited Baltimore tious, I could see his years of experience and good Civic Center Field Hospital for COVID-19 patients, judgment about how hospitals run. He’s very opened in March 2020. With a surge capacity of logical but very caring. He’s also good at spotting 250 beds, and a negative-pressure ward set up in young leaders and their talents.”

the center’s exhibit hall, it is jointly operated by Some people have a knack for solving prob- ediCine M the University of Maryland Medical System and lems, added Dr. Ziegelstein, Dr. Howell’s mentor opkins

Johns Hopkins Hospital. The field hospital’s mis- from his early days at Bayview. “Eric is different. h ohns

sion has since expanded to include viral tests, in- He’s someone who’s able to identify gaps, prob- J fusions of monoclonal antibodies, and COVID-19 lem areas, and vulnerabilities within an organi- ourtesy

vaccinations. zation and then come up with a potential menu C Planning for a smooth transition, Dr. Howell of solutions, think about which would be most Dr. Melinda E. Kantsiper is director of clinical oper- brought Melinda E. Kantsiper, MD, director of likely to succeed, implement it, and assess the ations in the division of hospital medicine at Johns clinical operations, Division of Hospital Medicine outcome. That’s the difference between a skilled Hopkins Bayview Medical Center, Baltimore. at Johns Hopkins Bayview, on board as associate manager and a true leader, and I’d say Eric had medical officer, to eventually replace him as CMO that ability while still in training,” Dr. Ziegelstein taking on too much change at one time,” Dr. Zie- after a few months working alongside him. “Eric said. gelstein said. “He understood people’s sensibil- brings that logical engineering eye to problem “Eric understood early on not only what the ities and concerns about this new service, and solving,” Dr. Kantsiper said. field of hospital medicine could offer, he also he catalyzed its growth through incremental “We wanted to build a very safe, high-quality understood how to catalyze change, without change.” the-hospitalist.org | 5 | March 2021

02_3_4_5_6_THN21_3.indd 5 2/19/2021 10:02:31 AM LEADERSHIP

Continued from previous page Dr. Scheurer believes choosing An example of an early career between clinical and administra- activity that Dr. Shen felt was valu- tive leadership is not so clear cut, able to future leaders was helping because in the health care setting in the development of a hospitalist they tend to morph into each other. core curriculum. “We would use the “Many times clinicians will end up core curriculum to educate students taking on a leadership role that has and residents coming through our a significant administrative com- rotation and have some degree of ponent to it,” she said. “I do think if commonality or standardization,” he clinicians make a career move and arolina C

said. “So even though I wasn’t an ex- get the right training then they outh S

of plicit leader of the hospitalist group can be exemplary leaders in health at the time, I’d say that helping de- care, but I do worry a little about niversity U velop the core curriculum aided me clinicians going into leadership roles al in understanding what leadership without any formal training. They c edi M was all about.” are usually well-intentioned but ,

Getting started in a leadership that’s not enough. It’s not any dif- esley role, Dr. Spector said, can be helped ferent than medical training. If you W

want to be a good leader you need rennan by embracing a knowledge of the B business of medicine. “Business and training to develop your skills, and a ourtesy finance are a reality you shouldn’t lot of those skills do not come natu- C avoid,” she said. “Another way to rally or easily. We thrust good clini- Dr. Danielle Scheurer (third from left) of the Medical University of South learn is to partner with your local cians into leadership roles because Carolina, Charleston, talks with colleagues. administrators or whoever is run- they are good clinicians, but if they ning your division or your depart- don’t have the right skills, being a time because it opens up opportuni- should look at leadership the same ment. There are business managers leader can be a problem.” ties and shows you are looking to do way. A lot of leadership theories and business partners in every in- more, not less.” change with the times and you stitution, and you can learn a great How do leaders improve? Also, Dr. Howell recommends should always try to get good ad- deal from them. It’s important to If you have made it to a leadership that leaders look for tools that help vice. You don’t take every piece of network and get to know people position, and have been in that role minimize blind spots, and acquire advice – just like in medicine when

Business and finance If you want to be a good are“ a reality you shouldn’t leader“ you need training avoid. Another way to to develop your skills, learn is to partner with and a lot of those skills your local administrators do not come naturally or whoever is running or easily. We thrust good your division or your clinicians into leadership department. There are roles because they are business managers and good clinicians, but if they business partners in every don’t have the right skills, institution, and you can being a leader can be a Dr. Nancy Spector learn a great deal.” problem.” Dr. Danielle Scheurer because we’re a people business, and for a while, you might start to feel information from staff through sur- you read an article and you try to opportunity comes when people that you are stuck in your growth vey assessments. “Get the input of apply it to patients in your practice. know who you are.” trajectory. If so, how do you contin- others on your strengths and weak- Take some advice, leave some advice, Dr. Howell noted that advocating ue to improve? nesses,” he said. “Nurses, doctors, and develop a leadership style that for yourself is sometimes hard, and According to Dr. Kennedy, wheth- and sometimes patients can give is genuine and authentic.” it can be a red flag to administrators er you are looking to get into leader- you good information that will help Dr. Kennedy believes that a hospi- in some circumstances, but you ship or want to improve, focusing on you grow as a leader. Don’t be afraid talist’s leadership potential may be should tell your bosses where you emotional intelligence is important. of feedback.” limited if he or she sees continued want to go professionally. “A book like Emotional Intelligence learning as a chore, rather than an “You can say to your supervisors 2.0 by Travis Bradbury is a great How can we never stop learning? opportunity. that you want to grow professional- introduction,” she said. “With my Dr. Scheurer said it is important for “If you resent continuing to learn ly, and let’s face it, there are natural- leadership team, we did a book club hospitalists to recognize that you about leadership, then is it really for ly inclined leaders. We all need to be where we read Primal Leadership, are never finished learning when you?” she asked. “I find myself read- transparent in goal paths,” he said. which is focused on emotional intel- you are a leader. ing on the topic or talking about “But if you want a leadership role ligence and on aspects like setting a “See leadership as a continuous it, and it’s fun. How do you make a for power, money, and prestige then culture.” learning journey. You can never be workplace environment function I don’t think you are applying the Dr. Howell said that to grow as a too good of a leader in medicine,” better, how do you inspire people, right thinking. If you want to help leader, be careful what you say no she said. “Never stop learning, be- how do you help them grow? These others and you have a mission you to. “I used to talk about having a tag cause the field keeps changing and are some of the most important believe in, you should communicate line that was ‘just say yes,’” he said. you have to constantly learn and questions leaders face. Isn’t it fun if that to your bosses.” “At least try to say yes most of the find pleasure in that learning. You you can find some answers?” March 2021 | 6 | The Hospitalist Post-ICU Experience.

When patients are discharged from a traditional hospital they often need continued acute-level care. Acute care providers need partners who can continue to provide care with the extended recovery time that chronically, critically ill patients need.

For over 30 years, Kindred Hospitals have been a partner of choice for many health systems around the country. With daily physician oversight, ICU/CCU-level staffing and specially trained caregivers, we work to improve outcomes, reduce costly readmissions and help patients transition to a lower level of care.

If you have patients who you think could benefit from the experience and specialized care at Kindred Hospitals, reach out to us at recoveratkindred.com.

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HOSP_07.inddWF189899 HD 1Post-ICU Experience AD 10.5x13.indd 1 2/10/20211/22/21 6:55:36 1:28 PM PM TECHNOLOGY Virtual is the new real Why did we fall short on maximizing telehealth’s value in the COVID-19 pandemic?

By Chandra S. Lingisetty, MD, MBA, Hospital-based care in the United States taps MHCM; Rupesh Prasad, MD, MPH, CPE, nearly 33% of national health expenditure. An ad- SFHM; Venkataraman Palabindala, MD, ditional 30% of national health expenditure that MBA, FACP, SFHM is related to physicians, prescriptions, and other facilities is indirectly influenced by care delivered he COVID-19 pandemic catalyzed the at health care facilities.3 Studies show that about transformation of Internet-based, re- 20% of ED visits could potentially be avoided via motely accessible innovative technol- virtual urgent care offerings.4 A rapidly changing ogies. Internet-based customer service health care ecosystem is proving formidable for Tdelivery technology was rapidly adopted and most hospital systems, and a test for their resil- utilized by several services industries, but health ience and agility. Not just the implementation of Dr. Lingisetty care systems in most of the countries across the telehealth is challenging, but getting it right is world faced unique challenges in adopting the the key success factor. technology for the delivery of health care ser- vices. The health care ecosystem of the United Hospital-based telehealth States was not immune to such challenges, and Expansion of telehealth coverage by the Centers several significant barriers surfaced while the for Medicare & Medicaid Services and most com- pandemic was underway. mercial payers did not quite ride the pandemic-in- Complexly structured, fragmented, unpre- duced momentum across the care continuum. pared, and overly burnt-out health systems in Hospitals are lagging far behind ambulatory care the United States arguably have fallen short of in implementing telehealth. As illustrated in the maximizing the value of telehealth in deliver- “4-T Matrix” (see graphic) we would like to exam- ing safe, easily accessible, comprehensive, and ine four key reasons for such a sluggish initial up- Dr. Prasad Dr. Palabindala cost-effective health care services. In this essay, take and try to propose four important strategies we examine the reasons for such a suboptimal that may help us to maximize the value created Dr. Lingisetty is a hospitalist and physician exec- performance and discuss a few important strate- by telehealth technologies. utive at Baptist Health System, Little Rock, Ark, gies that may be useful in maximizing the value and is cofounder/president of SHM’s Arkansas of telehealth in several, appropriate health care 1. Timing chapter. Dr. Prasad is medical director of care services. The health care system has always lagged far management and a hospitalist at Advocate Au- behind other service industries in terms of tech- rora Health in Milwaukee. He is cochair of SHM’s nology adaptation. Because of the unique nature IT Special Interest Group, sits on the HQPS of health care services, face-to-face interaction committee, and is president of SHM’s Wisconsin While most health systems took a supersedes all other forms of communication. chapter. Dr. Palabindala is the medical director, heroic“ approach to the adoption of A rapidly evolving pandemic was not matched utilization management, and physician advisory telehealth during COVID-19, despite by simultaneous technology education for pa- services at the University of Mississippi Medical tients and providers. The enormous choice of Center and an associate professor of medicine being unprepared, the need for a hard-to-navigate telehealth tools; time and la- and academic hospitalist at the University of systematic telehealth deployment is bor-intensive implementation; and uncertainty Mississippi, both in Jackson. around payer, policy, and regulatory expectations far from being adequately fulfilled. might have precluded providers from the rapid ” adoption of telehealth in the hospital setting. of burnout among physicians.5 In the current Patients’ specific characteristics, such as the ab- climate, administrators and health informaticists Hospitals and telehealth sence of technology-centered education, informa- have the responsibility to avoid adding increased Are hospitalists preparing ourselves “not to see” tion, age, comorbidities, lack of technical literacy, burdens to end users. patients in a hospital-based health care delivery and dependency on caregivers contributed to the Another issue is the limited connectivity in setting? If you have not yet started, now may be suboptimal response from patients and families. many remote/rural areas that would impact im- the right time! Yes, a certain percentage of doc- Deploying simple, ubiquitous, user-friendly, plementation of telehealth platforms. Studies in- tor-patient encounters in hospital settings will and technologically less challenging telehealth dicate that 33% of rural Americans lack access to remain virtual forever. solutions may be a better approach to increase high-speed broadband Internet to support video A well-established telehealth infrastructure is the adoption of such solutions by providers and visits.6 The recent successful implementation of rarely found in most U.S. hospitals, although the patients. Hospitals need to develop and distribute telehealth across 530 providers in 75 ambulatory COVID-19 pandemic has unexpectedly boosted telehealth user guides in all possible modes of practices operated by Munson Healthcare, a rural the rapid growth of telehealth in the country.1 communication. Provider-centric in-service ses- health system in northern Michigan, sheds light Public health emergency declarations in the Unit- sions, workshops, and live support by “superuser on the technology’s enormous potential in pro- ed States in the face of the COVID-19 crisis have teams” often work well in reducing end-user re- viding safe access to rural populations.6,7 facilitated two important initiatives to restore sistance. Privacy and safety of patient data are of para- health care delivery amidst formal and informal mount importance. According to a national poll lockdowns that brought states to a grinding halt. 2. Technical on healthy aging by the University of Michigan These extend from expansion of virtual services, Current electronic medical records vary widely in in May 2019, targeting older adults, 47% of survey including telehealth, virtual check-ins, and e-visits, their features and offerings, and their ability to responders expressed difficulty using technology to the decision by the Department of Health & Hu- interact with third-party software and platforms. and 49% of survey responders were concerned man Services Office of Civil Rights to exercise en- Dissatisfaction of end users with EMRs is well about privacy.8 Use of certification and other forcement discretion and waive penalties for the known, as is their likely relationship to burnout. tools offered by the Office of the National Co- use of relatively inexpensive, non–public-facing Recent research continues to show a strong re- ordinator for Health Information Technology mobile and other audiovisual technology tools.2 lationship between EMR usability and the odds would help reassure users, and the ability to cap- March 2021 | 8 | The Hospitalist TECHNOLOGY ture and share images between of care delivery.10 Excessive and providers would be of immense unused physical capacity can be benefit in facilitating e-consults. converted into digital care hubs. The need of the hour is re- Health maintenance, preven- designed workflow, to help tion, health promotion, health providers adopt and use virtual education, and chronic disease care/telehealth efficiently. Work- management not only can serve flow redesign must be coupled a variety of patient groups but with technological advances to can also help address the “last- allow seamless integration of mile problem” in health care. A third-party telehealth platforms successful digital strategy usu- into existing EMR systems or ally has three important compo- built directly into EMRs. Use of nents – Commitment: Hospital quality metrics and analytical leadership is committed to in- tools specific to telehealth would clude digital transformation as a a l help measure the technology’s a strategic objective; Cost: Digital d abin

impact on patient care, out- l strategy is added as a line item a P . comes, and end-user/provider r in the budget; and Control: Mea- D experience. d surable metrics are put in place an

, d to monitor the performance, im- rasa P

3. Teams and training . pact, and influence of the digital r D Outcomes of health care inter- , strategy. ventions are often determined ingisetty L .

by the effectiveness of teams. Ir- r Conclusion respective of how robust health D For decades, most U.S. health care systems may have been systems occupied the periphery initially, rapidly spreading infectious diseases like argue that it may be akin to strategic myopia, the of technological transformation when compared COVID-19 can quickly derail the system, bringing authors believed that such a response is strategi- to the rest of the service industry. While most the workforce and patients to a breaking point.5 cally imperative to keep the hospital afloat. It is health systems took a heroic approach to the Decentralized, uncoordinated, and siloed efforts reasonable to attribute the paucity of innovation adoption of telehealth during COVID-19, despite by individual teams across the care continuum to constrained resources, and health systems are being unprepared, the need for a systematic tele- were contributing factors for the partial success simply staying overly optimistic about “weather- health deployment is far from being adequately of telehealth care delivery pathways. The hospital ing the storm” and reverting soon to “business as fulfilled. The COVID-19 pandemic brought per- systems with telehealth-ready teams at the start usual.” The technological framework necessary manent changes to several business disciplines of the COVID-19 pandemic were so rare that the for deploying a telehealth solution often comes globally. Given the impact of the pandemic on the knowledge and technical training opportunities with a price. Financially challenged hospital health and overall well-being of American society, for innovators grew severalfold during the pan- systems rarely exercise any capital-intensive the U.S. health care industry must leave no stone demic. activities. By contrast, telehealth adoption by am- unturned in its quest for transformation. As per the American Medical Association, tele- bulatory care can result in quicker resumption of health success is massively dependent on build- patient care in community settings. A lack of op- References ing the right team. Core, leadership, advisory, and erational and infrastructure synchrony between 1. Finnegan M. “Telehealth booms amid COVID-19 crisis.” implementation teams comprising clinical repre- ambulatory and in-hospital systems has failed Computerworld. 2020 Apr 27. www.computerworld.com/arti- cle/3540315/telehealth-booms-amid-covid-19-crisis-virtual-care- sentatives, end users, administrative personnel, to capture telehealth-driven inpatient volume. is-here-to-stay.html. Accessed 2020 Sep 12. executive members of the organization, technical For example, direct admissions from ambulatory 2. Department of Health & Human Services. “OCR Announces experts, and payment/policy experts should be telehealth referrals was a missed opportunity in Notification of Enforcement Discretion for Telehealth Remote put together before implementing a telehealth several places. Referrals for labs, diagnostic tests, Communications During the COVID-19 Nationwide Public Health Emergency.” 2020 Mar 17. www.hhs.gov/about/news/2020/03/17/ 9 strategy. Seamless integration of hospital-based and other allied services could have helped hospi- ocr-announces-notification-of-enforcement-discretion-for-tele- care with ambulatory care via a telehealth plat- tals offset their fixed costs. Similarly, work flows health-remote-communications-during-the-covid-19.html. form is complete only when care managers are related to discharge and postdischarge follow up Accessed 2020 Sep 12. trained and deployed to fulfill the needs of a rarely embrace telehealth tools or telehealth care 3. National Center for Health Statistics. “Health Expenditures.” www.cdc.gov/nchs/fastats/health-expenditures.htm. Accessed diverse group of patients. Deriving overall value pathways. A brisk change in the health care eco- 2020 Sep 12. from telehealth is only possible only when there system is partly responsible for this. 4. Bestsennyy O et al. “Telehealth: A post–COVID-19 reality?” is a skill development, training and mentoring Digital strategy needs to be incorporated into McKinsey & Company. 2020 May 29. www.mckinsey.com/indus- team put in place. business strategy. For the reasons already dis- tries/healthcare-systems-and-services/our-insights/telehealth-a- quarter-trillion-dollar-post-covid-19-reality. Accessed 2020 Sep 12. cussed, telehealth technology is not a “nice to 5. Melnick ER et al. The Association Between Perceived Electronic 4. Thinking have” anymore, but a “must have.” At present, pro- Health Record Usability and Professional Burnout Among U.S. In most U.S. hospitals, inpatient health care is viders are of the opinion that about 20% of their Physicians. Mayo Clin Proc. 2020 March;95(3):476-87. equally distributed between nonprocedure and patient services can be delivered via a telehealth 6. Hirko KA et al. Telehealth in response to the COVID-19 pandemic: Implications for rural health disparities. J Am Med procedure-based services. Hospitals resorted to platform. Similar trends are observed among Inform Assoc. 2020 Nov;27(11):1816-8. . suspension of nonemergent procedures to miti- patients, as a new modality of access to care is in- 7. American Academy of Family Physicians. “Study Examines Tele- gate the risk of spreading COVID-19. This was fur- creasingly beneficial to them. Telehealth must be health, Rural Disparities in Pandemic.” 2020 July 30. www.aafp. ther compounded by many patients’ self-selection incorporated in standardized hospital workflows. org/news/practice-professional-issues/20200730ruraltelehealth. html. Accessed 2020 Dec 15. to defer care, an abrupt reduction in the influx of Use of telehealth for preoperative clearance will 8. Kurlander J et al. “Virtual Visits: Telehealth and Older patients from the referral base because of subop- greatly minimize same-day surgery cancella- Adults.” National Poll on Healthy Aging. 2019 Oct. hdl.handle. timally operating ambulatory care services, lead- tions. Given the potential shortage in resources, net/2027.42/151376. ing to low hospital occupancy. telehealth adoption for inpatient consultations 9. American Medical Association. Telehealth Implementa- Hospitals across the nation have gone through will help systems conserve personal protective tion Playbook. 2019. www.ama-assn.org/system/files/2020-04/ ama-telehealth-implementation-playbook.pdf. a massive short-term financial crunch and un- equipment, minimize the risk of staff exposure to 10. Smith AC et al. Telehealth for global emergencies: Implica- favorable cash-flow forecast, which prompted a COVID-19, and improve efficiency. tions for coronavirus disease 2019 (COVID-19). J Telemed Tele- paradoxical work force reduction. While some Digital strategy also prompts the reengineering care. 2020 Jun;26(5):309-13. the-hospitalist.org | 9 | March 2021 COMMENTARY

