Hospitalists Address Patient Experience During the Pandemic

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September 2021 FUTURE HOSPITALIST INTERNATIONAL KEY CLINICAL QUESTION Volume 25 l No. 9 A road map to HM in India during Albumin for infections in p8 diversity and justice p16 COVID p22 cirrhosis

Dr. Swati Mehta is director of quality and performance and patient experience at Vituity in Emeryville, Calif. Photo by Vituity

Hospitalists address patient experience during the pandemic Adopt strategies to communicate with compassion By Larry Beresford all – of these factors are captured in policies as doctors and other hospital the “patient experience” questions on staff donned masks, visors, and other patient’s lived experience the Hospital Consumer Assessment emotionally distancing personal proof being in the hospital is of Healthcare Providers and Systems tective equipment (PPE). All of these shaped by a variety of fac- (HCAHPS) survey that is sent to ran- factors impacted patients’ experience tors, according to Minesh Pa- domly selected patients shortly after as well as their hospitals’ HCAHPS Atel, MD, Mid-Atlantic regional medical their discharge from the hospital. scores, Dr. Patel said. And since these director for the Tacoma, Wash.–based In March 2020, the COVID-19 pan- policies applied to all hospitalized pa- ® hospitalist performance company demic caused hospitals to institute tients, a patient did not need to have the-hospitalist.org Sound Physicians. Some – but not quarantining measures and “no visitor” Continued on page 12

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SHM, 55 other groups PHYSICIAN EDITOR THE SOCIETY OF HOSPITAL MEDICINE Weijen W. Chang, MD, SFHM, FAAP Phone: 800-843-3360 [email protected] Fax: 267-702-2690 Website: www.HospitalMedicine.org urge health care vax PEDIATRIC EDITOR Anika Kumar, MD, FHM, FAAP Chief Executive Officer [email protected] Eric E. Howell, MD, MHM mandate COORDINATING EDITORS Alan Hall, MD Director of Communications