Hospital at Home Delivering hospital-level care without the hospital Part 1: History, efficacy, and early adoption

By Marina S. Farah, MD, MHA drome caused by the physiological COVID-19 pandemic amplified in- stress that patients experience in terest in HaH by creating an urgent he United States spends the hospital, leaving them vulnera- need for flexible hospital bed capac- one-third of the nation’s ble to clinical adverse events such as ity and heightening concerns about health dollars on hospital falls and infections.5 hospital care safety, especially for care, amounting to $1.2 tril- In the mid-1990s, driven by a goal vulnerable adults. Tlion in 2018.1 U.S. hospital beds are to “avoid the harm of inpatient care In this article series about HaH, prevalent,2 and expensive to build and honor the wishes of older adults we first introduce HaH history and and operate, with most hospital who refused to go to the hospital,” efficacy. Then, in a second article, services costs related to buildings, Bruce Leff, MD, director of the Cen- we discuss what it takes to success- equipment, salaried labor, and over- ter for Transformative Geriatric Re- fully implement HaH. head.3 search and professor of medicine at Despite their mission to heal, hos- Johns Hopkins University in Balti- Hospital at Home: History, pitals can be harmful, especially for more, and his team set out to devel- efficacy, and early adoption frail and elderly patients. A study op and test Hospital at Home (HaH) The earliest HaH study, a 17-patient completed by the Office of the In- – an innovative model for delivering pilot conducted by Dr. Leff’s team Dr. Farah is a hospitalist, physician spector General found that 13.5% hospital-level care to selected pa- from 1996 to 1998, proved that HaH adviser, and Lean Six Sigma of hospitalized Medicare patients tients in the safety of their homes. was feasible, safe, highly satisfac- Black Belt. She is a performance experienced an adverse event that More than 20 years later, despite tory, and cost effective for selected improvement consultant based in resulted in a prolonged hospital stay, extensive evidence supporting HaH acutely ill older patients with com- Corvallis, Ore., and a member of permanent harm, a life-sustaining safety and efficacy, and its success- munity-acquired pneumonia, chron- The Hospitalist’s editorial advisory intervention or death.4 In addition, ful rollout in other countries, the ic heart failure, chronic obstructive board. there is growing concern about model has not been widely adopted pulmonary disease, or cellulitis.6 In acquired posthospitalization syn- in the United States. However, the 2000-2002, a National Demonstra- tion and Evaluation Study of 455 pa- care, including physician services, is tients across three sites determined reimbursed via a partial DRG (diag- that patients treated in Hospital at nosis-related group) payment that Home had statistically significant was negotiated internally between shorter length of stay (3.2 vs. 4.9 the health system and Presbyterian days), lower cost ($5,081 vs. $7,480), Health Plan. and fewer complications.7 Equipped The results demonstrated that, with evidence, Dr. Leff and his team compared to hospitalized patients focused on HaH dissemination with similar conditions, patients in and implementation across several HaH had a lower rate of falls (0% health care systems.8 vs. 0.8%), lower mortality (0.93% Presbyterian Healthcare Services vs. 3.4%), higher satisfaction (mean in Albuquerque was one of the ear- score 90.7 vs. 83.9) and 19% lower liest adopters of HaH and launched cost.9 According to Dr. Guinn, more the program in 2008. The integrated recent results showed even larger system serves one-third of New cost savings of 42%.10 After starting Mexicans and includes nine hospi- the HaH model, Presbyterian has tals, more than 100 clinics, and the launched other programs that work state’s largest health plan. Accord- closely with HaH to provide a seam- ing to Nancy Guinn, MD, a medical less experience for patients. That in- Virtual Seminar Series director of Presbyterian Healthcare cludes the Complete Care Program, at Home, “Innovation is key to sur- which offers home-based primary, vive in a lean environment like New urgent, and acute care to members Mexico, which has the lowest per- covered through Presbyterian The New Generation of Leaders centage of residents with insurance Health Plan and has a daily census Gain the strategies and techniques that will help you from their employer and a high rate of 600-700 patients. of government payers.” Another important milestone effectively lead through a crisis and beyond. Attend SHM’s Presbyterian selected nine diag- came in 2014 when Icahn School of Virtual Leadership Academy Seminar Series. noses for HaH focus: congestive Medicine at Mount Sinai in New • March 11, 2021 • June 2021 heart failure, chronic obstructive York was awarded $9.6 million by • April 21, 2021 • September 2021 pulmonary disease, community-ac- the Center for Medicare and Med- quired pneumonia, cellulitis, deep icaid Innovation (CMMI) to test the venous thrombosis, pulmonary HaH model during acute illness and Learn More at hospitalmedicine.org/virtualseminar embolism, complicated urinary tract for 30 days after admission. A case infection or urosepsis, nausea and study of 507 patients enrolled in the vomiting, and dehydration. The HaH Continued on following page March 2021 | 10 | The Hospitalist NEWS More Americans readmitted for heart failure

By Patrice Wendling therapies,” said Dr. Ziaeian, of the Veterans Af- The present study did not risk-adjust readmis- fairts Greater Los Angeles Healthcare System and sion risk and included a population that was 51% eart failure (HF) hospitalizations and re- the University of California, Los Angeles. male, compared with about 98% male in the VA, admissions are on the rise in the United Sodium-glucose cotransporter 2 (SGLT2) inhib- the investigators noted. States, reversing a multiyear downward itors, which have shown clear efficacy and safety “The increasing hospitalization rate in our trend, a new national cohort study shows. in trials like DAPA-HF and EMPEROR-Reduced, study may represent an actual increase in HF HOverall primary HF hospitalization rates per provide a “huge opportunity” to add on to stan- hospitalizations or shifts in administrative cod- 1,000 adults declined from 4.4 in 2010 to 4.1 in 2013, dard therapies, he noted. Competition for VA con- ing practices, increased use of HF biomarkers, or and then increased from 4.2 in 2014 to 4.9 in 2017. tracts has brought the price down to about $50 a lower thresholds for diagnosis of HF with pre- Rates of unique patient visits for HF were also month for veterans, compared with a cash price served ejection fraction,” they wrote. on the way down – falling from 3.4 in 2010 to 3.2 of about $500-$600 a month. The analysis was based on data from the Na- in 2013 and 2014 – before climbing to 3.8 in 2017. Yet in routine practice, only 8% of veterans tionwide Readmission Database, which included Similar trends were observed for rates of post- 35,197,725 hospitalizations with a primary or sec- discharge HF readmissions (from 1.0 in 2010 to 0.9 ondary diagnosis of HF and 8,273,270 primary HF in 2014 to 1.1 in 2017) and all-cause 30-day readmis- We should be emphasizing the hospitalizations from January 2010 to December sions (from 0.8 in 2010 to 0.7 in 2014 to 0.9 in 2017). things“ we know work to reduce 2017. “We should be emphasizing the things we know heart failure hospitalization. A single primary HF admission occurred in work to reduce heart failure hospitalization, 5,092,626 unique patients and 1,269,109 had two or which is, No. 1, prevention,” senior author Boback ” more HF hospitalizations. The mean age was 72.1 Ziaeian, MD, PhD, said in an interview. with HF at his center are on an SGLT2 inhibi- years. Comorbidities that can lead to heart failure tor, compared with 80% on ACE inhibitors or The administrative database did not include crept up over the study period, such that by 2017, beta-blockers, observed Dr. Ziaeian. “This medi- clinical data, so it wasn’t possible to differentiate hypertension was present in 91.4% of patients, cation has been indicated for the last year and a between HF with preserved or reduced ejection diabetes in 48.9%, and lipid disorders in 53.1%, up half and we’re only at 8% in a system where we fraction, the authors noted. Patient race and eth- from 76.5%, 44.9%, and 40.4%, respectively, in 2010. have pretty easy access to medications.” nicity data also were not available. Half of all patients had coronary artery disease As reported online Feb. 10 in JAMA Cardiology “Future studies are needed to verify our find- at both time points. Renal disease shot up from (doi: 10.1001/jamacardio.2020.7472), notable sex ings to better develop and improve individualized 45.9% to 60.6% by 2017. differences were found in hospitalization, with strategies for HF prevention, management, and “If we did a better job of controlling our known higher rates per 1,000 persons among men. surveillance for men and women,” the investiga- risk factors, we would really cut down on the inci- In contrast, a 2020 report on HF trends in the tors concluded. dence of heart failure being developed and then, VA system showed a 2% decrease in unadjusted among those estimated 6.6 million heart failure 30-day readmissions from 2007 to 2017 and a de- A version of this article first appeared on patients, we need to get them on our cornerstone cline in the adjusted 30-day readmission risk. Medscape.com.

Continued from previous page (shared savings/losses) based on (a) that allowed hospitals to provide Acquired, Transient Condition of Generalized Risk. N Engl J Med. 2013 Jan;368:100-102. program in 2014 through 2017 re- total spending during the acute care services in other health care facil- 6. Leff B, et al. Home hospital program: a pilot vealed that HaH patients had statis- phase and 30 days afterward rela- ities and sites that are not part of study. J Am Geriatr Soc. 1999 Jun;47(6):697-702. tically significant shorter length of tive to a target price, and (b) perfor- the existing hospital.16 On Nov. 25, 7. Leff B, et al. Hospital at home: Feasibility and 12 stay (3.2 days vs. 5.5 days), and lower mance on quality measures. 2020, CMS announced expansion of outcomes of a program to provide hospital-level rates of all-cause 30-day hospital In June 2018, the HHS secretary the Hospital Without Walls initia- care at home for acutely ill older patients. Ann readmissions (8.6% vs. 15.6%), 30-day announced that he was not approv- tives to include a Hospital Care at Intern Med. 2005 Dec;143(11):798-808. ED revisits (5.8% vs. 11.7%), and SNF ing the proposal as written, citing, Home program that allows eligible 8. Source: www.johnshopkinssolutions.com/ solution/hospital-at-home/ admissions (1.7% vs. 10.4%), and were among other things, concerns about hospitals to treat eligible patients at 9. Cryer L, et al. Costs for ‘Hospital at Home’ 17 also more likely to rate their hospi- proposed payment methodology home. Patients Were 19 Percent Lower, with Equal or tal care highly (68.8% vs. 45.3%).11 and patient safety.13 With significant evidence sup- Better Outcomes Compared to Similar Inpa- In 2017, using data from their porting HaH’s safety and efficacy, tients. Health Affairs. 2012 Jun;31(6):1237–43. CMMI study, Mount Sinai submitted Hospital at Home: Present state and long overdue support from 10. Personal communication with Presbyterian Health Services. May 20, 2020. an application to the Physician-Fo- Despite additional evidence of HaH’s CMS, it’s now a matter of how to 11. Federman A, et al. Association of a bundled cused Payment Model Technical impact on lowering cost, decreasing successfully implement it. In our hospital-at-home and 30-day postacute transi- Advisory Committee (PTAC) to 30-day readmissions, and improving next article, we discuss what it takes tional care program with clinical outcomes and implement Hospital at Home as an patient satisfaction and functional to select and enroll patients, deliver patient experiences. JAMA Intern Med. 2018 Aug;178(8):1033–40. alternative payment model that outcomes without an adverse effect acute care at home, and ensure a 14, 15 12. Source: aspe.hhs.gov/system/files/pdf/ bundles the acute episode with 30 on mortality, the model has not smooth postacute transition within 255906/MtSinaiHAHReportSecretary.pdf days of postacute transitional care. been widely adopted, largely be- the HaH model. 13. Source: aspe.hhs.gov/system/files/pdf/255906/ The PTAC unanimously approved cause of lack of fee-for-service reim- Secretarial_Responses_June_13_2018.508.pdf the proposal and submitted their bursement from the public payers References 14. Shepperd S, et al. Admission avoidance recommendations to the Secretary (Medicare and Medicaid) and com- 1. Source: www.cms.gov/files/document/nations- hospital at home. Cochrane Database Syst Rev. health-dollar-where-it-came-where-it-went.pdf 2016;9(9):CD007491. DOI:10.1002/14651858. of Health & Human Services (HHS) plex logistics to implement it. CD007491.pub2. to implement HaH as an alternative However, the COVID-19 pandemic 2. Source: www.aha.org/statistics/fast-facts-us- hospitals 15. Levine DM, et al. Hospital-level care at home payment model that included two created an urgent need for flexible for acutely ill adults: a randomized controlled parts: hospital bed capacity and amplified 3. Roberts RR, et al. Distribution of variable trial. Ann Intern Med. 2020 Jan;172(2);77-85. vs fixed costs of hospital care. JAMA. 1999 16. Source: www.cms.gov/files/document/ 1. A bundled payment equal to a concerns about hospital care safe- Feb;281(7):644-9. covid-hospitals.pdf percentage of the prospective DRG ty for vulnerable populations. In 4. Levinson DR; US Department of Health and payment that would have been paid response, the Centers for Medicare 17. Centers for Medicare & Medicaid Services. Human Services; HHS; Office of the Inspector CMS Announces Comprehensive Strategy to to a hospital. & Medicaid Services introduced its General; OIG. Enhance Hospital Capacity Amid COVID-19 2. A performance-based payment Hospitals without Walls initiative 5. Krumholz HM. Post-Hospital Syndrome – An Surge. 2020 Nov 20. the-hospitalist.org | 11 | March 2021 COMMENTARY

PHM Fellows Inclusivity needed in PHM fellowships “Other avenues” to board certification must be considered

By Catherine Ezzio, MD with an “unmatched” notification in their inboxes. Approximately 200 graduating pediatricians be- year and a half ago, I found myself come pediatric hospitalists each year,1 but only 68 seated in a crowded hall at the nation- fellowship positions were available in the United al Pediatric Hospital Medicine con- States for matriculation in 2020.2 In 2019, PHM ference. Throughout the conference, fellowship candidates navigated the 6-month ap- Atrainees like me were warmly welcomed into plication journey with aspirations to further their small groups and lunch tables. I tried to keep my training in the profession they love. Of the candi- cool while PHM “celebrities” chatted with me in dates who submitted a rank list committing to 2 or the elevator. Most sessions were prepared with more years in PHM fellowship, 35% were denied. plenty of chairs, and those that were not encour- Unfortunately, despite expansion of PHM fel- aged latecomers to grab a spot on the floor or the lowship programs and 15 seats added from last back wall – the more the merrier. year, we learned this December that there still The intention of this “advice for applicants” are not enough positions to welcome qualified meeting was to inspire and guide our next steps applicants with open arms: Thirty-three percent toward fellowship, but a discomforting reality of candidates ranked PHM programs first in loomed over us. It was the first year graduating the NRMP but did not match – the highest un- pediatricians could not choose PHM board certi- matched percentage out of all pediatric subspe- cialties.3 The NRMP report shared a glimpse of our col- Dr. Ezzio is a first-year pediatric hospital medi- Unfortunately, despite expansion leagues who received interview invitations and cine fellow at Helen DeVos Children’s Hospital of“ PHM fellowship programs and submitted a rank list, but this is likely an under- in Grand Rapids, Mich. Her interests include estimation of pediatric graduates who wanted to medical education and advocacy. Dr. Ezzio 15 seats added from last year, we obtain PHM board certification and wound up would like to thank Dr. Jeri Kessenich and Dr. learned this December that there on a different path. Some residents anticipated Rachel “Danielle” Fisher for their assistance in the stiff competition and delayed their plans to revising the article. To submit to, or for inqui- still are not enough positions to apply for fellowship, while others matched into ries about, our PHM Fellows Column, please welcome qualified applicants with another subspecialty that was able to accommo- contact our Pediatrics Editor, Dr. Anika Kumar open arms. date them. Many pediatric graduates joined the ([email protected]). workforce directly as pediatric hospitalists know- ” ing the practice pathway to certification is not fication via the practice pathway – we needed an available to them. Along with other physicians roles, and for community hospitalists to feel that invitation in the form of a fellowship match. without board certification in PHM, they shoul- this structure undervalues their role within the The “hidden curriculum” was not subtle: People der concerns of being withheld from professional field of PHM. who scored a seat would keep their options open advancement opportunities. At a time when inclusivity and community in within the field of PHM, and those who did not For the foreseeable future it is clear that pedi- medicine are receiving much-needed recognition, had a murkier future. This message stood in stark atric hospitalists without board certification will the current fellowship application climate has contrast to the PHM inclusivity I had experienced be a large part of our community, and are crucial potential to create division within the PHM com- all conference, and planted seeds of doubt: Was I to providing high-quality care to hospitalized munity. Newly graduating pediatric residents welcome here? Did I “deserve” a seat? children nationally. In 2019, a national survey of are among the populations disproportionately I found the experience as a PHM fellowship pediatric hospital medicine groups revealed that affected by the practice pathway cutoff. Like applicant to be uncomfortable, and my all-too fa- 50% of pediatric hospitalist hires came directly other subspecialties with ever-climbing steps miliar friend “imposter syndrome” set up camp in out of residency, and only 8% of hires were fel- up the “ivory tower” of academia and specializa- my brain and made herself at home. I had no way lowship trained.4 The same report revealed that tion within medicine, the inherent structure of of knowing how many programs to apply to, how 26% of physicians were board certified. These the training pathway makes navigating it more many to interview at, or the chances of my match- percentages are likely to change over the next 5 difficult for pediatricians with professional, geo- ing at all. Once on the interview trail, I realized I years as the window of practice pathway certifi- graphic, and economic diversity or constraints. was not alone in my discomfort – most applicants cation closes and fellowship programs continue Med-Peds–trained colleagues have the added harbored some trepidation, and no one truly knew to expand. Only time will tell what the national challenge of finding a fellowship position that how the chips would fall on Match Day. prevalence of board-certified pediatric hospital- is willing and able to support their concurrent I am thrilled and relieved to have come out the ists settles out to be. internal medicine goals. International medical other end in a great position. The team I work Historically, PHM fellowship graduates have graduates make up about 20% of graduating res- with and learn from is phenomenal. I am grateful assumed roles that include teaching and research idents each year, and just 11% of matched PHM that ACGME accreditation ensures structures responsibilities, and ACGME fellowship require- fellows.3,6 Similarly, while DO medical graduates are in place for fellows to be supported in their ments have ensured that trainees graduate with make up 20% of pediatric residents in the United academic and educational efforts and have full skills in medical education and scholarship, and States, only 10% of matched PHM fellows were confidence that the skills I gain in fellowship will need only 4 weeks of training to be done in a DOs.3,6 New pediatricians with families or finan- help me contribute to progression of the field community hospital.5 Pediatric hospitalists who cial insecurity may be unable to invest in an ex- of PHM and improve my performance as a clini- do not pursue board certification are seeing the pensive application process, move to a new city, cian-educator. growing pool of PHM fellowship graduates pre- and accept less than half of the average starting Sadly, each year PHM match day celebrations pared for positions in academic institutions. It is salary of a pediatric hospitalist for 2-3 years.7 are dampened by the knowledge that a large por- reasonable that they harbor concerns about be- The prevalence of implicit bias in medicine is tion of our colleagues are being left out in the cold ing siloed toward primarily community hospital well documented, and there is growing evidence March 2021 | 12 | The Hospitalist COMMENTARY that it negatively impacts candidate selection in around a nonclinical academic curriculum). meet-ups in the face of the COVID-19 pandemic medical education and contributes to minorities In the absence of the solutions above, we collec- have shown us that with innovation (and a good being underrepresented in the physician work- tively hold the responsibility of maintaining in- Internet connection), networking and mentorship force.8 We must recognize the ways that adding a clusivity and support of our PHM colleagues with can be accomplished across thousands of miles. competitive costly hurdle may risk conflict with and without board certification. One important While there’s great diversity within PHM, this our mission to encourage diversity of representa- strategy provided by Gregory Welsh, MD,9 is to in- subspecialty has a history of attracting pedia- tion within PHM leadership positions. corporate community hospital medicine rotations tricians with some common core qualities: grit, We have not yet successfully bridged the gap into residency training. Sharing this side of PHM creativity, and the belief that a strong team is far between qualified PHM fellowship candidates and with residents may help some graduates avoid greater than the sum of its parts. I have confi- available fellowship positions. I worry that this a training pathway they may not want or need. dence that, if we approach this PHM transition gap and the lack of transparency surrounding it is More importantly, it would raise trainee exposure period with transparency about our goals and resulting in one portion of new pediatricians being challenges, this community can emerge from it welcomed by the subspecialty, and others feeling At a time when inclusivity strong and united. unsupported and alienated by the larger PHM community as early career physicians. and“ community in medicine References Right now, the only solution available is ex- are receiving much-needed 1. Leyenaar JK and Fritner MP. Graduating pediatric residents pansion of fellowship programs. We see progress entering the hospital medicine workforce, 2006-2015. Acad Pedi- atr. 2018 Mar;18(2):200-7. with the new addition of fellowship positions ev- recognition, the current fellowship 2. National Resident Matching Program. Results and data: ery year, but finding funding for each position is application climate has potential Specialties matching service 2020 appointment year. Washing- often a lengthy endeavor, and the COVID-19 pan- to create division within the PHM ton, DC 2020. demic has tightened the purse strings of many 3. National Resident Matching Program. Results and data: community. Specialties matching service 2021 appointment year. Washing- children’s hospitals. It may be many years before ton, DC 2021. the number of available fellowship positions ” 4. 2020 State of Hospital Medicine report. Society of Hospital more closely approximates the 200 pediatricians and interest toward a service that is both expan- Medicine. 2020. that become hospitalists each year. sive – approximately 70% of pediatric hospitalists 5. Oshimura JM et al. Current roles and perceived needs of The most equitable solution would be offer- practice in a community hospital – and crucial to pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7. ing other avenues to board certification while children’s health nationally. 6. National Resident Matching Program. Results and data: 2020 this gap is being bridged, either by extending Pediatric hospitalists who are not eligible for main residency match. Washington, DC 2020. the practice pathway option, or making a third board certification are vital and valued members 7. American Academy of Pediatrics Annual Survey of graduating pathway that requires less institutional funding of the PHM community, and as such need to residents 2003-2020. per fellow, but still incentivizes institutional in- maintain representation within PHM leadership. 8. Quinn Capers IV. How clinicians and educators can mitigate implicit bias in patient care and candidate selection in medical vestment in fellowship positions and resources Professional development opportunities need education. American Thoracic Society Scholar. 2020 Jun;1(3):211-17. (e.g., a pathway requiring some number of years to remain accessible outside of fellowship. The 9. Welsh G. The importance of community pediatric hospital in practice, plus 1 year in fellowship centered blossoming of virtual conferences and Zoom medicine. The Hospitalist. 2021 Jan;25(1):27.

SHM’s 2021 Awards of Excellence Winners Thank you for the extraordinary contributions you’ve made to hospital medicine this year.

Clinical Leadership for NPs/PAs Excellence in Teamwork in Krystle Apodaca, DNP, FHM Quality Improvement Intermountain Healthcare Clinical Leadership for Physicians Christopher Bruti, MD, MPH Junior Investigator Matthew Pappas, MD, MPH, FHM Diversity Leadership Lily Cervantes, MD Leadership for Practice Managers Leah Lleras Excellence in Humanitarian Services Eileen Barrett, MD, FACP, MPH, SFHM Outstanding Service in Excellence in Research Hospital Medicine Ryan Greysen, MD, MHS, MA, SFHM Robert Zipper, MD, MMM, SFHM

Excellence in Teaching Grace Huang, MD

hospitalmedicine.org/awards

the-hospitalist.org | 13 | March 2021 COMMENTARY Getting by with a little help from our friends Palliative care and hospital medicine partnerships in the pandemic

By Clarissa Johnston MD, ly ill with COVID-19. patients to counsel them on severity ed the staff’s desire to know their FACP; Victoria Cooremans, The PC team attended daily MICU of illness and prognosis based on loved one as an individual. MD; Sherine Salib, MD, FACP; multidisciplinary huddles, attentive risk factors, to elucidate wishes for It is also important to acknowl- Kirsten Nieto, MD; Snehal to both the medical and psychoso- intubation or resuscitation, and to edge setbacks. Early efforts to en- Patel, MD, FACP cial updates for each patient. During capture their desired medical deci- gage technology proved more foe huddles, residents or HM providers sion-maker. HM was notified of all than friend. We continue to strug- atients dying without their were asked to end their presenta- COVID and PUI admissions, allow- gle with using our iPads for video loved ones, families forced to tion with a clinical status “headline” ing us to speak with even critically visits. Most of our families prefer remotely decide goals of care and solicited feedback from the ill patients in the ER or ICU prior “WhatsApp” for video communica- without the physical pres- multidisciplinary team before mes- tion, which is not compatible with Pence or human connection of the saging to the family. Our hospital medicine operating systems on early versions care team, overworked staff phys- The PC team then communicated and“ palliative care teams of the iPad, which were generously ically isolated from their critically with families a succinct and cohe- and widely donated by local school ill patients, and at-risk community sive medical update and continu- have an established strong systems. members with uncertain and undoc- ously explored goals of care. This partnership. The COVID-19 Desperate to allow families to umented goals for care are among allowed the HM team, often over- connect, many providers resorted to the universal challenges confronted whelmed with admissions, co-man- pandemic created novel using personal devices to facilitate by hospitals and hospitalists during aging intensive care patients, and communication challenges video visits and family meetings. this COVID-19 pandemic. facilitating safe discharges, to focus And we discovered that many video Partnerships among hospital on urgent issues while PC provided but our shared mission visits caused more not less family medicine (HM) and palliative care continuity and personalized support toward patient-centered angst, especially for critically ill (PC) teams at Dell Medical School/ for patients and families. care allowed us to patients. Families often required Dell Seton Medical Center thrive The PC team’s ability to synthe- preparation and coaching on what on mutually shared core values of size and summarize clinical infor- effectively collaborate. to expect and how to interact with patient-centered care – compassion, mation from multiple teams and ” intubated, sedated, proned, and par- empathy, and humanity. then provide cohesive updates in to intubation in order to quickly alyzed loved ones. A key collaboration between PC patient-friendly language modeled and accurately capture patients’ Our hospital medicine and pallia- and HM involved adapting our mul- important communication skills for wishes for treatment and delegate tive care teams have an established tidisciplinary huddle to focus on learners and simultaneously bene- decision-makers. Our chaplains strong partnership. The COVID-19 communication effectiveness and fited HM providers. supported and supplemented these pandemic created novel communica- efficiency in the medical intensive Our chaplains, too, were central efforts by diligently and dutifully tion challenges but our shared mis- care unit (MICU). Expanded inter- to facilitating timely, proactive con- soliciting, hearing, and documenting sion toward patient-centered care professional and cross-specialty versations and documentation of patient MPOA delegates, with over allowed us to effectively collaborate collaboration promoted streamlined, Medical Power of Attorney (MPOA) 50% MPOA completion by 24 hours to bring the patients goals of care to succinct, and standardized com- for patients with COVID-19 admit- of hospitalization. the forefront aligning patients, fam- munication with patients’ families ted to our hospital. HM prioritized Another early PC-HM project, ilies, physicians, nurses, and staff while their loved ones were critical- early admission conversations with “Meet My Loved One,” was adapted during the COVID-19 surge. from the University of Alabama at Birmingham’s Palliative and Dr. Johnston is associate professor Comfort Unit. The absence of fam- at Dell Medical School at The ilies visiting the ICU and sharing University of Texas in Austin. pictures, stories, anecdotes of our She practices hospital medicine patients left a deeply felt, dehuman- and inpatient palliative care at izing void in the halls and rooms of Dell Seton Medical Center. Dr. our hospital. Cooremans is a resident physician To fill this space with life and at Dell Medical School. Dr. Salib humanity, furloughed medical stu- is the internal medicine clerkship dents on their “transition of care” director and an associate professor electives contacted family members at Dell Medical School. Dr. Nieto is of their “continuity” patients fo- an assistant professor and associate cusing primarily on those patients chief of the Division of Hospital expected to have prolonged ICU or Medicine at Dell Medical School. hospital stays and solicited personal, Dr. Patel is an assistant professor at humanizing information about our Dell Medical School. patients. Questions included: “What is your loved one’s preferred name This article is part of a series written or nickname?” and “What are three by members of the Division of things we should know to take bet- Hospital Medicine at Dell Medical ter care of your loved one?” School, exploring lessons learned ock

t With family permission, we post- from the coronavirus pandemic and nks i

h ed this information on the door outlining an approach for creating /T ng

i outside the patient’s room. Nursing COVID-19 Centers of Excellence. sh i staff, in particular, appreciated get- The article first appeared in The ubl P ting to know their patients more Hospital Leader, the official blog of ngram I personally and families appreciat- the Society of Hospital Medicine. March 2021 | 14 | The Hospitalist COVID-19 COVID-19: Another study links colchicine to better results Drug works on “overabundant inflammatory response”

By Randy Dotinga according to goodrx.com.) The median age in the groups was he gout drug colchicine ap- similar (55 years); and the placebo So far, it seems pears to lower the severity group had more women (61% vs. of COVID-19, a small new 47% in the colchicine group, P = .34). as“ if there is no Brazilian study finds, adding All 72 patients received the same safety problem Tto evidence that the familiar medi- COVID-19 treatment at the time of cation holds promise as a treatment the trial: azithromycin, hydroxychlo- with combining for hospitalized patients. roquine, and unfractionated hepa- colchicine with other Patients who received colchicine rin. Most patients, about two-thirds in this randomized, double-blinded, in both groups, also received meth- approaches, but placebo-controlled clinical trial pre- ylprednisolone because they needed this has not been sented better evolution in terms of higher amounts of supplemental studied in a rigorous the need for supplemental oxygen oxygen. and the length of hospitalisation. ... Patients in the colchicine group manner. Colchicine was safe and well tolerat- needed supplemental oxygen for ” ed,” the study authors wrote in RMD less time: Their median time of need Open (2021 Feb 4. doi: 10.1136/rm- was 4.0 days (interquartile range, Dr. Michael H. Pillinger dopen-2020-001455). However, deaths 2.0-6.0) vs. 6.5 days (IQR, 4.0-9.0) for were rare in the trial, they added, the placebo group (P < .001). The than the sample size that was esti- some other drugs. Its interaction and it is impossible to “evaluate the median time for hospitalization was mated to be needed based on power with the antibiotic clarithromycin capacity of colchicine to avoid admis- also lower at 7.0 days (IQR, 5.0-9.0) analysis,” he said. can be fatal, he noted. And, he said, sion to ICU and reduce mortality.” for the colchicine group vs. 9.0 (IQR, The Brazilian study is small, he the drug must be monitored in gen- The oral anti-inflammatory col- 7.0-12.0) for the placebo group (log noted. (In contrast, the ColCO- eral since it can cause rare, severe chicine, widely used as treatment rank test, 10.6; P = .001). RONA trial had 4,488 outpatient problems. in rheumatic disease, was first The researchers also reported the participants.) “This study differs “Overall, colchicine probably approved in the United States 60 percentage of patients who needed from ColCORONA in several ways works on the overabundant inflam- years ago. Researchers began to supplemental oxygen at day 2 as – the most important being that matory response to COVID, and it explore its potential as a COVID-19 67% with colchicine vs. 86% with it is a study of inpatients with may be that it can be combined with treatment in the early months of placebo, and at day 7 as 9% vs. 42% moderate to severe COVID (really other drugs that affect viral repli- the pandemic. (log rank test, 10.6; P = .001). Two mostly moderate),” Dr. Pillinger cation or promote immunity – e.g. On Jan. 25, an international team patients in the placebo group died, added. “ColCORONA is looking vaccines,” Dr. Pillinger said. “So far, it of researchers reported in a press both from ventilator-associated at a target audience that is much seems as if there is no safety prob- release – but not yet a published pa- pneumonia. larger – outpatients with mild to lem with combining colchicine with per – that the drug seemed to reduce As for side effects, new or wors- moderate COVID with risk factors other approaches, but this has not hospitalizations, mechanical ven- ened diarrhea was reported more of- for hospitalization. Both questions been studied in a rigorous manner.” tilation, and deaths in the ColCO- ten in the colchicine group (17% vs. are really important and certainly Moving forward, he said, the RONA trial. Earlier, a much-smaller, 6% with placebo), but the difference not mutually exclusive, since our drug’s very low price outside of the randomized, open-label, Greek was not statistically significant (P = care remains inadequate in both United States “could provide re- trial linked the drug to reduced .26), and diarrhea was controlled via venues. This study also adds value source-poor countries with a way to time to clinical deterioration and medication. in that several other studies have help keep patients out of precious hospital stay (JAMA Netw Open. The researchers reported that been conducted in hospital patients hospital beds – or help them go 2020;3[6]:e2013136. doi: 10.1001/jama- limitations include the exclusion cri- with enrollment criteria relatively home sooner once admitted.” networkopen.2020.13136). teria and their inability to link col- similar to this one, and all showed For now, however, “we need a The Brazilian authors of the new chicine to rates of ICU admissions benefit, but those were open-label large-scale inpatient study, and one study, led by Maria Isabel Lopes and death. or retrospective, and this is blinded is currently going on in Great Brit- of the University of São Paulo’s The drug appears to help patients and placebo-controlled.” ain. We also need validation of the Ribeirão Preto Medical School, with COVID-19, the study authors outpatient ColCORONA study, and randomly assigned 75 hospitalized wrote, by “inhibiting inflammasome, Use of colchicine in patients studies to look at whether colchicine patients with moderate to severe reducing neutrophil migration and with COVID-19 can work in conjunction with other COVID-19 to colchicine or placebo. activation, or preventing endothelial Should hospitalists turn to colchi- strategies,” he said. A total of 72 subjects completed the damage.” cine in patients with COVID-19? “I The study was funded by grants April-August 2020 trial: 36 received would rather that it still be used in from the São Paulo Research Foun- colchicine (typically 0.5 mg three A “well-conceived and well- the context of research until formal dation, Brazilian National Council times for 5 days, then 0.5 mg twice designed” study recommendations can be made by for Scientific and Technological daily for 5 days; doses were adjusted In an interview, NYU Langone bodies like the NIH and CDC,” Dr. Development, and CAPES Founda- in low-weight patients and those Health rheumatologist Michael H. Pillinger said. “But certainly, there tion. No disclosures are reported. with chronic kidney disease). The Pillinger, MD – an investigator with may be times when physicians feel Dr. Pillinger reports serving as an other 36 received the placebo. the ColCORONA trial – praised the compelled to treat patients off la- investigator for the ColCORONA (In the United States, 0.6-mg tab- Brazilian study. It “appears well-con- bel.” trial and receiving a unrelated inves- lets of generic colchicine cost as lit- ceived and well-designed, and was He cautioned, however, that col- tigator-initiated grant from Hikma, tle as $1.90 each with free coupons, enrolled at a rate that was greater chicine should never be used with a colchicine manufacturer. the-hospitalist.org | 15 | March 2021 COVID-19 Microthrombi, necrosis seen in hearts on autopsy