The FuTure hospiTalisT Brett Radler By Ken Terry An analysis by WebMD and Med- [email protected] scape Medical News estimated that Keri Holmes-Maybank, MD, FhM s COVID-19 cases, hospi- 25% of hospital workers who had inTerpreTing DiagnosTic TesTs Communications Specialist Myles Daigneault talizations, and deaths contact with patients were unvacci- [email protected] mount again across the nated at the end of May. CONTRIBUTING WRITERS country, the Society of More than 38% of nursing workers Jessica Nave Allen, MD, FHM; SHM BOARD OF DIRECTORS AHospital Medicine, the American were not fully vaccinated by July 11, Eileen Barrett, MD, MPH; Jaleesa President Baulkman; Larry Beresford; Romil Chadha, Medical Association, and 54 oth- according to an analysis of Centers Jerome C. Siy, MD, MHA, SFHM MD, MPH, SFHM; Jeff Craven; Liam President-Elect er medical and allied health care for Medicare & Medicaid Services Davenport; Andrew Delapenha, MD, MPH; Rachel Thompson, MD, MPH, SFHM associations released a joint state- data by LeadingAge, which was cited Richard Franki; Marcia Frellick; Tara Haelle; Treasurer ment calling on “all health care by the Washington Post. And more Daniel Herchline, MD, MSED; Kris Rehm, MD, SFHM Eric E. Howell, MD, MHM; Flora Kisuule, Secretary and long-term care employers” to than 40% of nursing home employ- MD, MPH; Shannon K. Martin, MD, MS; Flora Kisuule, MD, MPH, SFHM require their workers to receive the ees have not been fully vaccinated, Matt Pesyna; Aksharananda Rambachan, Immediate Past President COVID-19 vaccine. according to the Centers for Disease MD, MPH; Heidi Splete; Steve Stiles; Danielle Scheurer, MD, MSCR, SFHM Ken Terry; Gwendolyn Williams, MD Board of Directors “SHM’s mission is to promote Control and Prevention. Tracy Cardin, ACNP-BC, SFHM high-quality care for hospitalized The joint statement did not give Bryce Gartland, MD, SFHM patients. As an organization, we sup- any indication of how many em- FRONTLINE MEDICAL Efren C. Manjarrez, MD, SFHM COMMUNICATIONS EDITORIAL STAFF Mark W. Shen, MD, SFHM port vaccinating health care work- ployees of physician practices have Executive Editor Kathy Scarbeck, MA Darlene Tad-y, MD, SFHM ers, including hospitalists, to help failed to get COVID shots. However, Editor Richard Pizzi Chad T. Whelan, MD, MHSA, SFHM stop the spread of COVID-19 and the a recent AMA survey shows that Creative Director Louise A. Koenig Robert P. Zipper, MD, MMM, SFHM Director, Production/Manufacturing increasingly dominant Delta vari- 96% of physicians have been fully Rebecca Slebodnik FRONTLINE MEDICAL ant,” said Eric E. Howell, MD, MHM, vaccinated. COMMUNICATIONS ADVERTISING STAFF chief executive officer of SHM. “We The main reason for vaccine EDITORIAL ADVISORY BOARD Senior Director Business Development aim to uphold the highest standards mandates, according to the health Ramesh Adhikari, MD, MS, SFHM; Hyung Angelique Ricci, 973-206-2335 among hospitalists and other health care associations’ statement, is “the (Harry) Cho, MD, SFHM; cell 917-526-0383 [email protected] Recruitment Sales Representative care providers to help protect our ethical commitment to put patients Ilaria Gadalla, DMSc, PA-C; James Kim, MD; Linda Wilson, 973-290-8243 fellow health care professionals, our as well as residents of long-term Ponon Dileep Kumar, MD, FACP, CPE; [email protected] patients, and our communities.” care facilities first and take all steps Shyam Odeti, MD, MS, SFHM; Senior Director of Classified Sales The document, issued July 26, necessary to ensure their health and Venkataraman Palabindala, MD, SFHM; Tim LaPella, 484-921-5001 Tiffani M. Panek, MA, SFHM, CLHM; cell 610-506-3474 [email protected] covers everyone in health care, well-being.” Kranthi Sitammagari, MD; Emanuel Ezekiel, MD, PhD, chair of In addition, the statement noted, Amith Skandhan, MD, FHM; Advertising Offices 7 Century Drive, the department of medical ethics vaccination can protect health care Lonika Sood, MD, FACP, FHM; Suite 302, Parsippany, NJ 07054-4609 Amit Vashist, MD, FACP 973-206-3434, fax 973-206-9378 and health policy at the University workers and their families from get- of Pennsylvania, Philadelphia, and ting COVID-19. the organizer of the joint statement, The statement also pointed out said in an interview. that many health care and long- That includes not only hospitals, term care organizations already 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 but also physician offices, ambu- require vaccinations for influenza, and trends in hospital medicine. THE HOSPITALIST Frontline Medical Communications Inc., 7 Century latory surgery centers, home care hepatitis B, and pertussis. 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- agencies, skilled nursing facilities, Workers who have certain medical health care administrators interested in the practice cine members. Annual paid subscriptions are avail- pharmacies, laboratories, and imag- conditions should be exempt from and business of hospital medicine. Content for able to all others for the following rates: THE HOSPITALIST is provided by Frontline Medical ing centers, he said. the vaccination mandates, the state- Communications. Content for the Society Pages is Individual: Domestic – $195 (One Year), The exhortation to get vaccinated ment added. provided by the Society of Hospital Medicine. $360 (Two Years), $520 (Three Years), Canada/Mexico – $285 (One Year), $525 (Two Years), also extends to federal and state While recognizing the “historical Copyright 2021 Society of Hospital Medicine. All $790 (Three Years), Other Nations - Surface – $350 health care facilities, including mistrust of health care institutions” 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 those of the military health system among some health care workers, any means and without the prior permission in writing Years), $1,325 (Three Years) – TRICARE and the Department of the statement said, “We must contin- from the copyright holder. The ideas and opinions expressed in The Hospitalist do not necessarily Institution: United States – $400; Veterans Affairs – which instituted a ue to address workers’ concerns, en- reflect those of the Society or the Publisher. The Canada/Mexico – $485 All Other Nations – $565 mandate the same day. gage with marginalized populations, Society of Hospital Medicine and Frontline Medical Student/Resident: $55 Communications will not assume responsibility for The American Hospital Associa- and work with trusted messengers damages, loss, or claims of any kind arising from Single Issue: Current – $35 (US), $45 (Canada/ tion and other hospital groups re- to improve vaccine acceptance.” 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) cently said they supported hospitals There has been some skepticism products, drugs, or services mentioned herein. 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Box 3000, Denville, NJ 07834-3000. their personnel to get vaccinated. health care workers to get vaccinat- The Society of Hospital Medicine’s headquarters Several dozen health care organi- ed as a condition of employment, 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, zations have already done so, in- partly because the U.S. Food and or have any questions or changes related to your cluding some of the nation’s largest Drug Administration had, at press Editorial Offices: 2275 Research Blvd, Suite 400, subscription, call Subscription Services at 1-833-836- Rockville, MD 20850, 973-206-3434, fax 240-221-2548 2705 or e-mail [email protected]. health systems. time, not yet fully authorized any of A substantial fraction of U.S. the COVID-19 vaccines. BPA Worldwide is a global industry resource for verified audience data and health care workers have not yet But in June, a federal judge turned The Hospitalist is a member. gotten vaccinated, although how down a legal challenge to Houston To learn more about SHM’s relationship with industry partners, visit www.hospitalmedicine.com/industry. many are unvaccinated is unclear. Methodist’s vaccination mandate. September 2021 | 2 | The Hospitalist NEWS Hospitalist movers and shakers