By Debra L. Beck imaging tests that will show these is very rare in COVID-19 autopsies. between those with and without focal areas of necrosis, but that Only three of 14 individuals (21.4%) necrosis. utopsies on patients who doesn’t mean it’s not there.” with evidence of myocyte necrosis Going one step further, Dr. Finn’s died from COVID-19 are The finding of myocyte necrosis showed evidence of acute MI, which team compared cardiac microthrom- providing important in about one-third of samples is Dr. Finn and colleagues define as an bi from their COVID-19–positive clues on how to treat the consistent with another study that area of necrosis at least 1 cm2 in size. autopsy cases with intramyocardial Adisease. In an analysis of 40 hearts showed that 30%-40% of patients The remaining 11 (78.6%) had only thromboemboli from COVID-19 cas- from COVID-19 patients who died hospitalized with COVID-19 have discrete areas of myocyte necrosis es. They also compared the samples early in the pandemic, myocyte ne- elevated troponins, noted Dr. Finn. (>20 necrotic myocytes with an area with aspirated thrombi obtained crosis was seen in 14 hearts, or 35%. The investigators were unable to of ≥0.05 mm2, but <1 cm2). during primary percutaneous coro- In the majority of these hearts, pa- obtain troponin levels on their pa- “This makes sense when we saw nary intervention from uninfected thologists found both small areas of what type of thrombus there was in and COVID-19–infected patients focal necrosis and cardiac thrombi, these cases; it wasn’t thrombus in ma- presenting with ST-segment eleva- most of which were microthrombi What we’re seeing … is jor epicardial vessels but microthombi tion MI (STEMI). in myocardial capillaries, arterioles, “ in small vessels,” said Dr. Finn. The autopsy-obtained micro- and small muscular cells. evidence of an immune- In those with necrosis, cardiac thrombi had significantly more In an interview, senior author mediated reaction. thrombi were present in 11 of 14 fibrin and terminal complement Aloke V. Finn, MD, CVPath Insti- ” (78.6%) cases, with 2 of 14 (14.2%) C5b-9 immunostaining than in- tute, Gaithersburg, Md., stressed having epicardial coronary artery tramyocardial thromboemboli from the importance of understand- tients, which could limit the clinical thrombi and 0 of 14 (64.3%) having COVID-19–negative subjects and ing what they saw, but also what translation of myocardial necrosis microthrombi in myocardial capil- than aspirated thrombi from either they didn’t see. detected at autopsy. laries, arterioles, and small muscular COVID-positive or COVID-negative “What we saw in the majority of Dr. Finn and colleagues pub- arteries. STEMI patients. patients with myocardial injury lished their findings online Further supporting the role of “Basically, what we’re seeing in were these small areas of infarct in Circulation (doi: 10.1161/CIRCULA- COVID-19–related hypercoagula- these thrombi is evidence of an im- and microthrombi in small ves- TIONAHA.120.051828). bility as the cause of myocardial mune-mediated reaction,” said Dr. sels. What we didn’t see was any The report is a follow-up to anoth- injury in many patients, the inves- Finn. “It is nonspecific but can also evidence of myocarditis or huge er just published by Dr. Finn’s group tigators noted that the incidence lead to coagulation problems.” infarcts inthe LAD artery,” he said. in the Journal of the American Col- of severe coronary artery disease “There is no test that will tell you lege of Cardiology (2021 Jan;77[3]314- (defined as >75% cross sectional nar- A version of this article first ap- there are microthrombi and no 25), which showed that myocarditis rowing) did not differ significantly peared on Medscape.com. Tough pain relief choices in the pandemic

By Allison Shelley decisions were driving the conversation,” Dr. and COX-2 enzymes in the body, which are crucial Wilen said. “Millions of people are taking NSAIDs for the generation of prostaglandins. These lipid ore people with fever and body aches are every day and clinical decisions about their care molecules play a role in inflammation and are turning to NSAIDs to ease symptoms, but shouldn’t be made on a hypothesis.” blocked by NSAIDs. Mthe drugs have come under new scrutiny One theory is that NSAIDs alter susceptibility The investigators found no evidence of a harm- as investigators work to determine whether they to infection by modifying ACE2. The drugs might ful effect of NSAIDs on COVID-19–related deaths; are a safe way to relieve the pain of COVID-19 also change the cell entry receptor for SARS- their results were published in the Annals of vaccination or symptoms of the disease. CoV-2, alter virus replication, or even modify the the Rheumatic Diseases (doi: 10.1136/annrheum- Early on in the pandemic, French health of- immune response. dis-2020-219517). ficials warned that NSAIDs, such as ibuprofen, British researchers, also questioning the safety The results are in line with a Danish study that could worsen coronavirus disease, and they rec- of NSAIDs in patients with COVID-19, delved into also showed no evidence of a higher risk for se- ommended switching to acetaminophen instead. National Health Service records to study two vere COVID-19 outcomes with NSAID use (PLoS The National Health Service in the United King- large groups of patients, some of whom were tak- One. 2020 Sep 8. doi: 10.1371/journal.pmed.1003308). dom followed with a similar recommendation ing the pain relievers. “It’s reassuring,” Dr. Wong said, “that patients for acetaminophen. “We were watching the controversy and the can safely continue treatment.” But the European Medicines Agency took a lack of evidence and wanted to contribute,” lead Dr. Wilen’s team found that SARS-CoV-2 infec- different approach, reporting “no scientific evi- investigator Angel Wong, PhD, from the London tion stimulated COX-2 expression in human and dence” that NSAIDs could worsen COVID-19. The School of Hygiene and Tropical Medicine, said in mice cells. However, suppression of COX-2 by two U.S. Food and Drug Administration also opted not an interview. And with nearly 11 million NSAID commonly used NSAIDs, ibuprofen and meloxi- to take a stance. prescriptions dispensed in primary care in En- cam, had no effect on ACE2 expression, viral en- The debate prompted discussion on social me- gland alone in the past 12 months, the inconsis- try, or viral replication. dia, and inspired Craig Wilen, MD, PhD, from Yale tency was concerning. Understanding the effect of NSAIDs on cy- University, New Haven, Conn., and associates The team compared COVID-19–related deaths in tokine production is critical, Dr. Wilen pointed to examine the effect of NSAIDs on COVID-19 two groups: one group of more than 700,000 peo- out, because they might be protective early in infection and immune response. Their findings ple taking NSAIDs, including patients with rheu- COVID-19 but pathologic at later stages. were published in the Journal of Virology (doi: matoid arthritis and osteoarthritis; and another of 10.1128/JVI.00014-21). almost 3.5 million people not on the medication. A version of this article first appeared on “It really bothered me that non–evidence-based NSAIDs work by inhibiting cyclooxygenase-1 Medscape.com. March 2021 | 16 | The Hospitalist COVID-19 Characteristics of kids in ICU for COVID-19

By Marcia Frellick More of the patients who required likely to experience progression to hospitalized children were Hispanic. intensive care had preexisting con- severe disease. They also found that 88.8% of the ittle has been known about ditions (58.2% vs. 44.3%; P = .01), the “The information may help physi- children older than 2 years who had children sick enough with most common of which was asthma. cians be more mindful of deteriora- been hospitalized with COVID-19 COVID-19 to require intensive For both the ICU patients and the tion in those patients and be more were overweight or obese, with a care because such patients non-ICU group, the most common aggressive in their management,” he BMI >25 kg/m2. Lare relatively few, but preliminary presenting symptom was fever. said. When children are brought to Jerry Zimmerman, MD, PhD, direc- data analyzed from a nationwide Symptoms that were more com- the emergency department with the tor of continuous quality improve- registry indicate that they are more mon among children needing ICU features this analysis highlights, he ment at Seattle Children’s Hospital, likely to be older, to be Black, and to care included nausea/vomiting said, “physicians should have a low said that he found it interesting that have asthma. (38.4% vs. 22.1%; P < .01), dyspnea threshold for treating or admitting in the Nadiger study, “All of the chil- Gastrointestinal distress is also (31.8% vs. 17.7%; P < .01), and abdomi- the patients.” dren with severe illness had MIS-C as more common in children with nal pain (25.2% vs. 14.1%; P < .01). Another study that was presented compared to adults, who typically are severe COVID-19, according to re- Significantly higher proportions on Feb. 3 in parallel with the registry critically ill with severe acute respira- search by Sandeep Tripathi, MD. Dr. of ICU patients had multisystem study described patterns of illness tory distress syndrome.” Dr. Zimmer- Tripathi, a pediatric intensivist and inflammatory syndrome of child- among 68 children hospitalized with man was not involved in either study. associate professor at the University hood (MIS-C) (44.2% vs. 6.8%; P < .01) COVID-19 in a tertiary-care pediatric He said that, although the high of Illinois at Peoria, presented the and acute kidney injury (9.34% vs. center. percentage of Hispanic patients in findings on Feb. 3 at the Society for 1.7%; P < .01). In that analysis, Meghana Nadiger, the hospitalized population may Critical Care Medicine 2021 Critical “The children who presented with MD, a critical care fellow with Nick- reflect the high percentage of His- Care Congress. MIS-C tended to be much sicker laus Children’s Hospital in Miami, panic children in the Miami area, it Results from the SCCM’s VIRUS: than children who present with found that all patients admitted may also reflect challenges of con- COVID-19 Registry, which involved just COVID,” Dr. Tripathi said in an to the pediatric ICU (n = 17) had trolling the disease in the Hispanic data from 49 sites, included 181 chil- interview. either MIS-C or severe illness and community. Such challenges might dren admitted to an intensive care In this analysis, among children in COVID-19–related Kawasaki-like include shortages of personal pro- unit between February and July ICUs with COVID, the mortality rate disease. tective equipment, poorer access to 2020. Those in the ICU were older was 4%, Dr. Tripathi said. The investigators also found that health care, and difficulty in social than patients who did not receive He said he hopes the information, the patients with serious illness distancing. care in the ICU (10 years vs. 3.67 which will be periodically published were more commonly adolescents years; P < .01) and were more likely with updated data, will raise aware- with elevated body mass index A version of this article first ap- to be Black (28.8% vs. 17.8%; P = .02). ness of which children might be (73%). In this study, 83.8% of the peared on Medscape.com.

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the-hospitalist.org | 17 | March 2021 TELEMEDICINE

Technology Continued from page 1 to be admitted to the hospital and can be safely ended up staying in hospital 1 extra night, while ing hospitals billions of dollars as well as leading followed up as an outpatient. The patient does the ER is getting backlogged waiting on discharg- to physician turnover: It could cost a hospital not require any further intervention and is dis- es. somewhere between $500,000 and $1 million to charged from the ED. These scenarios highlight some of the import- replace just one physician.3 Hence, the potential ant and prevalent pain points in health care as exists for a telehospitalist program in these set- Scenario 2 shown in Figure 1. tings to address this dilemma. Dr. N is a hospitalist in a rural hospital that does Scenario 1 and part of scenario 2 describe what Scenario 3 sheds light on the operational issues not have intensivist support at night. She works is called potentially avoidable interfacility trans- resulting in reduced patient satisfaction and lost 7 on/7 off and is on call 24/7 during her “on” week. fers. One study showed that around 8% of trans- revenues, both on the outpatient and inpatient Dr. N cannot be physically present in the hos- ferred patients (transferred from one ED to sides by cancellation of office visits and ED pital 24/7. She receives messages from the another) were discharged after ED evaluation backlog. Telemedicine use in these situations can hospital around the clock and feels that in the second hospital, meaning they could improve the turnaround time of physicians who this call schedule is no longer sustainable. have been retained locally without neces- can see some of those patients while staying at She doesn’t feel comfortable admitting sarily getting transferred if they could one location as they wait on other patients to patients in the ICU who come to the have been evaluated by the specialist.1 show up in the clinic or wait on the operation hospital at night without physically Access Transferring a patient from one room crew, or the procedure kit etcetera, hence seeing them and without ICU back- hospital to another isn’t as simple as improving the length of stay, ED throughput, up. Therefore, some of the patients picking up a person from point A patient satisfaction, and quality of care. This also who are sick enough to be admit- and dropping him off at point B. can improve overall workflow and the wellness of ted in ICU for closer monitoring Safety Rather it’s a very complicated, physicians. but can be potentially handled high-risk, capital-intensive, and One common outcome in all these scenarios in this rural hospital get time-consuming process that is emergency department overcrowding. There transferred out to a differ- not only leads to excessive have been multiple studies that suggest that ED ent hospital. Patient cost involved around trans- overcrowding can result in increased costs, lost Cost Dr. N has been asking satisfaction fer but also adds addition- revenues, and poor clinical outcomes, including the hospital to provide al stress and burden on delayed administration of antibiotics, delayed her intensivist back up the patient and family. administration of analgesics to suffering pa- at night and to give Waste of ED In these scenarios, tients, increased hospital length of stay, and even her some flexibility resource crowding having a specialist increased mortality.4-6 A crowded ED limits the in the call schedule. available via tele- ability of an institution to accept referrals and However, from consult could increases medicolegal risks. (See Figure 2.) hospital’s per- have eliminated Another study showed that a 1-hour reduction Physician Physician Quality of spective, the much of this in ED boarding time would result in over $9,000 Turnover Wellness care volume isn’t hassle and of additional revenue by reducing ambulance high enough cost, allow- diversion and the number of patients who left to hire a Figure 1: Pain points in health care ing the pa- without being seen.7 Another found that using dedicatedFigure 1: Pain Points in Healthcare tient to stay tele-emergency services can potentially result in nocturnist, and because the hospital is in the locally close to family and get access to necessary net savings of $3,823 per avoided transfer, while small rural area, it is having a hard time attract- medical expertise from any part of the country in accounting for the costs related to tele-emergen- ing more intensivists. After multiple conversa- a timely manner. cy technology, hospital revenues, and patient-as- tions between both parties, Dr. N finally resigns. Scenario 2 talks about the recruitment and re- sociated savings.8 tention challenges in low-volume, low-resourced There are other instances where gaps in staff- Scenario 3 locations because of call schedule and the lack of ing and cracks in workflow can have a negative Dr. A is a specialist who is on call covering dif- specialty support. It is reported in one study that impact on hospital operations. For example, the ferent hospitals and seeing patients in clinic. His 19% of common hospitalist admissions happen busier hospitals that do have a dedicated noctur- call is getting busier. He has received many new nist also struggle with physician retention, since consults and also has to follow up on his other When physicians are on vacation such hospitals have higher volumes and higher patients in hospital who he saw a day prior. cross-coverage needs, and are therefore hard to Dr. A started receiving many pages from the or“ there is surge capacity (that manage by just one single physician at night. hospitals – some of his patients and their families can be forecast by using various Since these are temporary surges, hiring another are anxiously waiting on him so that he can let full-time nocturnist is not a viable option for the them go home once he sees them, while some are predictive analytics models), hospitals and is considered an expense in many waiting to know what the next steps and plan of hospitals can make plans places. action are. He ends up canceling some of his clin- Similarly, during day shift, if a physician goes ic patients who had scheduled an appointment accordingly and make use of on vacation or there are surges in patient vol- with him 3, 4, or even 5 months ago. It’s already telemedicine services. umes, hiring a locum tenens hospitalist can be afternoon. ” an expensive option, since the cost also includes Dr. A now drives to one hospital, sees his new between 7:00 p.m. and 7:00 a.m. Eighty percent of travel and lodging. In many instances, hiring lo- consults, orders tests which may or may not get admissions occurred prior to midnight. Nonrural cum tenens in a given time frame is also not pos- results the same day, follows up on other pa- facilities averaged 6.69 hospitalist admissions sible, and it leaves the physicians short staffed, tients, reviews their test results, modifies treat- per night in that study, whereas rural facilities fueling both physicians’ and patients’ dissatisfac- ment plans for some while clearing other patients averaged 1.35 admissions.2 It’s like a double-edged tion and leading to other operational and safety for discharge. He then drives to the other hospital sword for such facilities. While having a dedicat- challenges, which are highlighted above. and follows the same process. Some of the pa- ed nocturnist is not a sustainable model for these Telemedicine services in these situations can tients aren’t happy because of the long wait, a hospitals, not having adequate support at night provide cross-coverage while nocturnists can few couldn’t arrange for the ride to go home and impacts physician wellness, which is already cost- focus on admissions and other acute issues. Also, March 2021 | 18 | The Hospitalist Scenario 1 Scenario 2 Scenario 3 TELEMEDICINE