By Matt Pesyna ber of the Society of Hospital Med- Program at the University of Ala- DCH Health System (Tuscaloosa, icine, one of the first two elected bama at Birmingham, where she is Ala.) recently selected Capstone Chi-Cheng Huang, MD, SFHM, was members of the an assistant professor in the depart- Health Services Foundation (Tus- recently was named one of the Board of SHM, its ment of family medicine. caloosa) and IN Compass Health Notable Asian/ former president, Dr. Maycock helped create hospi- (Alpharetta, Ga.) as its joint hospital- Pacific American founding editor talist services at Vaughan Regional ist service provider for facilities in Physicians in of the Journal of Medical Center (Selma, Ala.) – Selma Northport and Tuscaloosa. Capstone U.S. History by Hospital Medi- Family Medicine’s primary teaching will provide the physicians, while the American cine, and principal site – and currently serves as its IN Compass will handle staffing Board of Internal investigator for hospitalist director and on its Med- management of the hospitalists, as Medicine. May Project BOOST. ical Executive Committee. She has well as day-to-day operations and was Asian/Pacific He established Dr. Williams worked at the facility since 2017. calculating quality care metrics. The American Heri- the first hospi- agreement is slated to begin on Oct. Dr. Huang tage Month. Dr. talist program at a public hospital Preetham Talari, MD, SFHM, has 1, 2021, at Northport Medical Center, Huang is the ex- (Grady Memorial in Atlanta) in 1998, been named as- and on Nov. 1, 2021, at DCH Regional ecutive medical director and service and later became the founding chief sociate chief of Medical Center. line director of general medicine of the Division of Hospital Medicine quality safety for Capstone is an affiliate of the and hospital medicine within the in 2007 at Northwestern Universi- the Division of University of Alabama and oversees Wake Forest Baptist Health System ty School of Medicine in Chicago. Hospital Medicine University Hospitalist Group, which (Winston-Salem, N.C.) and associate At the University of Kentucky, he at the University currently provides hospitalists at professor at Wake Forest School of established the Center for Health of Kentucky’s DCH Regional Medical Center. Its Medicine. Services Research and the Division UK HealthCare partnership with IN Compass in- Dr. Huang is a board-certified hos- of Hospital Medicine in 2014. in Lexington. Dr. cludes working together in recruit- pitalist and pediatrician, and he is At Washington University, Dr. Wil- Talari is an asso- Dr. Talari ing and hiring physicians for both the founder of the Bolivian Children liams will be tasked with translating ciate professor of facilities. Project, a nonprofit organization the division of hospital medicine’s internal medicine in the Division of that focuses on sheltering street chil- scholarly work, innovation, and re- Hospital Medicine at the UK College UPMC Kane Medical Center (Kane, dren in La Paz and other areas of Bo- search into practice improvement, of Medicine. Pa.) recently announced the creation livia. Dr. Huang was inspired to start focusing on developing new systems Over the last decade, Dr. Talari’s of a virtual telemedicine hospitalist the project during a year sabbatical of health care delivery that are pa- work in quality, safety, and health program. UPMC Kane is partnering from medical school. He worked at tient centered and cost effective, care leadership has positioned with the UPMC Center for Commu- an orphanage and cared for children and provide outstanding value. him as a leader in several UK nity Hospitalist Medicine to create who were victims of physical abuse. Healthcare committees and trans- this new mode of care. The Bolivian Children Project sup- Jordan Messler, formation projects. In his role as Telehospitalists will care for UPMC ports those children, and Dr. Huang’s MD, SFHM, has associate chief, Dr. Talari collab- Kane patients using advanced diag- book, When Invisible Children Sing, been named the orates with hospital medicine di- nostic technique and high-definition tells their story. new chief medical rectors, enterprise leadership, and cameras. The physicians will bring officer at Glytec medical education leadership. expert service to Kane 24 hours per Joshua Lenchus, DO, RPh, SFHM, (Waltham, Mass.), Dr. Talari is the president of the day utilizing physicians and special- has been elected president-elect of where he has Kentucky chapter of SHM and is a ists based in Pittsburgh. Those hos- the Florida Med- worked as exec- member of SHM’s Hospital Quality pitalists will work with local nurse ical Association. utive director of and Patient Safety Committee. practitioners and support staff and Upon his inaugu- clinical practice Dr. Messler deliver care to Kane patients. ration in 2022, it since 2018. Dr. Adrian Paraschiv, MD, FHM, is will be the first Messler will be tasked with leading being recognized by Continental Wake Forest Baptist Health (Win- time in its history strategy and product development Who’s Who as a ston-Salem, N.C.) has launched a that the FMA will while also supporting efforts in Trusted Internist Hospitalist at Home program with have a DO and quality care, customer relations, and and Hospitalist in hopes of keeping patients safe while a hospitalist as delivery of products. the field of Med- also reducing time they spend in the Dr. Lenchus its president. Dr. Glytec provides insulin man- icine in acknowl- hospital. The telehealth initiative Lenchus is a hos- agement software across the care edgment of his kicked into gear at the start of 2021 pitalist and chief medical officer at continuum and is touted as the only commitment to and considered the first of its kind the Broward Health Medical Center cloud-based software provider of providing quality in the region. in Fort Lauderdale, Fla. its kind. Dr. Messler’s background health care ser- Patients who qualify for the pro- includes expertise in glycemic man- vices. Dr. Paraschiv gram establish a plan before they Mark V. Williams, MD, MHM, will agement. In addition, he still works Dr. Paraschiv leave the hospital. Wake Forest join Washington University School as a hospitalist and medical director is a board-certified Internist at Baptist Health paramedics makes of Medicine and BJC HealthCare, at Morton Plant Hospitalist Group Garnet Health Medical Center in home visits and conducts care with both in Saint Louis, as professor (Clearwater, Fla.). Middletown, N.Y. He also serves in a hospitalist reviewing the visit vir- and chief for the Division of Hos- Dr. Messler is a senior fellow with an administrative capacity as the tually. Those appointments continue pital Medicine in October 2021. Dr. SHM and is physician editor of Garnet Health Doctors Hospital- until the patient does not require Williams is currently professor and SHM’s blog The Hospital Leader. ist Division’s Associate Program monitoring. director of the Center for Health Director. He is also the Director of The impetus of creating the pro- Services Research at the Universi- Tiffani Maycock, DO, recently was Clinical Informatics. Dr. Paraschiv gram was the COVID-19 pandemic; ty of Kentucky and chief quality named to the Board of Directors for is certified as the Epic physician however, Wake Forest said it expects officer at UK HealthCare, both in the American Board of Family Med- builder in analytics, information to care for between 75 and 100 pa- Lexington. icine. Dr. Maycock is director of the technology, and improved docu- tients through Hospitalist at Home Dr. Williams was a founding mem- Selma Family Medicine Residency mentation. at any one time. the-hospitalist.org | 3 | September 2021 NEWS Trio of awardees illustrate excellence in SHM chapters 2020 required resiliency, innovation