Avoidable Transfer

Safety and Quality Delay in Care Delay in Care Issues Delay in Discharge Transport related Injuries Increased LOS Improve Access Increased Cost Physician Improve Improve Transportation Cost Turnover Reduced ED Throughput Physician Quality of Wellness Care

Redundant Test Increased Avoidable Days Increased Waste

Decreased Revenue Cancellation of Office Improve Improve Reduced Patient Retention Patient Visits Revenues Satisfaction Decreased Access Reduced Physician Impact on Physician Wellness Inpatient Satisfaction Telemedicine Programs

ED OVERCROWDING Reduce ED Reduce Cost Crowding Medical Errors Quality and Safety Issues Delay in Care including decreased administration of antibiotics and analgesics, increased ICU length of stay, increased mortality Ia

Reduce Z Reduce ED- Reduced Patient Length of ED transfers areer Stay . s Satisfaction r

Patient Leaving Without Being Seen D Patient Decreased Access Retention

Ambulance Diversion courtesy

Reduced Revenues mages I

FigureFigure 2: 2:Relationship Relationship of oflimited limited human human capital (physicians) capital (physicians) to pain points toof healthcare pain points of healthFigure 3: LikelyFigure Impact 3: Likely of Inpatient impact Telemedicine of inpatient Programs telemedicine on Healthcare programs Industry on health care care industry when physicians are on vacation or there is surge over a 15-month period from adopting a tele- Dr. Zia is an internal medicine board-certified capacity (that can be forecast by using various medicine model in the ICU, and a reduction in physician who has worked as a hospitalist in a predictive analytics models), hospitals can make 60-day readmissions by 2.1%.10 Similarly, another medically underserved area. She is a founder of a plans accordingly and make use of telemedicine study showed that one large health care center telemedicine company called Virtual Hospitalist. services. For example, Providence St. Joseph improved its direct contribution margins by 376% She has served in various leadership roles including Health reported improvement in timeliness and (from $7.9 million to $37.7 million) because of in- medical director of the department of hospital creased case volume, shorter lengths of stay, and medicine, medical staff president, and physician higher case revenue relative to direct costs. When adviser. She has a special interest in improving There are barriers to the combined with a logistics center, they reported access to health care in physician shortage areas improved contribution margins by 665% (from by leveraging technology. integration“ and implementation of $7.9 million to $60.6 million).11 inpatient telemedicine, including There are barriers to the integration and imple- References regulations, reimbursement, mentation of inpatient telemedicine, including 1. Kindermann DR et al. Emergency department transfers and regulations, reimbursement, physician licensing, transfer relationships in United States hospitals. Acad Emerg Med. 2015 Feb;22(2):157-65. physician licensing, adoption of adoption of technology, and trust among staff 2. Sanders RB et al. New hospital telemedicine services: Potential technology, and trust among staff and patients. However, I am cautiously optimis- market for a nighttime hospitalist service. Telemed J E Health. tic that increased use of telehealth during the 2014 Oct 1;20(10):902-8. and patients. COVID-19 pandemic has allowed patients, physi- 3. Shanafelt T et al. The business case for investing in physician ” cians, nurses, and health care workers and leaders well-being. JAMA Intern Med. 2017;177(12):1826-32. to gain experience with this technology, which 4. Pines JM et al. The impact of emergency department crowding measures on time to antibiotics for patients with community-ac- efficiency of care after implementation of a will help them gain confidence and reduce hes- quired pneumonia. Ann Emerg Med. 2007 Nov;50(5):510-6. telehospitalist program. Their 2-year study at a itation in adapting to this new digital platform. 5. Pines JM and Hollander JE. Emergency department crowding partner site showed a 59% improvement in pa- Ultimately, the extent to which telemedicine is is associated with poor care for patients with severe pain. Ann tients admitted prior to midnight, about $547,000 able to positively impact patient care will revolve Emerg Med. 2008 Jan;51(1):1-5. improvement in first-day revenue capture, an around overcoming these barriers, likely through 6. Chalfin DB et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care increase in total revenue days and comparable an evolution of both the technology itself and the unit. Crit Care Med. 2007 Jun;35(6):1477-83. patient experience scores, and a substantial in- attitudes and regulations surrounding it. 7. Pines JM et al. The financial consequences of lost demand crease in inpatient census and case mix index.9 I do not suggest that telemedicine should and reducing boarding in hospital emergency departments. Ann Other institutions have successfully imple- replace the in-person encounter, but it can be Emer Med. 2011 Oct;58(4):331-40. mented some inpatient telemedicine programs implemented and used successfully in addressing 8. Natafgi N et al. Using tele-emergency to avoid patient transfers in rural emergency. J Telemed Telecare. 2018 Apri;24(3):193-201. – such as telepsych, telestroke, and tele-ICU – and the pain points in U.S. health care. (See Figure 3.) 9. Providence.org/telehealthhospitalistcasestudy. some have also reported positive outcomes in To that end, the purpose of this article is to 10. Woodruff Health Sciences Center. CMS report: eICU program terms of patient satisfaction, improved access, spark discussion around different ways of im- reduced hospital stays, saved millions, eased provider shortage. reduced length of stay in the ED, and improved plementing telemedicine in inpatient settings 2017 Apr 5. quality metrics. Emory Healthcare in Atlanta to solve many of the challenges that health care 11. Lilly CM et al. ICU telemedicine program financial outcomes. reported $4.6 million savings in Medicare costs faces today. Chest. 2017 Feb;151(2):286-97. the-hospitalist.org | 19 | March 2021 SOCIETY NEWS New SHM Fellows: Class of 2021

he Society of Hospital Med- Douglas A. Dodds II, MD, FAAP, SFHM Thomas Pineo, DO, SFHM Hollie L. Hurner, PA-C, FHM icine has announced its 2021 Coley B. Duncan, MD, CPE, MMM, SFHM Mauricio Pinto, MD, SFHM Doug Hutcheon, MD, FHM class of Master Fellows, Se- Noah Finkel, MD, SFHM Lakmali C. Ranathunga, MBBS, SFHM Varalakshmi Janamanchi, MD, FHM Justin Glasgow, MD, PhD, SFHM Matthew Reuter, MD, SFHM Brian Keegan, MD, FACP, FHM nior Fellows, and Fellows in Taylor Goot, MD, SFHM Erik P. Rufa, MD, SFHM Qasim Khalil, MD, FHM THospital Medicine. Craig G. Gunderson, MD, SFHM Dipali Ruby Sahoo, DO, MBA, SFHM Irfana Khan, MD, FHM All Fellowship classes are listed in Alan Hall, MD, SFHM Chady Sarraf, MD, SFHM Muhammad O. Khan, MD, FAAFP, MBA, alphabetical order. Vivian Hamlett, MD, SFHM Suchita S. Sata, MD, SFHM FHM Kathrin Harrington, MD, SFHM Klint Schwenk, MD, FAAP, MBA, SFHM Smita Kohli, MD, FHM Master Fellows Class of 2021 Hossan Hassan, MD, SFHM Aaron M. Sebach, CRNP, DNP, MBA, Julie Kolinski, MD, FAAP, FHM Nasim Afsar, MD, MBA, MHM Anand D. Hongalgi, MD, FACP, SFHM PhD, SFHM Ewa Kontny, MD, FHM Shaun D. Frost, MD, MHM Akshata Hopkins, MD, FAAP, SFHM Kevin Sowti, MD, MBA, SFHM Sungmi Lian, MD, FHM Jeffrey L. Schnipper, MD, MPH, MHM Neelima Kamineni, MD, SFHM Joseph G. Surber, DO, FAAFP, SFHM Brian Lichtenstein, MD, FHM Sudheer R. Kantharajpur, MBBS, MD, Bright Thilagar, MD, SFHM Fernando Madero Gorostieta, MD, FHM MHA, SFHM Thomas S. Trawick Jr., MD, SFHM Vipul Mahajan, MD, FACP, FHM Senior Fellows Class of 2021 Prakash Karki, MD, SFHM Rehman Usmani, MD, SFHM Neetu Mahendraker, MD, FHM Akindele Adaramola, MD, MPH, SFHM Susrutha Kotwal, MD, SFHM Arash Velayati, MD, SFHM Victoria McCurry, MD, FHM Ramesh Adhikari, MD, SFHM Ethan Kuperman, MD, SFHM Jose A. Ventura, MD, FAAFP, SFHM Bridget McGrath, PA-C, FHM Pankaj Agrawal, MD, SFHM Rumman A. Langah, MD, FACP, SFHM Andre Wajner, MD, PhD, SFHM Evan Meadors, MD, FHM Robert L. 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Bhuma, MD, SFHM Anuj Mehta, MBBS, MD, MBA, SFHM Waqas Adeel, MD, FHM Ifedolapo S. Olanrewaju, MD, MBchB, FHM John P. Biebelhausen, MD, MBA, SFHM Prem Nair, MD, FACP, SFHM Rajender K. Agarwal, MD, MBA, MPH, FHM Mobolaji Olulade, MD, FHM Matthew T. Calestino, MD, FACP, SFHM Don J. Neer, MD, FACP, SFHM Khaalisha Ajala, MD, MBA, FHM Elizabeth H. Papetti, MBA, FHM Domingo Caparas Jr., MD, FAAFP, SFHM Shyam Odeti, MD, FAAFP, SFHM Faraz S. Alam, MD, FHM Love Patel, MBBS, FHM Darren Caudill, DO, FACP, SFHM Amy T. O’Linn, DO, SFHM Amee Amin, MD, FHM Kamakshya P. Patra, MD, MMM, FHM Julie M. Cernanec, MD, FAAP, SFHM Mihir Patel, MD, FACP, MBA, MPH, SFHM Muhammad W. Amir, MD, FACP, FHM Charles Pizanis, MD, FHM Will Cushing, PA-C, SFHM Kimberly S. Pedram, MD, FACP, SFHM Saba Asad, MD, FHM Rajat Prakash, MD, FHM Logan Atkins, MD, FHM Chris Pribula, MD, FHM Navneet Attri, MD, FHM Michael Puchaev, MD, FHM Jennifer Barnett, PA, FHM Ryan Punsalan, MD, FHM Karyn Baum, MD, FHM Bhavya Rajanna, MD, FHM Prabhjot Bedi, MD, FHM Miguel A. Ramirez, MD, FHM Nicolle R. Benz, DO, FHM Raymund Ramirez, MD, FHM Ricky Bhimani, MD, FHM Sandeep Randhawa, MBBS, FHM Stay Elizabeth Blankenship, PA-C, FHM Rohit Rattan, MD, FHM Rahul Borsadia, MD, FHM Denisha Powell Rawlings, MD, FHM Kalpana Chalasani, MD, FHM Praveen K. Reddy, MD, MPH, FHM Rani Chikkanna, MD, FHM Michael Ree, DO, MPH, FHM Curious Venu Chippa, MBBS, MD, FHM Patrick Rendon, MD, FHM Lisa M. Coontz, FNP, FHM David J. Rizk, MD, FAAFP, MBA, FHM SHM's Education app Christie Crawford, MD, FHM Michael Roberts, MD, FHM offers you lifelong Rene Daniel, MD, PhD, FHM Edwin Rosas, MD, FHM learning tools. Elda Dede, FHM Devjit Roy, MD, FHM Radha Denmark, CNP, FHM Sabyasachi Roy, MD, FHM Alvine N. Nwehla Desamours, PA-C, FHM Paul Sandroni, CMPE, MSM, FHM Satyendra Dhar, MD, FHM Vijairam Selvaraj, MD, MPH, FHM Manuel Jose Diaz, MD, FHM Megha Shah, MD, MMM, FHM Tiffany Egbe, MD, FHM Edie Shen, MD, FHM Chinwe Egbo, MD, FHM Gurpinder Singh, MD, FACP, FHM SHM members can earn up Study for the FPHM exam Access additional Mohammad A. Farkhondehpour, MD, Vishwas A. Singh, MD, FHM to 20 FREE CME and MOC anywhere, anytime. educational resources. credits per year through the FACP, FHM Karen Slatkovsky, MD, FHM Question of the Day. Shaheen Faruque, MBBS, FHM Sean M. Snyder, MD, FHM Chris W. Fellin, MD, FACP, FHM Jaclyn Spiegel, MD, FHM Juan Carlos Fuentes-Rosales, MD, FACP, Dale Stapler Jr., MD, FHM Download today MPH, FHM Christina E. Stovall, MD, FHM hospitalmedicine.org/eduapp Evelyn W. Gathecha, MD, FHM Daniel Suders, DO, FHM Benjamin P. Geisler, MD, FACP, MPH, FHM Clayton Swalstad, CMPE, MSM, FHM Matthew George, MD, FHM Harshil Swaminarayan, MD, FHM Not a member of SHM? Visit hospitalmedicine.org/join to become part of the hospital medicine movement. Sonia George, DO, FHM Keniesha Thompson, MD, FHM Mirna Giordano, MD, FHM Tet Toe, MD, FACP, FHM Rebecca Gomez, MD, FHM Christine Tsai, MD, FHM David Gonzales, MD, FHM Ajay Vaikuntam, MD, FHM Accreditation Statement The Society of Hospital Medicine is accredited by the Maria A. Guevara Hernandez, MD, FACP, Valerie Vaughn, MD, FHM Accreditation Council for Continuing Medical Education (ACCME) FHM Jane N. Wainaina, FACP, MBchB, FHM to provide continuing medical education for physicians. Shubhra Gupta, MBBS, FHM Neshahthari Wijeyakuhan, MD, FACP, FHM Rohini Harvey, MD, FHM Chia-Shing Yang, MD, FHM Allison Heinen, DO, FHM Jennifer Zagursky, MD, FHM March 2021 | 20 | The Hospitalist NEWS Study dispels ‘Lazarus phenomenon’

By Patrice Wendling countries to 75 seconds in infant The longest period of pulseless- organ, and we maybe should antici- heart donors at one Colorado hos- ness before the heart showed signs pate these things happening, where mong critically ill patients pital. of activity again was 4 minutes and at the end of life the heart may re- pulseless after planned Reports of patients recovering 20 seconds. “So that was a reassur- start for minutes.” withdrawal of life-sus- 10 minutes after pulselessness have ing number, because that’s within In this situation, it’s important to taining therapies, cardiac raised concerns about the Lazarus our 5-minute window that we cur- wait the 13 minutes for the heart to Aactivity restarted in 14% of cases, phenomenon, or autoresuscitation, rently use,” Dr. Dhanani said. stop again and then “wait another research shows. but are based in patients after car- Importantly, “nobody woke up, 5 minutes to make sure it doesn’t re- Reassuringly, most resumption of diopulmonary resuscitation was nobody ended up being resuscitated, start before determining death,” he heart activity happened in the first terminated. and all of these individuals died. said. “I think that’s where this study 1-2 minutes and most lasted 1 or 2 The present study, known as And I think that’s going to be very is going to now inform policy mak- seconds. Death Prediction and Physiology Af- helpful in this context,” he added. ers and guidelines, especially in the “The reason we wanted to look ter Removal of Therapy (DePParRT), In all, there were 77 cessations context of donations.” at death determination specifically enrolled patients at 20 intensive care and resumptions in 67 of the 480 The findings will be taken as is we know that the stories persist sites in Canada, the Czech Republic, patients. The median duration of strong support for the 5-minute about people coming back to life and the Netherlands, only if sur- resumed cardiac activity was 3.9 sec- window, said Robert Truog, MD, following death, and that’s not just rogate decision-makers agreed on onds but, notably, ranged from 1 sec- director of the Harvard Medical in the public, it’s in the medical com- withdrawal of life-sustaining mea- ond to 13 minutes and 14 seconds. School Center for Bioethics, Boston. munity as well,” lead author Sonny sures without CPR and imminent “Though surprising, I think may- Dhanani, MD, of Children’s Hospital death was anticipated. be not unreasonable,” observed Dr. A version of this article first ap- of Eastern Ontario, Ottawa, said. As reported Jan. 28 in the New Dhanani. “The heart is a very robust peared on Medscape.com. “We thought that, if we provided England Journal of Medicine scientific evidence of whether this (2021;384:345-52), physicians observed happened or not, we might dispel resumption of circulation or cardi- some myths and misunderstanding, ac activity prospectively in 1% of which would hopefully promote or- 631 patients based on bedside ECG, gan donation.” arterial pressure catheter monitors, About 70% of organ donations palpated arterial pulse, breaths, or occur after brain death, but an in- physical movements. creasing number follow circulatory A retrospective review of data es determination of death, he noted. from 480 patients with complete g ma Most protocols recommend 5 min- ECG and arterial waveforms and at I etty

utes of apnea and pulselessness by least 5 minutes of continuous wave- /G arterial catheter monitor before form monitoring after pulselessness poloskun declaring death. But practices vary showed resumption of cardiac activ- - from 10 minutes in some European ity in 14% of patients. enot Ceftolozane-tazobactam found effective in critically ill

By Mark S. Lesney, PhD complicated with sepsis (49.5%) or septic shock able clinical response, which was defined as a res- (45.3%), and bacteremia (10.5%). olution of presenting symptoms and signs of the eftolozane-tazobactam (C/T) was found A total of 46 episodes were treated with high- infection by the end of therapy. Microbiological effective for treating pneumonia, intra-ab- dose C/T (3 g every 8 hours), and 38 episodes were eradication was documented in 42.1% (40/95) of Cdominal infections, and urinary tract treated with standard dosage (1.5 g every 8 hours). the episodes. However, the global ICU mortality infections caused by Pseudomonas aeruginosa, Almost half (44.2%) of the patients were treated was still high, at 36.5%, with mortality mainly re- according to the results of a retrospective, obser- with C/T monotherapy, and the remaining group lated to the severity of the infection. vational study conducted in critically ill patients. received combination therapy with other antibi- Mortality was found to be significantly cor- The multicenter, observational study assessed otics, according to the researchers. related with the Charlson Comorbidity Index (5.7 95 patients who received C/T for P. aerugino- The primary outcome of the study was to as- vs. 4.3; P = .04) and the need for life-supporting sa serious infections, according to a report sess the efficacy and toxicity of C/T therapy. The therapies such as vasopressors (66.6% vs. 46.9%; published online in the International Journal secondary outcome was to evaluate the risk fac- P = .03) and renal replacement therapy (46.6% vs. of Antimicrobial Agents (doi: 10.1016/j.ijantimi- tors for all-cause 30-day mortality from the first 18.1%; P = .002). In addition, mortality was signifi- cag.2020.106270). day of therapy. cantly associated with a higher sequential organ C/T is a novel beta-lactam/beta-lactamase–in- Most of the infections (93.7%) were severe and failure assessment (SOFA) score during C/T thera- hibitor combination active against gram-negative included the presence of sepsis (49.5%) or septic py (SOFA1, SOFA 3, and SOFA 7; P < .001). bacteria including P. aeruginosa. This paper pres- shock (45.3%). Bacteremia was observed in 15 “The lack of a positive effect from combined ents the largest real-life experience published on (15.7%) patients. Bacteremia was secondary to therapy suggests that C/T monotherapy may be C/T therapy for treating serious P. aeruginosa nosocomial pneumonia in eight cases, catheter in- sufficient for treating P. aeruginosa isolates that infections according to researchers Barbara Bal- fection in five, urinary tract infection in one, and are susceptible to that agent,” the researchers sug- andin, MD, of the Hospital Universitario Puerta soft tissue infection in one. According to their gested. “This study shows that C/T appears to be de Hierro, Majadahonda, Spain, and colleagues. susceptibility profiles, 46 (48.4%) of the strains a suitable, effective, and safe drug for treating se- The main infections treated were nosocomial were classified as extensively drug-resistant vere infections due to P. aeruginosa, highlighting pneumonia (56.2%), intra-abdominal infection (XDR) P. aeruginosa and 35 (36.5%) were multi- nosocomial pneumonia caused by MDR/XDR P. (10.5%), tracheobronchitis (8.4%), and urinary drug-resistant (MDR) P. aeruginosa. aeruginosa in ICU patients with multiple comor- tract infection (6.3%). Most infections were Sixty-eight (71.6%) patients presented a favor- bidities … and needing life-sustaining therapies.” the-hospitalist.org | 21 | March 2021 NEWS Dexmedetomidine, propofol similar in ventilated adults with sepsis Results confirm current guidelines

By Marcia Frellick by the Society of Critical Care Med- dard-of-care agent – was not clear. interview that she is impressed with icine. Researchers discovered that, the study design and said the results utcomes for mechani- Lead author Christopher G. “despite theoretical advantages give definitive confirmation of cur- cally ventilated adults Hughes, MD, chief of anesthesiology of dexmedetomidine, that did not rent guidelines. with sepsis receiving in critical care medicine at Van- translate into the clinical realm “The rigorous study design is light sedation were the derbilt University Medical Center, when patients were receiving up-to- different from previous compara- Osame whether they received dexme- Nashville, Tenn., told this news or- date sedation care,” he said. tive-effectiveness trials on the drugs detomidine or propofol, according ganization that previous trials have Guidelines currently recommend in this group of patients,” she said. to data from a 13-center randomized, either drug when light sedation is As to what clinicians think about controlled, double-blind study pub- needed for adults on ventilators. when choosing one over the other, lished online Feb. 2 in the New En- It’s important that we The drugs are different in the way Dr. Kane-Gill said that with dex- gland Journal of Medicine (2021. doi: did“ not find a difference in they affect arousability, immunity, medetomidine, there may be more 10.1056/NEJMoa2024922). either the main cognition and inflammation, but a comparison concern about bradycardia, whereas Dexmedetomidine (an alpha2-re- of outcomes in adults with sepsis – propofol may be associated with ceptor agonist) and propofol (a or the other cognitive in terms of days alive without brain concerns of high triglycerides. gamma-aminobutyric acid [GABA]– scores between the two dysfunction – had never before been “There may be more comfort with receptor agonist) have similar safety performed in a randomized, con- use of propofol,” and dexmedetomi- profiles. agents. trolled trial. dine can be more costly than propo- The findings from the Maximizing ” In this trial, 422 patients were fol, she added, so those could be the Efficacy of Sedation and Reduc- shown that dexmedetomidine is randomly assigned to receive either ing Neurological Dysfunction and likely superior to benzodiazepines, dexmedetomidine (0.15-1.5 mcg/kg COVID patients would Mortality in Septic Patients with especially in improving delirium, of body weight per hour) or propo- Acute Respiratory Failure (MENDS2) coma, and time on a ventilator. Until fol (5-50 mcg/kg per minute). Doses “be the type of patients we trial were published on an acceler- this trial, dexmedetomidine’s perfor- were adjusted by bedside nurses enrolled in this study, with ated schedule to coincide with the mance in a head-to-head comparison (who were unblinded) to achieve Critical Care Congress sponsored with propofol – the current stan- specified sedation goals. the high severity of illness The primary outcome was days and the infection on top of alive without delirium or coma in the 14 days of intervention. The research- being on a ventilator. ers found no difference between the ” two groups (adjusted median, 10.7 vs. factors in decision-making as well. 10.8 days; odds ratio, 0.96; 95% confi- Dr. Hughes said this study offers dence interval, 0.74-1.26). a robust look at cognition after the I value my SHM There was also little difference in ICU, which is getting increasing at- membership because… three secondary outcomes: ventila- tention. tor-free days (adjusted median, 23.7 “We had a much more extensive vs. 24.0 days; OR, 0.98); death at 90 cognitive battery we performed on days (38% vs. 39%; hazard ratio, 1.06); patients than in previous studies,” or the Telephone Interview for Cog- Dr. Hughes said, “and it’s important It has been a huge help to my nitive Status (TICS) Total score mea- that we did not find a difference suring global cognition at 6 months in either the main cognition or the career, providing me with the (adjusted median score, 40.9 vs. 41.4; other cognitive scores between the OR, 0.94). two agents.” opportunity to educate myself Dr. Hughes said the researchers Enrollment was completed be- and my administrative partners “specifically went with a high-sever- fore the pandemic, but he said the ity-of-illness cohort that would be results are relevant to COVID-19 around all things hospital most likely to see an effect.” patients because those who are on He said the drugs have different ventilators in the ICU are in a sick, medicine – from national quality adverse-effect profiles, so a clinician septic-shock cohort. and safety initiatives to business can consider those in deciding be- “COVID patients would be the tween the two, but either should be type of patients we enrolled in this and finance. fine at baseline. study,” he said, “with the high severi- The researchers note that at ty of illness and the infection on top least 20 million patients each year of being on a ventilator. We know Carole Nwelue, MD, FACP, SFHM develop sepsis with severe organ that sedation regimens have been dysfunction, and more than 20% re- challenging in COVID patients.” ceive mechanical ventilation. Dr. Hughes and Dr. Kane-Gill have disclosed no relevant financial rela- Discover what opportunities await you. Confirmation of current tionships. hospitalmedicine.org/join guidelines Sandra Kane-Gill, PharmD, pres- A version of this article first ap- ident-elect of SCCM, stated in an peared on Medscape.com. March 2021 | 22 | The Hospitalist CLINICAL

In the Literature Clinician reviews of HM-centric research

By Haley Briggs, PA-C; Khooshbu Dayton, MD; Reem Hanna, MD; Mark Kissler, MD; Maria Klimenko, MD; Robert Metter, MD; Joshua Raines, MD; Alexander Sun, MD; Michael Tozier, MD; Bethany Zablotsky, PA-C Division of Hospital Medicine, University of Colorado School of Medicine, Aurora

IN THIS ISSUE CITATION: The WHO REACT Work- Generalization may be limited in ing Group. Association between some hospitalized patients since 1. Systemic corticosteroids associated with lower mortality in critically ill administration of systemic corti- only two centers participated and patients with COVID-19 costeroids and mortality among patients with refractory shock, 2. Over-the-scope clip an effective initial treatment for severe nonvariceal critically ill patients with COVID-19: severe hemorrhage (transfusion of upper GI bleeding A meta-analysis. JAMA Intern Med. greater than 6 3. Drug-coated balloon angioplasty superior to standard angioplasty for 2020;324(13):1330-41. doi: 10.1001/ units RBCs), or dysfunctional dialysis AVFs jama.2020.17023. malignancy with 4. Oral fluoxetine does not improve functional outcome after acute stroke Ms. Briggs is a clinical instructor in less than 30-day 5. Empagliflozin reduces HF hospitalizations in HFrEF patients with or the division of hospital medicine at predicted survival without diabetes the University of Colorado, Aurora. were excluded. 6. Postoperative atrial fibrillation is associated with stroke risk BOTTOM LINE: 7. Ciprofloxacin not effective in treatment of incompletely recovered Initial treatment COPD exacerbations By Khooshbu Dayton, MD with OTSC re- 8. Morphine is safe and may improve health status in patients with COPD Over-the-scope clip an duced rates of Dr. Dayton 9. Low-dose edoxaban cuts stroke incidence in elderly patients with Afib 2effective initial treatment for rebleeding, severe and bleeding risk factors severe non-variceal upper GI complications, and RBC transfu- 10. Genotype-guided CYP2Y12-inhibitor selection and ischemic events in bleeding sions, compared with standard post-PCI patients endoscopic hemostasis, in patients CLINICAL QUESTION: Do over-the- with severe NVUGIBs. Patients with scope clips (OTSC) improve patient major SRH (active bleed, visible ves- outcomes, compared with standard sel, adherent clot) benefitted signifi- By Haley Briggs, PA-C SYNOPSIS: Seven trials met criteria hemostasis in initial endoscopic cantly from OTSC; however, those Systemic corticosteroids to be included in the meta-analy- treatment of severe nonvarice- with lesser SRH (oozing, flat spots) 1associated with lower sis. Of a total of 1,703 patients, 678 al upper gastrointestinal bleeds did not benefit. mortality in critically ill patients were randomized to corticosteroids (NVUGIB)? CITATION: Jensen DM et al. Ran- with COVID-19 and 1,025 to usual care or placebo. BACKGROUND: Recurrent gastro- domized controlled trial of over- Median age was 60 years, and 29% intestinal bleeding is common in the-scope clip as initial treatment CLINICAL QUESTION: Is there an of patients were women. “Critically NVUGIBs (bleeding ulcers or Dieu- of severe non-variceal upper association between the use of sys- ill” varied from a 6 L/min oxygen lafoy lesions) and can cause signifi- gastrointestinal bleeding. Clin temic corticosteroids and decreased requirement to cant morbidity and mortality. There Gastroenterol Hepatol. 2020 Aug mortality among critically ill pa- need for intuba- have been no randomized controlled 20:S1542-3565(20)31155-1. doi: 10.1016/j. tients with coronavirus disease 2019 tion/mechanical trials comparing initial treatment cgh.2020.08.046. (COVID-19)? ventilation. The with OTSC vs. standard endoscopic Dr. Dayton is assistant professor in BACKGROUND: Amid an ongoing primary outcome treatments. the division of hospital medicine at global pandemic, there is increased was 28-day all- STUDY DESIGN: Randomized, dou- the University of Colorado, Aurora. need for safe and effective therapies cause mortality. ble-blind, controlled trial. to treat COVID-19. Corticosteroids There were 222 SETTING: Two academic medical are an attractive putative therapy deaths (32.7%) centers. By Reem Hanna, MD since they are affordable, widely Ms. Briggs among patients SYNOPSIS: Of patients meeting Drug-coated balloon available, and generally well-toler- randomized clinical and endoscopic parameters 3angioplasty superior to ated. This meta-analysis is the first to corticosteroids and 425 deaths (ulcers, Dieulafoy lesions, or stig- standard angioplasty for to address their use in critically ill (41.4%) among patients randomized mata of recent hemorrhage [SRH]), dysfunctional dialysis AVFs patients with COVID-19. to usual care or placebo (odds ratio, 53 were randomized to OTSC or STUDY DESIGN: Prospective me- 0.66; 95% confidence interval, 0.53- standard endoscopic hemostasis CLINICAL QUESTION: Does ta-analysis of randomly controlled 0.82; P less than .001). arms. Patients had similar baseline drug-coated balloon angioplasty trials. Limitations include inconsisten- risk factors and were followed pro- have better outcomes than standard SETTING: Investigators systemati- cies between trials based on vary- spectively for 30 days. There was angioplasty in vascular stenosis of cally searched ClinicalTrials.org, the ing days of reported mortality and a significant reduction in rate of arteriovenous fistulas? Chinese Clinical Trial Registry, the inconsistent reporting of adverse rebleeding in the OTSC vs. standard BACKGROUND: Vascular stenosis EU Clinical Trials Register, and the events. Furthermore, the analysis endoscopic hemostasis group (4% of arteriovenous fistulas (AVFs) WHO Rapid Evidence Appraisal for could not assess the optimal dose vs. 29%). Number needed to treat is common and can lead to inade- COVID-19 Therapies (REACT) Work- and duration of treatment. was 4. There was also a lower rate of quate hemodialysis. With standard ing Group to identify open prospec- BOTTOM LINE: Administration of severe complications and red blood angioplasty, about 50% of patients tive, randomized, controlled studies systemic corticosteroids is associat- cell (RBC) transfusions in the OTSC require repeat intervention within 6 evaluating the therapeutic efficacy ed with a reduced 28-day all-cause group, compared with the control months. Paclitaxel drug-coated bal- of corticosteroids in treating criti- mortality in critically ill patients group (0% vs. 14%). All patients with loon angioplasty has been shown to cally ill patients with COVID-19. with COVID-19. rebleeding had SRH on endoscopy. Continued on following page the-hospitalist.org |3 2 | March 2021 CLINICAL | In the Literature

Continued from previous page Among patients with heart failure with reduced SHORT TAKES be effective and safe in the femoral ejection“ fraction already on recommended goal-directed artery, but its efficacy and safety in Bedside optic nerve patients with dysfunctional fistulas therapy, adding empagliflozin resulted in a lower risk ultrasonography for has yet to be determined. of hospitalization for HF, regardless of the presence of diagnosing increased STUDY DESIGN: Prospective, sin- intracranial pressure gle-blind, randomized, controlled diabetes. A systematic review and meta- trial. ” analysis of optic nerve ultraso- SETTING: Twenty-nine sites in the stroke. Several prior studies, in- By Maria Klimenko, MD nography found that a normal United States, Japan, and New Zea- cluding a 2011 randomized trial Empagliflozin reduces HF optic nerve sheath diameter (less land. (FLAME), reported improved out- 5 hospitalizations in HFrEF than 5.0 mm) had a high sensitiv- SYNOPSIS: Of participants with comes with SSRIs. AFFINITY is patients with or without ity and low negative likelihood new or restenotic lesions in native part of a three-trial effort (includ- diabetes ratio, which may help rule out upper-extremity AVFs, 330 were ing FOCUS and EFFECTS) to better increased intracranial pressure enrolled. Following angioplasty, characterize the role of SSRIs after CLINICAL QUESTION: Does em- (ICP). An elevated diameter 170 patients were treated with a acute stroke. pagliflozin reduce the risk of heart (greater than or equal to 5.0 mm) drug-coated STUDY DESIGN: Randomized, dou- failure events in patients with had a high specificity and pos- balloon, and 160 ble-blind, placebo-controlled trial. HFrEF regardless itive likelihood ratio indicating were treated with SETTING: Forty-three hospital of diabetes sta- increased ICP and need for addi- a standard bal- stroke units in Australia, New Zea- tus? tional confirmatory testing. loon. During the land, and Vietnam. BACKGROUND: CITATION: Koziarz A et al. Bed- 6 months after SYNOPSIS: In a sample of 1,280 The recent Da- side optic nerve ultrasonography index procedure, poststroke patients, 20 mg fluox- pagliflozin in for diagnosing increased intra- target-lesion etine daily for 6 months did not Patients With cranial pressure: a systematic primary patency improve disability scores, as mea- Heart Failure review and meta-analysis. Ann Dr. Hanna was maintained sured by the modified Rankin Scale and Reduced Intern Med. 2019 Dec 17;171(12):896- in 82.2% (125 of (mRS), when compared with pla- Dr. Klimenko Ejection Fraction 905. doi: 10.7326/M19-0812. 152) in the drug-coated balloon cebo. Importantly, patients in the (DAPA-HF) trial group versus 59.5% (88 of 148) in the treatment group also had signifi- showed that dapagliflozin reduces standard-balloon group (P less than cantly increased risk of falls, bone absolute risk for heart failure (HF) white; however, these demographics .001). Serious adverse events within fracture, and seizures. hospitalization and cardiovascular are similar to study populations in 30 days were compared, and the Strengths of the trial include death among individuals with heart other trials. drug-coated balloon was found to be ethnic diversity and adherence to failure with reduced ejection frac- BOTTOM LINE: Among patients noninferior to the standard balloon the assigned groups. The study was tion (HFrEF), regardless of the pres- with HFrEF already on recommend- (4.2% [7 of 166] and 4.4% [7 of 158], slightly under- ence of diabetes. The study reviewed ed goal-directed therapy, adding em- respectively; P = .002 for noninferi- powered (data here is the second largest trial that pagliflozin resulted in a lower risk of ority). was calculated evaluates the effect of sodium glu- hospitalization for HF, regardless of Limitations of this study include for 1,256 patients, cose cotransporter-2 (SGLT2) inhibi- the presence of diabetes. the lack of a double-blind trial de- with plan for tors in patients with HFrEF, with or CITATION: Packer M et al. Cardio- sign, industry sponsorship, and a 1,440 based on without diabetes. vascular and renal outcomes with short follow-up period. power analysis). STUDY DESIGN: Double-blind, ran- empagliflozin in heart failure. N BOTTOM LINE: Drug-coated bal- The results of domized, placebo-controlled trial. Engl J Med. 2020 Oct 8;383(15):1413-24. loon angioplasty is superior to this trial are con- SETTING: International, multicenter doi: 10.1056/NEJMoa2022190. standard angioplasty in achieving sistent with those Dr. Kissler trial. Dr. Klimenko is assistant professor in and maintaining patency of stenotic seen in FOCUS SYNOPSIS: Of patients with class the division of hospital medicine at or restenotic arteriovenous fistulas and EFFECTS and with a Cochrane II-IV HF and ejection fraction less the University of Colorado, Aurora. without an increase in serious ad- review of controlled trials of fluox- than 40% and already on recom- verse events. etine following acute stroke. mended goal-directed therapy, with CITATION: Lookstein RA et al. The question remains whether pa- or without diabetes, 3,730 received By Robert Metter, MD Drug-coated balloons for dysfunc- tients with more severe stroke may empagliflozin (10 mg daily) or placebo Postoperative atrial tional dialysis arteriovenous fistu- still derive some benefit from SSRIs, and were followed for a median of 16 6 fibrillation is associated with las. N Engl J Med. 2020;383(8):733-42. as patients in AFFINITY had lower months. Fewer patients on empagli- stroke risk doi: 10.1056/ NEJMoa1914617. NIH stroke scale scores than those flozin required hospitalization for Dr. Hanna is assistant professor in the in the FLAME trial. HF, compared with placebo (13.2% CLINICAL QUESTION: Is new-onset division of hospital medicine at the BOTTOM LINE: When added to vs. 18.3%, number needed to treat 19). atrial fibrillation in the postoper- University of Colorado, Aurora. multidisciplinary stroke care, daily There was no significant difference ative setting associated with in- fluoxetine does not significantly im- in cardiovascular death. Annual rate creased risk of stroke? prove functional status at 6 months of decline in estimated glomerular BACKGROUND: New-onset post- By Mark Kissler, MD and is associated with increased ad- filtration rate was also slower in the operative atrial fibrillation (AFib) is verse events. empagliflozin group (–0.55 vs. –2.28 often treated as a temporary phe- Oral fluoxetine does not 2 4 improve functional outcome CITATION: Hankey GJ et al. Safety mL/min per 1.73 m of BSA/year). The nomenon because of postoperative after acute stroke and efficacy of fluoxetine on func- effect of empagliflozin was consistent stress and inflammation. It is un- tional outcome after acute stroke in patients, regardless of the presence known whether it is associated with CLINICAL QUESTION: Does daily (AFFINITY): A randomised, dou- of diabetes. Uncomplicated genital increased risk of subsequent AFib oral fluoxetine decrease disability at ble-blind, placebo-controlled trial. tract infection was more frequent and/or stroke. 6 months after acute stroke? Lancet Nuerol. 2020;19:651-60. doi: with empagliflozin (1.7% vs 0.6%). STUDY DESIGN: Retrospective co- BACKGROUND: Currently, there 10.1016/S1474-4422(20)30207-6. Limitations of this study include hort study. are conflicting data about the role Dr. Kissler is a clinical instructor in the that it was industry sponsored and SETTING: Postoperative patients in of selective serotonin reuptake division of hospital medicine at the that only 24% of the study partic- Olmsted County, Minn. inhibitors (SSRIs) following acute University of Colorado, Aurora. ipants were women and 70% were SYNOPSIS: Of patients who had March 2021 |4 2 | The Hospitalist CLINICAL | In the Literature