By Heidi Splete “above and beyond” to showcase their ability to positioned to do just that. Recognizing individual withstand and rise above hardships, as well as to chapters is a great way to highlight these benefits he Society of Hospital Medicine’s annual successfully adapt and position the chapter for and to promote new ideas – which other chapters Chapter Excellence Exemplary Awards long-term sustainability and success, according can incorporate into their future plans.” have additional meaning this year, in to Ms. Kroll. “The Hampton Roads Chapter re- The Hampton Roads Chapter demonstrated its the wake of the persistent challenges ceived this award for the 2020 year. Some of the resilience in many ways during the challenging Tfaced by the medical profession as a result of the chapter’s accomplishments included initiating a year of 2020, Dr. Miller said. COVID-19 pandemic. provider well-being series.” “We love our in-person meetings,” he em- “The Chapter Excellence Award program is an Ms. Kroll noted that the Hampton Roads Chap- phasized. “When 2020 took that away from us, annual rewards program to recognize outstand- ter thrived by trying new approaches and ideas to we tried to make the most of the situation by ing work conducted by chapters to carry out the bring hospitalists together across a wide region, embracing the reduced overhead of the virtual SHM mission locally,” Lisa Kroll, associate direc- such as by utilizing the virtual format to provide format to offer more specialized outreach pro- tor of membership at SHM, said in an interview. more specialized outreach to providers and rec- grams, such as ‘Cultural Context Matters: How The Chapter Excellence Award program is com- ognize hospitalists’ contributions to the broader Race and Culture Impact Health Outcomes’ and posed of Status Awards (Platinum, Gold, Silver, community. ‘Critical Care: Impact of Immigration Policy on and Bronze) and Exemplary Awards. “Chapters The Most Engaged Chapter Leader Award was U.S. Healthcare.’ ” The critical care and immi- that receive these awards have demonstrated given to Alabama-based hospitalist Dr. Skandhan, gration program “was a great outreach to our growth, sustenance, and innovation within their who “has demonstrated how he goes above and many international physicians who have faced chapter activities,” Ms. Kroll said. beyond to grow and sustain the Wiregrass Chap- special struggles during COVID; it not only For 2020, the Houston Chapter received the ter of SHM and continues to carry out the SHM highlighted these issues to other hospitalists, Outstanding Chapter of the Year Award, the mission,” Ms. Kroll said. but to the broader community, since it was Hampton Roads (Va.) Chapter received the Re- Dr. Skandhan’s accomplishments in 2020 in- a joint meeting with our local World Affairs siliency Award, and Amith clude inviting four Alabama state representatives Council,” he added. Skandhan, MD, SFHM, of the and three Alabama state senators to participate Dr. Miller also was impressed with the resil- Wiregrass Chapter in Alabama, in a case discussion with Wiregrass Chapter lead- ience of other chapter members, such as vice received the Most Engaged ers; creating and moderating a weekly check-in president Gwendolyn Williams, MD, “who put Chapter Leader Award. platform for the Alabama state hospital-medicine together a provider well-being series, ‘Hospital- “SHM members are assigned program directors’ forum through the Wiregrass ist Well Being & Support in Times of Crisis.’ ” He to a chapter based on their geo- Chapter – a project that enabled him to encour- expressed further appreciation for the multiple graphical location and are pro- age the sharing of information between hospital chapter members who supported the chapter’s vided opportunities for educa- medicine program directors; and working with virtual resident abstract/poster competition. Dr. Skandhan tion and networking through the other Wiregrass Chapter leaders to launch a “Despite the limitations imposed by 2020, we in-person and virtual events, poster competition on Twitter with more than 80 have used unique approaches that have held volunteering in a chapter leadership position, and posters presented. together a strong core group while broaden- connecting with local hospitalists through the ing outreach to new providers in our region chapter’s community in HMX, SHM’s online en- Hampton Roads Chapter embraces virtual through programs like those described,” said gagement platform,” Ms. Kroll said. connections Dr. Miller. “At the same time, we have promoted The Houston Chapter received the Outstanding “I believe chapters are one of the best answers to hospital medicine to the broader community Chapter of the Year Award because it “exempli- the question: ‘What’s the value of joining SHM?’ ” through a joint program, increased social media fied high performance during 2020,” Ms. Kroll Thomas Miller, MD, FHM, leader of the Hampton presence, and achieved cover articles in Hamp- said. “During a particularly challenging year for Roads Chapter, said in an interview. ton Roads Physician about hospital medicine everyone, the chapter was able to rethink how “Sharing ideas and experiences with other hos- and a ‘Heroes of COVID’ story featuring chapter they could make the largest impact for members pitalist teams in a region, coordinating efforts to members. We also continued our effort to add and expand their audience with the use of virtual improve care, and the personal connection with value by providing ready access to the newly meetings, provide incentives for participants, and others in your field are very important for hos- state-mandated CME with ‘Opiate Prescribing expand their leadership team.” pitalists,” he emphasized. “Chapters are uniquely in the 21st Century.’ “The Houston Chapter has been successful “In a time when even family and close friends in establishing a Houston-wide Resident Inter- struggled to maintain connection, we found ways est Group to better involve and provide SHM to offer that to our hospitalist teams, at the same resources to the residents within the four local time experimenting with new tools that we can internal medicine residency programs who are in- put to use long after COVID is gone,” Dr. Miller terested in hospital medicine,” Ms. Kroll said. “Ad- added. ditionally, the chapter created its first curriculum r Houston Chapter supports residents, to assist residents in knowing more about hospi- apte h C tal medicine and how to approach the job search. s provides levity oad

The Houston Chapter has provided sources of R “As a medical community, we hope that the award

support, both emotionally and professionally, and pton recognition brings more attention to the issues m a incorporated comedians and musicians into their H for which our chapter advocates,” Jeffrey W.

web meetings to provide a much-needed break SHM Chen, MD, of the Houston Chapter and a hospital- from medical content.” The SHM Hampton Roads (Va.) chapter won ist at Memorial Hermann Hospital Texas Medical The Resiliency Award is a new SHM award the 2020 Resiliency Award, one of the Chapter Center, said in an interview. category that goes to one chapter that has gone Excellence Exemplary Awards given by SHM. Continued on following page September 2021 | 4 | The Hospitalist NEWS SHM’s Center for Quality Improvement to partner on NIH grant

he Society of Hospital Medi- investigator Sunitha Kaiser, MD, (within the American Academy of plementation strategies (audit and cine has announced that its MSc, a pediatric hospitalist at the Pediatrics), the Pediatric Research feedback, electronic order sets, award-winning Center for University of California, San Fran- in Inpatient Settings Network, Plan-Do-Study-Act cycles) are as- Quality Improvement will cisco, the study will employ rigorous America’s Hospital Essentials, and sociated with clinicians’ guideline Tpartner on the National Institutes implementation science methods the National Improvement Partner- adoption. of Health’s National, Heart, Lung, and SHM’s mentored implementa- ship Network. In collaboration with “SHM’s Center for Quality Im- and Blood Institute study, “The SIP tion model. these national organizations and provement is a recognized partner Study: Simultaneously Implement- “The lessons learned from this the participating hospitals, the team in facilitating process and culture ing Pathways for Improving Asth- study could inform improved care seeks to realize the following aims: change in the hospital to improve ma, Pneumonia, and Bronchiolitis delivery strategies for the millions • Aim 1 (Preimplementation). Identi- outcomes for patients,” said Eric E. Care for Hospitalized Children” (NIH of children hospitalized with respi- fy barriers and facilitators of imple- Howell, MD, MHM, chief executive R61HL157804). The core objectives of ratory illnesses across the U.S. each menting a multicondition pathway officer of SHM. “SHM is committed the planned 5-year study are to iden- year,” said Jenna Goldstein, chief of intervention and refine the inter- to supporting quality-improvement tify and test practical, sustainable strategic partnerships at SHM and vention for community hospitals. research, and we look forward to strategies for implementing a multi- director of SHM’s Center for Quality • Aim 2a. Determine the effects of contributing to improved care for condition clinical pathway interven- Improvement. the intervention, compared with hospitalized pediatric patients tion for children hospitalized with The team will recruit a diverse control via chart reviews of chil- through this study and beyond.” asthma, pneumonia, or bronchiolitis group of community hospitals in dren hospitalized with asthma, To learn more about SHM’s Center in community hospitals. partnership with SHM, the Value pneumonia, or bronchiolitis. for Quality Improvement, visit hos- Under the leadership of principal in Inpatient Pediatrics Network • Aim 2b. Determine if the core im- pitalmedicine.org/qi.

Continued from previous page events, including a comedian and band to bring “We would start the meeting with each par- “We hope that it encourages more residents some light during tough times.” ticipant reporting the total number of cases, to pursue hospital medicine, and encourages ventilator usage, COVID-19 deaths, and one policy early-career hospitalists to get plugged in to the Strong leader propels team efforts change they did that week to address a pressing incredible opportunities our chapter offers,” “The Chapter Exemplary Awards Program is issue,” Dr. Skandhan said. “Over time the meet- he said. “We are so incredibly honored that the important because it encourages higher perfor- ings helped address common challenges and were Society of Hospital Medicine has recognized the mance while increasing membership engage- a source of physician well-being.” decade of work that has gone on to get to where ment and retaining talent,” said Dr. Skandhan, In addition, Dr. Skandhan and his chapter col- we are now. We started with one officer, and we of Southeast Health Medical Center in Dothan, leagues were concerned that academics were tak- have worked so hard to grow and expand over Ala., and winner of the Most Engaged Chapter ing a back seat to the pandemic, so they rose to the years so we can help support our fellow hos- Leader award. “Being recognized as the most the challenge by designing a Twitter-based poster pitalists across the city and state. engaged chapter leader is an honor, especially competition using judges from across the coun- “We are excited about what given the national and international presence try. “This project was led by one of our chapter our chapter has been able of SHM. leaders, Dr. Arash Velayati of Southeast Health to achieve,” said Dr. Chen. “Success is achieved through the help and Medical Center,” said Dr. Skandhan. The contest “We united the four internal support of your peers and mentors, and I am included 82 posters, and the participants were medicine residencies around fortunate to have found them through this able to showcase their work to a large, virtual Houston and created a Hous- organization,” said Dr. Skandhan. “This award audience. ton-wide Hospitalist Interest brings attention to the fantastic work done by Dr. Skandhan and colleagues also decided to Group to support residents, the engaged membership and leadership of the partner with religious leaders in their communi- providing them the resources Wiregrass Chapter. This recognition makes me ty to help combat the spread of misinformation Dr. Chen they need to be successful in proud to be part of a team that prides itself on about COVID-19. “We teamed with the Southern pursuing a career in hospital improving the quality health and well-being of Alabama Baptist Association and Interfaith medicine. We also are proud of the support we the patients, providers, and public through inno- Council to educate these religious leaders on the provided this year to our early-career hospitalists, vation and collaboration; this is a testament to issues around COVID-19,” and addressed topics helping them navigate the transitions and stay their work.” including masking and social distancing, and up to date in topics relevant to hospital medicine. Dr. Skandhan’s activities as a chapter leader provided resources for religious leaders to tackle We held our biggest abstract competition yet, and included visiting health care facilities in the rural misinformation in their communities, he said. held a virtual research showcase to celebrate the Southeastern United States. “I slowly began to “As chapter leaders, we need to learn to think incredible clinical advancements still happening learn how small towns and their economies tied outside the box,” Dr. Skandhan emphasized. “We during the midst of the pandemic. into a health system, how invested the health can affect health care quality when we strive “It was certainly a tough and challenging year care providers were toward their communities, to solve more significant problems by bringing for all chapters, but despite us not being able and how health care disparities existed between people together, brainstorming, and collaborating. to hold the in-person dinners that our mem- the rural and urban populations,” he explained. SHM and chapter-level engagement provide us bers love so much, we were proud that we were “When the COVID-19 pandemic hit, I worried with that opportunity. “Hospitalists are often af- able to have such a big year,” said Dr. Chen. “We about these hospitals and their providers. fected by the downstream effects of limited pre- were thankful for the physicians who led our COVID-19 was a new disease with limited under- ventive care addressing chronic illnesses. There- COVID-19 talks, which provided an opportunity standing of the virus, treatment options, and pre- fore, we have to strive to see the bigger picture. for hospitalists across Houston to collaborate and vention protocols.” To help smaller hospitals, the As we make changes at our local institutions and share ideas on which treatments and therapies Wiregrass Chapter created a weekly check-in for chapter levels, we will start seeing the improve- were working well for their patients. During such hospital medicine program directors in the state ment we hope to see in the care of our patients a difficult year, we also hosted our first wellness of Alabama, he said. and our communities.” the-hospitalist.org | 5 | September 2021