SHORT TAKES In patients with incompletely recovered COPD incompletely recovered COPD exac- exacerbations,“ the addition of ciprofloxacin at 14 days erbations, the addition of ciproflox- SARS-CoV-2 RNA presence in acin at 14 days did not impact the renal tissue associated with did not impact the time to next exacerbation. time to next exacerbation. AKI and reduced survival ” CITATION: Ritchie AI et al. Targeted In a postmortem series of 63 pa- retreatment of incompletely recov- tients with SARS-CoV-2 respira- transient arrhythmia limited to the SETTING: Four academic hospitals ered chronic obstructive pulmonary tory infection, SARS-CoV-2 viral postoperative period and is associ- in the United Kingdom. disease exacerbations with cipro- RNA was detected in a higher ated with increased risk of stroke SYNOPSIS: Of patients with a re- floxacin: A double-blind, random- percentage of patients with acute and TIA. Further studies are needed cent COPD exacerbation who had ized, placebo-controlled, multicenter, kidney injury than without and to determine persistent symptoms or a CRP great- phase 3 clinical trial. American Jour- was associated with a reduction whether or not er than 8 mg/L, 144 were randomized nal of Respiratory and Critical Care in survival time. anticoagulation is to ciprofloxacin vs. placebo. Inclu- Medicine. 2020;202(4):549-557.doi: CITATION: Braun F et al. SARS- effective in reduc- sion criteria included patients older 10.1164/rccm.201910-2058oc. CoV-2 renal tropism associates ing this risk. than 45 years of age and GOLD Dr. Raines is clinical instructor in the with acute kidney injury. Lan- BOTTOM LINE: stage II-IV COPD. There was no division of hospital medicine at the cet. 2020 Aug 29;396:598-98. doi: New-onset AFib significant difference between the University of Colorado, Aurora. 10.1016/S0140-6736(20)31759-1. after noncar- groups in the primary outcome of diac surgery is time to next exacerbation within a Aspirin reduces incidence of associated with Dr. Metter 90-day follow-up. Prespecified sec- By Alexander Sun, MD colorectal cancer in Lynch increased risk of ondary outcomes, including median Morphine is safe and may Syndrome stroke or TIA. time to exacerbation, duration of 8 improve health status in A 10-year follow-up of patients CITATION: Siontis KC et al. As- symptoms, changes in spirometry, patients with COPD with Lynch syndrome ran- sociation of new-onset atrial quality of life, and CRP levels, also domized to aspirin vs. placebo fibrillation after noncardiac sur- showed no difference. The lack of CLINICAL QUESTION: Does low- showed a 4% absolute risk re- gery with subsequent stroke and improvement with ciprofloxacin dose, sustained-release morphine duction of colorectal cancer, transient ischemic attack. JAMA. suggests that persistent symptoms safely improve disease-specific although there was no reduction 2020 Sep 1;324(9):871-8. doi: 10.1001/ and/or CRP elevations are driven by health status in chronic obstructive in other cancers associated with jama.2020.12518 airway inflammation, rather than pulmonary disease patients with Lynch Syndrome. Dr. Metter is assistant professor in the bacterial infection. The small num- chronic breathlessness? CITATION: Burn J et al. Can- division of hospital medicine at the ber of enrolled patients does raise BACKGROUND: Breathlessness is cer prevention with aspirin in University of Colorado, Aurora. the possibility of a type II error, or common in chronic obstructive pul- hereditary colorectal cancer failure to reject the null hypothesis. monary disease (COPD) and can have (Lynch syndrome), 10-year fol- BOTTOM LINE: In patients with Continued on following page low-up and registry-based 20- By Joshua Raines, MD year data in the CAPP2 study: Ciprofloxacin not effective A double- blind, randomised, 7 in treatment of incompletely placebo- controlled trial. The Lan- recovered COPD exacerbations cet. 2020;395(10240):1855-63. doi: Advancing the practice of good medicine. 10.1016/s0140-6736(20)30366-4. CLINICAL QUESTION: In patients CITATION: Koziarz A et al. Bed- with incompletely recovered chronic NOW AND FOREVER. side optic nerve ultrasonography obstructive pulmonary disease exac- We’re taking the mal out of malpractice insurance. for diagnosing increased intra- erbations, does additional treatment However you practice in today’s ever-changing healthcare environment, cranial pressure: a systematic with ciprofloxacin impact time to we’ll be there for you with expert guidance, resources, and coverage. It’s not lip service. It’s in our DNA to continually evolve and support review and meta-analysis. Ann next exacerbation? the practice of good medicine in every way. That’s malpractice Intern Med. 2019 Dec 17;171(12):896- BACKGROUND: Chronic obstruc- insurance without the mal. Join us at thedoctors.com 905. doi: 10.7326/M19-0812. tive pulmonary disease (COPD) exacerbations are associated with accelerated lung function decline new-onset AFib within 30 days of and increased undergoing noncardiac surgery mortality. By 5 under general anesthesia, 452 were weeks after ex- matched 1:1 with non-AFib controls. acerbation, 25% Type of surgery was included in of patients do match criteria. Mean follow-up peri- not recover to od was 5.4 years (interquartile range, baseline, and by 1.4-9.2). Hazard ratio for ischemic 3 months, 33% do stroke or transient ischemic attack not recover. An el- (TIA) for patients with postoperative evated c-reactive Dr. Raines AFib, compared with those without, protein (CRP) at was 2.69 (1.35-5.37); for subsequent 14 days after exacerbation has been AFib, the hazard ratio was 7.94 (4.85- associated with increased risk of re-

12.98). Of note, CHADS2VASC scores current exacerbations. This finding Exclusively endorsed by were significantly higher in new-on- suggests that unresolved bacterial set postoperative AFiv patients vs. infections may contribute to pro- those who did not develop postoper- longed symptoms, prompting the ® ative AFib (median 4 vs. 3 [IQR, 2-5]; hypothesis that additional antibiot- P less than .001). ics may provide a benefit. This study suggests that postop- STUDY DESIGN: Double-blind, ran- erative AFib may not simply be a domized, placebo-controlled trial. the-hospitalist.org 7843_SHM_Hospitalist_SP_Mar2021_v2.indd | 25 | March 2021 1 1/27/21 11:20 AM CLINICAL | In the Literature

Continued from previous page SHORT TAKES a detrimental effect on health status. Post-PCI genotype-guided therapy for CYP2C19 loss- Low-dose opioids have been used for of-function“ carriers may not be more effective than Cancer is rare in primary care treatment of chronic breathlessness, patients with unexpected but prior studies were limited by conventional therapy with clopidogrel at preventing weight loss sample size or duration, leaving con- recurrent ischemic events. A retrospective study of 63,973 cerns about safety and efficacy. ” adults with unexpected weight STUDY DESIGN: Randomized, dou- loss in primary care offices found ble-blinded, placebo-controlled trial. stroke prevention in elderly patients BOTTOM LINE: In this study of that only 1.4% were subsequently SETTING: A pulmonary rehabilita- with atrial fibrillation who would patients older than 80 years with diagnosed with cancer within 6 tion center and two hospitals in the otherwise not be prescribed antico- AFib and higher bleeding risk, for months. Patients with greater Netherlands. agulation because of bleeding risk? every 100 patients treated with low- than 3% risk of cancer warrant- SYNOPSIS: Of patients with COPD BACKGROUND: In patients with dose edoxaban, 4 fewer patients ing further investigation includ- who had completed pulmonary reha- nonvalvular atrial fibrillation (AFib), experienced ischemic strokes and ed men older than 50 years with bilitation and had modified Medical age is associated with increased 1 additional patient experienced a smoking history and patients Research Council (mMRC) breathless- stroke risk but is also an indepen- gastrointestinal bleeding, compared with certain clinical features or ness grades 2, 3, or 4, 111 were random- dent risk factor for bleeding. Prior with placebo. lab abnormalities associated with ized to 10 mg oral sustained-release retrospective studies and meta-anal- CITATION: Okumura K et al. Low- malignancy. morphine vs. placebo twice daily for yses have shown elderly patients dose edoxaban in very elderly pa- CITATION: Nicholson BD et al. 4 weeks. Patients receiving morphine generally benefit from anticoagu- tients with atrial fibrillation. N Engl Prioritising primary care pa- had improved COPD assessment lation with direct-acting anticoag- J Med. 2020;383:1735-45. doi: 10.1056/ tients with unexpected weight test scores (–2.18 points; P = .03). In ulants; however, there have been NEJMoa 2012883. loss for cancer investigation: subgroup analysis of mMRC grades no randomized trials evaluating Dr. Tozier is a clinical instructor in the Diagnostic accuracy study. BMJ. 3-4, there was no significant change. efficacy and safety in very elderly division of hospital medicine at the 2020;370:m2651. Published 2020 There was no dif- patients for whom providers would University of Colorado, Aurora. Aug 13. doi: 10.1136/bmj.m2651. ference in breath- otherwise not prescribe anticoagu- lessness. Patients lation because bleeding risk. on morphine had STUDY DESIGN: Industry-spon- By Bethany Zablotsky, PA-C myocardial infarction, stroke, no significant sored, multicenter, block-ran- Genotype-guided stent thrombosis, and recurrent differences in domized, double-blinded, CYP2Y12-inhibitor ischemia over 12 months. These PaCO or amount placebo-controlled trial. 10 events occurred in 5.85% of the gen- 2 selection and ischemic events in of time nocturnal SETTING: Multiple centers in Japan. post-PCI patients otype-guided group and 4.03% of SpO2 was below SYNOPSIS: Patients were random- the conventional- Dr. Sun 90%. Patients ex- ized to 15 mg daily edoxaban or CLINICAL QUESTION: Is genotype- therapy group. perienced similar placebo, with 492 patients per arm. guided oral CYP2Y12 inhibitor selec- This absolute overall incidence of any adverse event Participants were over 80 years of tion more effective than traditional difference of 1.8% (nausea, vomiting, drowsiness, consti- age with nonvalvular AFib and were clopidogrel therapy at preventing did not meet the pation, and sleepiness), COPD exacer- not on anticoagu- recurrent ischemic events in treat- pre-established bations, and hospitalizations. Patients lation because of ment of patients post–percutaneous superiority crite- on morphine had more constipation. renal impairment coronary intervention? ria hazard ratio The study was limited by decreased (creatin clear- BACKGROUND: Current guide- of 0.66, 95% con- enrollment, with only 27% of eligible ance, 15-30 mL/ lines do not recommend genetic fidence interval, Ms. Zablotsky patients giving consent, leading to in- min), bleeding testing prior to starting clopido- 0.43-1.02; P = .6. clusion of mMRC grade 2 patients. history, weight grel, a commonly used oral platelet Study limitations included non- BOTTOM LINE: Low-dose, sus- less than 45 kg, adenosine diphosphate CYP2Y12 compliance and individual prefer- tained-release morphine may im- NSAID use, or receptor inhibitor that must be me- ence to use clopidogrel instead of prove COPD specific health status Dr. Tozier antiplatelet use. tabolized by CYP2C19 to its active the assigned ticagrelor. The trial without affecting PaCO2 or causing Average age was metabolite. There are concerns that was also underpowered to detect other serious adverse effects. 87 years, weight 50.6 kg, body mass poor metabolizers of clopidogrel a relative risk reduction less than CITATION: Verberkt CA et al. Effect index 22, CHADS2-VASc 4.9, HAS- may have a higher incidence of 50%. of sustained-release morphine for BLED 2.3, and CrCl 36.3 mL/min. ischemic events. BOTTOM LINE: Post-PCI geno- refractory breathlessness in chron- Median follow-up was 466 days. In STUDY DESIGN: Open-label, ran- type-guided therapy for CYP2C19 ic obstructive pulmonary disease the edoxaban arm, the rate of the domized, clinical trial. loss-of-function carriers may not be on health status: A randomized primary efficacy outcome of stroke SETTING: Forty medical centers in more effective than conventional clinical trial. JAMA Intern Med. or systemic embolism was 2.3% per the United States, Canada, South therapy with clopidogrel at prevent- 2020;e203134. doi: 10.1001/jamaint- patient year vs. 6.7% with placebo Korea, and Mexico. ing recurrent ischemic events; how- ernmed. 2020.3134. (hazard ratio, 0.34; confidence in- SYNOPSIS: Of patients who un- ever, a better powered study may Dr. Sun is assistant professor in the terval, 0.19-0.61), driven by ischemic derwent percutaneous coronary yield different results. division of hospital medicine at the stroke. The primary safety outcome intervention (PCI), 5,302 were divid- CITATION: Pereira NL et al. Effect University of Colorado, Aurora. of major bleeding occurred at 3.3% ed into a genotype-guided group of genotype-guided oral P2Y12 in- per patient year vs. 1.8 % with pla- or conventional-therapy group. hibitor selection vs conventional cebo (HR, 1.87; CI, 0.9-3.89), driven by In the genotype-guided group, pa- clopidogrel therapy on ischemic By Michael Tozier, MD gastrointestinal bleeding. tients identified as having CYP2C19 outcomes after percutaneous Low-dose edoxaban cuts Limitations include a high loss-of-function carriers were pre- coronary intervention: The TAI- 9 stroke incidence in elderly withdrawal rate, with 81 and 75 scribed ticagrelor, and the rest were LOR-PCI randomized clinical trial. patients with AFib and bleeding withdrawals in the edoxaban and given clopidogrel. Everyone in the JAMA. 2020;324(8):761-71. doi: 10.1001/ risk factors placebo arms, respectively. The very conventional group received clopi- jama.2020.12443 elderly, low body mass index, Japa- dogrel. All patients received aspirin Ms. Zablotsky is an Advanced CLINICAL QUESTION: Is low-dose nese population in this study may as well. Primary end point was Practice Fellow in Hospital Medicine edoxaban effective and safe for limit external validity. composite cardiovascular death, at the University of Colorado, Aurora. March 2021 |6 2 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

Hospitalist Opportunities Gorgeous Lakes, Ideal Climate, Award-winning Downtown Inspire health. Serve with compassion. Be the difference.