02to6HOSP21_9.indd 5 8/23/2021 12:01:44 PM PRACTICE MANAGEMENT

Survey Insights Mean leadership The differences between the mean and median of leadership data

By Romil Chadha, MD, MPH, The median ratio of leadership FTE Another helpful pattern is the de- SFHM to total FTE lies between 2% and 5% crease in standard deviation with the in pediatric groups and between 3% increase in group size. The hospital et me apologize for misleading and 6% for most adult groups. The medicine leaders and CEOs of the hos- all of you; this is not an article only two outliers are on the adult side, pital need to watch this number close- about malignant physician with less than 5 FTE and multistate ly; any extremes on high or low side leaders; instead, it goes over management companies. The higher would be indicators for a deep dive in Lthe numbers and trends uncovered median for the less than 5 FTE group leadership structure and health. by the 2020 State of Hospital Med- size is understandable because of the icine report (SoHM).1 The hospital small number of hospitalist FTEs that Total number and total dedicated medicine leader ends up doing many the leader’s time must be spread over. FTE for all physician leaders tasks like planning, growth, collabo- Even a small amount of dedicated Once we start seeing the differences ration, finance, recruiting, schedul- leadership time will result in a high between the mean and median of ing, onboarding, coaching, and most ratio of leader time to hospitalist clini- leadership data, we can see the medi- Dr. Chadha is chief of the division near and dear to our hearts, putting cal time if the group is very small. an is relatively static while the mean of hospital medicine at the out the fires and conflict resolution. The multistate management com- has increased year after year and University of Kentucky Healthcare, pany is probably a result of multiple took a big jump in the 2020 SoHM. Lexington. He actively leads efforts Ratio of leadership FTE to layers of physician leadership (for ex- The chart below shows trends for of recruiting, practice analysis, and physician hospitalists FTE ample, regional medical directors) and the number of individuals in leader- operation of the group. If my pun has already put you off, travel-related time adjustments. Still, ship positions (“Total No” and total you can avoid reading the rest of the it raises the question of why the local FTEs allocated to leadership (“Total piece and go to the 2020 SoHM to look leadership is not developed to decrease FTE”) over the last several surveys. the right (positive); so, it makes sense at pages 52 (Table 3.7c), 121 (Table 4.7c), the leadership cost and better access. The data are heavily skewed toward to use the median in this case rather and 166 (Table 5.7c). It has a newly add- than mean. A few factors could ex- ed table (3.7c), and it is phenomenal; plain the right skew of data. it is the ratio of leadership full-time • Large groups of 30 or more hos- equivalent to physician hospitalists pitalists are increasing, and so is FTE. As an avid user of SoHM, I al- their leadership need. ways ended up doing a makeshift cal- • There is more recognition of the culation to “guesstimate” this number. need for dedicated leadership indi- Now we have it calculated for us and viduals and FTE. the ultimate revelation lies in its nar- • The leadership is getting less con- row range across all groups. We might centrated among just one or a few differ by region, employment type, leaders. academics, teaching, or size, but this • Outliers on the high side. range is relatively narrow. • Lower bounds of 0 or 0.1 FTE.

Highest-ranked leader dedicated FTE and premium compensation Another pleasing trend is an increase in dedicated FTE for the highest-paid leader. Like any skill-set development, leadership requires the investment of deliberate practice, financial acumen, negotiation skills, and increased vulnerability. Time helps way more in developing these skill sets than money. SoHM trends show increase in dedicated FTE for the highest physician leader over the years and static premium compensation. At last, we can say median leadership is always better than “mean” leadership in skewed data. Every group needs leadership, and SoHM offers a nice window into trends in leadership amongst many practice groups. It is a valuable resource for every group.