Prisma Health-Upstate employs 16,000 people, including 1,200+ physicians on staff. Our system includes clinically excellent facilities with 1,627 beds across 8 campuses. Additionally, we host 19 residency and fellowship programs and a 4-year medical edu- cation program: University of South Carolina School of Medicine–Greenville, located on LIVE. Prisma Health-Upstate’s Greenville Memorial Medical Campus. Prisma Health-Upstate also has developed a unique Clinical University model in collaboration with the University WORK. of South Carolina, Clemson University, Furman University, and others to provide the aca- demic and research infrastructure and support needed to become a leading academic PLAY. health center for the 21st century. Patient centered. Physician centric. Quality focused. Culture driven. Greenville, South Carolina is a beautiful place to live and work and is located on the I-85 corridor between Atlanta and Charlotte and is one of the fastest growing areas This is how our physicians describe us. If you're ready to join a company where your in the country. Ideally situated near beautiful mountain ranges, beaches and lakes, contribution as a patient-focused team member is valued, elevate your career with we enjoy a diverse and thriving economy, excellent quality of life and wonderful American Physician Partners. cultural and educational opportunities. Check out all that Greenville, SC has to offer! Now with 150+ practice sites across the #yeahTHATgreenville country, you can LIVE, WORK and PLAY with the best. Ideal Candidates: • BC/BE Internal Medicine Physicians • IM procedures highly desired, but not required. Simulation center training & bedside

appartners.com | 855.246.8607 | [email protected] 310928 training available if needed. • Comfort managing critically ill patients. Details Include: • Group comprised of career hospitalists with low turnover • Relocation allowance available • EPIC Electronic Medical Record system • 7 on/7 off schedule with 1 week of vacation per year • Additional shifts paid at a premium Find your Available Opportunities: Nocturnist Hospitalist, Oconee Memorial Hospital next job today! • $340K base salary with $10K incentive bonus and CME stipend for Nocturnist • Up to $40K sign on bonus for a 4 year commitment visit SHMCAREERCENTER.ORG Hospitalist, Laurens County Hospital • $291K base salary with $40K incentive bonus and CME stipend • Up to $40K sign on bonus for a 4 year commitment

*Public Service Loan Forgiveness (PSLF) Program Qualified Employer* Please submit a letter of interest and CV to: Natasha Durham, Physician Recruiter, [email protected], ph: 864-797-6114 312627

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

March 2021 | 27 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

About Concord, MA and Emerson Hospital

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

life balance Not a J-1 of H1B opportunity 313100

TT0221

To advertise in The Hospitalist or the Journal of Hospital Medicine

CONTACT:

Heather Gonroski 973.290.8259 [email protected]

or

Linda Wilson 973.290.8243 [email protected]

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

Hospitalists/Nocturnists

Ochsner Health is seeking physicians to join our hospitalist team. BC/BE Internal Medicine and Family Medicine physicians are welcomed to apply. Highlights of our opportunities are: • Hospital Medicine was established at Ochsner in 1992. We have a stable 50+ member group. • 7 on 7 off block schedule with exibility To advertise in • Dedicated nocturnists cover nights The Hospitalist or the • Base plus up to 40 K in incentives • Average census of 14-18 patients Journal of Hospital Medicine • E-ICU intensivist support with open ICUs at the community hospitals • EPIC medical record system with remote access capabilities • Dedicated RN and Social Work Clinical Care Coordinators Contact: • Community based academic appointment Heather Gonroski • The only Louisiana Hospital recognized by U.S. News and World Report Distinguished 973.290.8259 Hospital for Clinical Excellence award in 3 medical specialties [email protected] • Co-hosts of the annual Southern Hospital Medicine Conference • We are a medical school in partnership with the University of Queensland providing or clinical training to third and fourth year students. Linda Wilson • Leadership support focused on professional development, quality improvement, and 973.290.8243 academic committees & projects • Opportunities for leadership development, research, resident and medical student [email protected] teaching • Skilled nursing and long term acute care facilities seeking hospitalists and mid-levels with an interest in geriatrics • Paid malpractice coverage and a favorable malpractice environment in Louisiana • Generous compensation and bene ts package Ochsner Health is a system that delivers health to the people of Louisiana, Mississippi and the Gulf South with a mission to Serve, Heal, Lead, Educate and Innovate. Ochsner Health is a not-for-pro t committed to giving back to the communities it serves through preventative screenings, health and wellness resources and partnerships with innovative organizations that share our vision. Ochsner Health healed more than 876,000 people from across the globe in 2019, providing the latest medical breakthroughs and therapies, including digital medicine for chronic conditions and telehealth specialty services. Ochsner Health is a national leader, named the top hospital in Louisiana and a top children’s hospital by U.S. News & World Report. As Louisiana’s leading healthcare educator, Ochsner Health and its partners educate thousands of healthcare professionals annually. Ochsner Health is innovating healthcare Find your by investing in new technologies and research to make world-class care more accessible, affordable, convenient and effective. Ochsner’s team of more than 26,000 employees and 4,500 providers are working to reinvent the future of health and wellness in the region. To next job today! learn more about Ochsner Health, please visit www.ochsner.org. To transform your health, please visit www.ochsner.org/healthyyou. visit SHMCAREERCENTER.ORG Interested physicians should apply to: https://ochsner.wd1.myworkdayjobs.com/en-US/OchsnerPhysician/job/ New-Orleans---New-Orleans-Region---Louisiana/Hospital-Medicine-Sourcing-Requisition ---all-regions_REQ_00022186 Sorry, no opportunities for J1 applications. Ochsner is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, disability status, protected veteran status, or any other characteristic protected by law. 309952

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]

March 2021 | 29 | The Hospitalist COMMENTARY When the X-Waiver gets X’ed Implications for hospitalists

By Richard Bottner, DHA, disorder (OUD) treatment. day review. The excitement about PA-C, and Marlene Martin, MD Buprenorphine effectively treats the waiver’s eradication further opioid withdrawal, reduces OUD-re- dampened on Jan. 25, when the plan here are two pandemics per- lated mortality, and decreases hos- was halted because of procedural meating the United States: pital readmissions related to OUD. factors coupled with the concern COVID-19 and addiction. To To prescribe buprenorphine for that HHS may not have the author- date, more than 468,000 peo- OUD in the outpatient setting or on ity to void requirements mandated Tple have died from COVID-19 in the hospital discharge, providers need by Congress. United States. In the 12-month peri- an X-Waiver. The X-Waiver is a result Many of us continue to be hopeful od ending in May 2020, over 80,000 of the Drug Addiction Treatment that the X-Waiver will soon be gone. died from a drug related cause – the Act 2000 (DATA 2000), which was The Substance Abuse and Mental highest number ever recorded in a enacted in 2000. It permits physi- Health Services Administration year. Many of these deaths involved has committed to working with opioids. As buprenorphine federal agencies to increase access Dr. Bottner COVID-19 has worsened outcomes to buprenorphine. The Biden admin- for people with addiction. There is becomes“ more accessible, istration also committed to address- less access to treatment, increased we can be leaders in ing our country’s addiction crisis, isolation, and worsening psychoso- including a plan to “make effective cial and economic stressors. These further adopting it (and prevention, treatment, and recovery factors may drive new, increased, or other substance use services available to all, including more risky substance use and return through a $125 billion federal invest- to use for people in recovery. As hos- disorder medications …) ment.” pitalists, we have been responders ” Despite the pause on HHS’s recent in both COVID-19 and our country’s cians to prescribe buprenorphine attempt to “X the X-Waiver,” we now worsening overdose and addiction for OUD treatment after an 8-hour have renewed attention and interest crisis. training. In 2016, the Comprehensive in this critical issue and an opportu- In December 2020’s Journal of Addiction and Recovery Act ex- nity for greater and longer-lasting Hospital Medicine article “Converg- tended buprenorphine prescribing legislative impact. SHM supports ing crises: Caring for hospitalized to physician assistants (PAs) and that Congress repeal the legislative Dr. Martin adults with substance use disorder advanced-practice nurses (APNs). requirement for buprenorphine in the time of COVID-19” (2020 Oct. However, PAs and APNs are re- training dictated by DATA 2000 so Dr. Bottner is a physician assistant in 15[10]:628-30), Dr. Honora Englander quired to complete a 24-hour train- that it cannot be rolled back by the Division of Hospital Medicine at and her coauthors called on hospi- ing to receive the waiver. future administrations. To further Dell Medical School at The University talists to actively engage patients On Jan. 14, 2021, the U.S. Depart- increase access to buprenorphine of Texas at Austin and director of with substance use disorders during ment of Health & Human Services treatment, the training requirement the hospital’s Buprenorphine Team. hospitalization. The article highlights under the Trump administration should be removed for all providers Dr. Martin is a board-certified the colliding crises of addiction and announced it was removing the who care for individuals with OUD. addiction medicine physician and COVID-19 and provides eight practi- X-Waiver training previously re- The X-Waiver has been a barrier hospitalist at University of California, cal approaches for hospitalists to ad- quired for physicians to prescribe to hospitalist adoption of this crit- San Francisco, and director of the dress substance use disorders during this life-saving medication. How- ical, life-saving medication. HHS’s Addiction Care Team at San Francisco the pandemic, including initiating ever, on Jan. 20, 2021,150490.graphic the Biden stance to nix the waiver, though General Hospital. Dr. Bottner and Dr. buprenorphine for opioid withdraw- administration froze the training fleeting, should be interpreted as an Martin colead the SHM Substance al and prescribing it for opioid use requirement removal pending a 60- urgent call to the medical commu- Use Disorder Special Interest Group. nity, including us as hospitalists, to Table 1. Resources for buprenorphine education learn aboutIMNG buprenorphine Print Colors with theHeadline for a Bar Graphic many resources available (see Table could support hospitalist-specific If a deck headline is needed, use this style. Resource Description 1). As hospital medicine providers, buprenorphine trainings and extend we can order buprenorphine for the models to include additional Providers Clinical Support Provides buprenorphine education, including a free Label style and size System X-Waiver training patients with OUD during hospital- medications for addiction. ization. It is discharge prescriptionsAxes numberThere style is anda large size body of evidence California Bridge program Resources include ordersets, work ows, and lectures that have been limited to providers regarding buprenorphine’s safety on substance use disorder treatment Note: Trade Gothic Medium, 8/11 ush left with an X-Waiver. and efficacy in OUD treatment. Source: Trade Gothic Medium, 8/11 ush left SAMHSA Treatment Improvement Reviews medications for OUD and how to address What can we do now to prepare With a worsening overdose crisis, Protocol 63 OUD across practice settings as well as other for the eventual X-Waiver training there have been increasing opioid- support strategies Style Guide: removal? We can start by educating related hospitalizations. When Keep the background white. SHM Substance Use Disorder Regular venue to support hospital efforts to improve ourselves with the resources listed new medications for diabetes, Use the IMNG colors. Special Interest Group substance use disorder care and advocacy in Table 1. Those of us who are al- hypertension, or DVT treatment UCSF* National Clinician Peer-to-peer consultation for providers available ready buprenorphine champions Movebecome the entire available, graph toas alignhospitalists the bar we labels left at the blue guide bar. Consultation Center Substance Monday-Friday from 9 a.m. to 8 p.m. ET at could lead trainings in our home (Resizingincorporate may need them to into be doneour toolbox. on the graph to €t in the space.) Use Warmline 855-300-3595 institutions. In a future without theIf a deeperAs buprenorphine or shorter template becomes is more needed, ac- adjust in Window > Artboards. American Society of Addiction Provides multiple X-Waiver training options waiver there will be more flexibility (Standard,cessible, as we shown can be here, leaders is 28 in furtherpicas x 20 picas.) Medicine to develop hospitalist-focused bu-

MDedge News To createadopting the dotted it (and lines other if substance they change, use use the clear arrow tool, click prenorphine trainings, as the previ- on disorderthe line thatmedications needs to while be changed, we are atuse the eyedropper tool, then *University of California, San Francisco ous ones were geared for outpatient clickit) onas ourthe standarddotted rule of provided care for peopleon the side of the template. Source: Dr. Bottner, Dr. Martin providers. Hospitalist organizations with OUD. March 2021 |0 3 | The Hospitalist COMMENTARY Who do you call in those late, quiet hours, when all seems lost? Selfless acts, fortitude of spirit

By Jordan Messler, MD, SFHM giene. Today, these acts of hygiene, handwash- ing, mask-wearing, and sanitation are discussed Dr. Messler is the exec- I swear by Apollo Physician and Asclepius and Hy- across the world louder than ever. While we’re utive director, quality geia and Panacea and all the gods and goddesses, all wishing for a panacea, we know it will take all initiatives at Glytec and making them my witnesses, that I will fulfill ac- the attributes of medicine to get us through this works as a hospitalist at cording to my ability and judgment this oath and pandemic. Morton Plant Hospitalist this covenant. Hospitalists are part of the frontline teams group in Clearwater, Fla. facing this pandemic head-on. Gowning up for n my desk sits a bust of Hygeia, a MRSA isolation seems quaint nowadays. mask from Venice, next to a small My attendings spoke of their fears, up against as they remind us of the work that was done for sculpture and a figurine of the plague the unknown while on service in the 1980s, when centuries: pestilence, famine, war. The great kill- doctor. Nearby, there is a Klimt close- HIV appeared; 2014 brought the Ebola biocon- ers never go away completely. Oup of Hygeia, a postcard portraying Asclepius, tainment units. Now, this generation works St. Sebastian paintings, and quotes from Mai- daily against a modern plague, where every day Fast forward to today monides. They whisper secrets and nod to the is a risk of exposure. When every patient is in These medical specters serve as reminders of challenges of the past. These medical specters, isolation, the garb begins to reflect the PPE that what makes the field of medicine so inspiring: ancient voices of the past, keep me grounded. emerged during a 17th-century plague epidemics, the selfless acts, the fortitude of spirit, the heal- They speak, listen, and elevate me, too. They bring the plague doctor outfit. ers, the long history, and the shoulders of giants life into my otherwise quiet room. Godfather II fans recall the famous portrayal we stand upon. From these stories, we spring the We all began our careers swearing to Apollo, of the Aug. 16th festival to San Rocco play out in healing waters we bathe in to give us the courage Asclepius, Hygeia, and Panacea when we recited the streets of New York. For those stricken with to wake up and care for our patients each day. the Hippocratic Oath. I call upon them, and other COVID-19 and recovered, you emulate San Rocco, These specters encourage us to defeat any and all in your continued return to service. of the scourges that come our way. The Scuola Grande di San Rocco, in Venice, I hear and read stories about the frontline he- Hospitalists march into the is the epitome of healing and greatness in one roes, the vaccine makers, the PPE creators, the hospital“ risking their lives. We building. Tintoretto, the great Venetian painter, health care workers, grocery store clerks, and always wear PPE for MRSA, ESBL, assembled the story of healing through art and teachers. I’m honored to hear of these stories and portraits of San Rocco. The scuola, a confraterni- your sacrifices. I’m inspired to continue uphold- or C. diff. And enter reverse isolation ty, was a community of healers, gathered in one ing your essence, your fight, and your stories. In rooms wearing N95s for possible TB place to look after the less fortunate. Hospitalists march into the hospital risking Asclepius, son of Apollo, was cases. But those don’t elevate to the their lives. We always wear PPE for MRSA, ESBL, “hailed as a god of medicine. He volume, to the same fear, as gowning or C. diff. And enter reverse isolation rooms wear- healed many from plagues at his up for COVID-19. ing N95s for possible TB cases. But those don’t el- evate to the volume, to the same fear, as gowning temples throughout the Ancient ” up for COVID-19. gods and totems, and saints and ancient healers, Hospitalists, frontline health care workers, Greek and Roman empires. He was now more than ever. As an atheist, I don’t appeal embody the story of San Sebastian, another mentored in the healing arts by the to them as prayers, but as Hippocrates intended. plague saint who absorbed the arrows, the centaur, Chiron. His many daughters I look to their supernatural healing powers as a symbolic plagues, onto his own shoulders so no source of strength and as revealers of the natural one else had to bear them. San Sebastian was a and sons represent various aspects and observable phenomena. Christian persecuted by a Roman emperor once of medicine. Apollo was one of the Twelve Olympians, a God his beliefs were discovered. He is often laden of medicine, father of Asclepius. He was a healer, with arrows in spots where buboes would have keeping with ancient” empire metaphors, you are though his arrows also bore the plagues of the appeared: the armpits and the groin. His sacri- taking the slings of the diseased arrows flying Gods. fice for others’ recovery became a symbol of ab- to our brethren as you try to keep yourself and For centuries, Apollo was found floating above sorbing the plague, the wounds, and the impact others safe. the marble dissection table in the Bologna ana- of the arrows. The sheathing of this sword will come. These tomical theater, guiding students who dove into This sacrifice epitomizes the daily work the arrows will be silenced. But until then, I lean on the secrets of the human body. frontline nurses, ER docs, intensivists, hospital- these pictures, these stories, and these saints, to Asclepius, son of Apollo, was hailed as a god ists, and the entire hospital staff perform daily, give us all the strength to wake up each morning of medicine. He healed many from plagues at bearing the slung arrows of coronavirus. and continue healing. his temples throughout the Ancient Greek and One of the images I think of frequently during They serve as reminders of what makes the Roman empires. He was mentored in the healing this time lies atop Castel San Angelo in Rome. field of medicine so great: the selfless acts, the arts by the centaur, Chiron. His many daughters Built in 161 AD, it has served as a mausoleum, pris- fortitude of spirit, the healers, the long history, and sons represent various aspects of medicine on, papal residence, and is currently a museum. and the shoulders of giants we stand upon. From including cures, healing, recovery, sanitation, Atop San’Angelo stands St. Michael, the destroyer these stories spring the healing waters we bathe and beauty. To Asclepius, temples were places of of the dragon. He is sheathing his sword in repre- in to give us the courage to wake up and care healing, an ancient ancestor to modern hospi- sentation of the end of the plague in 590. for our patients each day and defeat any and all tals. The arrows flow, yet the sword will be scourges that come our way. Two of his daughters, Panacea and Hygeia, sheathed. Evil will be halted. The stories of these This commentary appeared initially on The gave us the healing words of panacea and hy- ancient totems and powers can give us strength Hospital Leader, the official blog of SHM. the-hospitalist.org |1 3 | March 2021 HOSP_32.indd 1 10/14/2020 11:40:59 AM