Reference 1. 2020 State of Hospital Medicine. www. hospitalmedicine.org/practice-management/ shms-state-of-hospital-medicine/. 2020 SHM State of HoSpital Medicine RepoRt September 2021 | 6 | The Hospitalist Live From Nashville

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HOSP_07.indd 1 8/13/2021 11:32:05 AM COMMENTARY

Future Hospitalist Embedding diversity, equity, inclusion, and justice in hospital medicine A road map for success

By Andrew Delapenha, MD, these inequities to persist have exist- MPH; Flora Kisuule, MD, MPH; ed for decades, and superficial efforts Shannon K. Martin, MD, MS; will not bring sufficient change. Our Eileen Barrett, MD, MPH institutions require new building blocks from which the foundation of he language of equality in a wholly inclusive and equal system America’s founding was never of practice can be constructed. En- truly embraced, resulting in couragingly, some institutions and a painful legacy of slavery, hospital medicine groups have taken Tracial injustice, and gender inequality steps to modernize their practices. Dr. Delapenha Dr. Kisuule Dr. Martin Dr. Barrett inherited by all generations. Howev- We offer examples and suggestions er, for as long as America has fallen of concrete practices to begin this Dr. Delapenha and Dr. Kisuule are based in the department of internal short of this unfulfilled promise, journey, organizing these efforts into medicine, division of hospital medicine, at Johns Hopkins University, Baltimore. individuals have dedicated their lives three broad categories: Dr. Martin is based in the department of medicine, section of hospital medicine to the tireless work of correcting 1. Recruitment and retention at the University of Chicago. Dr. Barrett is a hospitalist in the department of injustice. Although the process has 2. Scholarship, mentorship, and internal medicine, University of New Mexico, Albuquerque. been painstakingly slow, our nation sponsorship has incrementally inched toward the 3. Community engagement and part- groups, such as underrepresented in opportunities.”9 While the goal of promised vision of equality, and these nership. medicine (UIM), women in medicine mentorship is professional develop- efforts continue today. With increased (WIM), or LGBTQ+ groups. Affini- ment, sponsorship emphasizes pro- attention to social justice movements Recruitment and retention ty groups provide a safe space for fessional advancement. Deliberate such as #MeToo and Black Lives Mat- Improving equity and inclusion members and allies to support and steps to both mentor and then spon- ter, our collective social consciousness begins with recruitment. Search uplift each other. Institutional and sor diverse hospitalists and future may be finally waking up to the sys- and hiring committees should be as- HMG leaders must educate them- hospitalists (including trainees) are temic injustices embedded into our sembled intentionally, with gender selves and their members on the im- important to ensure equity. fundamental institutions. balance, and ideally with diversity portance of language (see table, p. 9), More inclusive HMGs can be bol- Medicine is not immune to these or equity experts invited to join. and the more insidious forms of bias stered by prioritizing peer education injustices. Persistent underrepre- All members should receive uncon- and discrimination that adversely on the professional imperative that sentation of women and minorities scious bias training. For example, affect workplace culture. Microin- we have a diverse workforce and remains in medical school faculty and the University of Colorado utilizes a sults and microinvalidations, for ex- equitable, just workplaces. Aca- the broader physician workforce, and toolkit to ensure appropriate steps ample, can hurt and result in failure demic institutions may use existing the same inequities exist in hospital are followed in the recruitment to recruit or turnover. structures such as grand rounds to medicine.1-6 The report by the Asso- process, including predetermined Conducting exit interviews when provide education on these crucial ciation of American Medical Colleges candidate selection criteria that are any hospitalist leaves is important topics, and all HMGs can host journal on diversity in medicine highlights ranked in advance. to learn how to improve, but holding clubs and professional development the impact widespread implicit and Job descriptions should be re- “stay” interviews is mission critical. sessions on leadership competencies explicit bias has on creating exclu- viewed by a diversity expert, en- Stay interviews are an opportunity that foster inclusion and equity. sionary environments, exemplified suring unbiased and ungendered for HMG leaders to proactively un- Sessions coordinated by women and by research demonstrating lower pro- language within written text. Adver- derstand why hospitalists stay, and minorities are also a form of justice, motion rates in non-White faculty.7,8 tisements should be wide-reaching, what can be done to create more by helping overcome barriers to ca- The report calls us, as physicians, to and the committee should consider inclusive and equitable environ- reer advancement. Diverse faculty a broader mission: “Focusing solely asking applicants for a diversity ments to retain them. This process presenting in educational venues will on increasing compositional diversi- statement. Interviews should in- creates psychological safety that result in content that is relevant to ty along the academic continuum is clude a variety of interviewers and brings challenges to the fore to be more audience members and will ex- insufficient. To effectively enact insti- interview types (e.g., 1:1, group). addressed, and spotlights best prac- emplify that leaders and experts are tutional change at academic medical Letters of recommendation deserve tices to be maintained and scaled. of all races, ethnicities, genders, ages, centers ... leaders must focus their special scrutiny; letters for women and abilities. efforts on developing inclusive, equi- and minorities may be at risk of be- Scholarship, mentorship, and spon- Groups should prioritize mento- ty-minded environments.”7 ing shorter and less record focused, sorship ring trainees and early-career hos- We have a clear moral imperative and may be subject to less profes- Women and minorities are known to pitalists on scholarly projects that to correct these shortcomings for sional respect, such as use of first be over-mentored and under-spon- examine equity in opportunities of our profession and our patients. It is names over honorifics or titles. sored. Sponsorship is defined by care, which signals that this science incumbent on our institutions and Once candidates are hired, insti- Ayyala et al. as “active support by is valued as much as basic research. hospital medicine groups to embark tutions and HMGs should prioritize someone appropriately placed in When used to demonstrate areas on the necessary process of systemic developing strategies to improve the organization who has signifi- needing improvement, these proj- institutional change to address in- retention of a diverse workforce. cant influence on decision making ects can drive meaningful change. equality and justice within our field. This includes special attention to processes or structures and who is Even projects as straightforward as workplace culture, and thoughtful- advocating for the career advance- studying diversity in conference pre- A road map for DEI and justice ly striving for cultural intelligence ment of an individual and recom- senters, disparities in adherence to in hospital medicine within the group. Some examples mends them for leadership roles, guidelines, or quality improvement The policies and biases allowing may include developing affinity awards, or high-profile speaking projects on how race is portrayed in September 2021 | 8 | The Hospitalist COMMENTARY the medical record can be powerful hospitalists are already equipped the most) are engaged early and re- AAMC website. https://tinyurl.com/49789z3f. tools in advancing equity. with the fundamental tools needed main involved throughout the cycle 3. Diversity in Medicine: Facts and Figures 2019. A key part of mentoring is train- to advance change across their insti- (for a PDSA graphic, see the online Figure 15. Percentage of full-time U.S. medical school faculty by race/ethnicity, 2018. AAMC ing hospitalists and future hospital- tutions – QI processes in the form of version of this article at the-hospi- website. https://tinyurl.com/au2t2dc). ists in how to be an upstander, as in Plan-Do-Study-Act (PDSA) cycles. talist.org). 4. Diversity in Medicine: Facts and Figures 2019. how to intervene when a peer or pa- They allow a continuous cycle As hospitalists, we have signif- Figure 6. Percentage of acceptees to U.S. medi- tient is affected by bias, harassment, of successful incremental change icant work ahead to ensure that cal schools by race/ethnicity (alone), academic year 2018-2019. AAMC website. https://tinyurl. or discrimination. Receiving such based on direct evidence and expe- we develop and maintain a diverse, com/ssda6tjc. training can prepare hospitalists for rience. Any efforts to deconstruct equitable, and inclusive work- 5. Diversity in Medicine: Facts and Figures 2019 these nearly inevitable experiences systematic bias within our orga- force. This work to bring change Figure 18. Percentage of all active physicians and receiving training during usual nizations must also be a continual will not be easy and will require a by race/ethnicity, 2018. AAMC website. https:// tinyurl.com/337akbnm. work hours communicates that this process. Our female colleagues and considerable investment of time 6. Herzke C et al. Gender issues in academic is a valuable and necessary profes- colleagues of color need our insti- and resources. However, with the hospital medicine: A national survey of hospital- sional competency. tutions to engage unceasingly to strategies and tools that we have ist leaders. J Gen Intern Med. 2020;35(6):1641-6. bring about the equality they de- outlined, our institutions and 7. Diversity in Medicine: Facts and Figures Community engagement and part- serve. To that end, PDSA cycles are HMGs can start the change needed 2019. Fostering diversity and inclusion. AAMC website. https://tinyurl.com/94swsthd. nership an apt tool to utilize in this work in our profession for our patients 8. Diversity in Medicine: Facts and Figures 2019. Institutions and HMGs should delib- as they can naturally function in a and the workforce. In doing so, we Executive summary. AAMC website. https:// erately work to promote community never-ending process of improve- can all be accomplices in the fight tinyurl.com/zbvhsxyr. engagement and partnership within ment. to achieve racial and gender equity, 9. Ayyala MS et al. Mentorship is not enough: their groups. Beyond promoting With PDSA as a model, we en- and social justice. Exploring sponsorship and its role in career advancement in academic medicine. Acad Med. health equity, community engage- vision a cycle with steps that are 2019;94(1):94-100. ment fosters inclusivity by allowing intentionally purposed to fit the References 10. Ejike OC et al. Contribution of individual community members to share their needs of equitable institutional 1. Diversity in Medicine: Facts and Figures 2019: and neighborhood factors to racial disparities ideas and give recommendations to change: Target-Engage-Assess-Mod- Figure 19. Percentage of physicians by sex, 2018. in respiratory outcomes. Am J Respir Crit Care AAMC website. https://tinyurl.com/9e4yvz8m. the institutions that serve them. ify. These modifications ensure that Med. 2021 Apr 15;203(8):987-97. There is a growing body of lit- stakeholders (i.e., those that un- 2. Diversity in Medicine: Facts and Figures 2019. 11. Galiatsatos P et al. The effect of community Figure 16. Percentage of full-time U.S. medical socioeconomic status on sepsis-attributable erature that demonstrates how equal practices and policies affect school faculty by sex and race/ethnicity, 2018. mortality. J Crit Care. 2018 Aug;46:129-33. disadvantages by individual and neighborhood-level socioeconomic status (SES) contribute to disparities in specific disease conditions.10,11 Strategies to narrow the gap in SES disadvantages may help reduce race-related health disparities. Insti- tutions that engage the community and develop programs to promote health equity can do so through bi- directional exchange of knowledge and mutual benefit. An institution-specific example is Medicine for the Greater Good at Johns Hopkins. The founders of this program wrote, “health is not synon- ymous with medicine. To truly care for our patients and their communities, health care professionals must understand how to deliver equitable health care that meets the needs of the diverse populations we care for. The mission of Medicine for the Greater Good is to promote health and wellness beyond the confines of the hospital through an interactive and engaging partnership with the community ...” Community engagement also provides an opportunity for growing the cultural intelligence of institutions and HMGs.

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approach for implementing and D , refining policies and procedures can cultivate more inclusive and elapenha D . r equitable environments. Thankfully, D the-hospitalist.org | 9 | September 2021 PEDIATRICS As common respiratory viruses resurface, children are at serious risk

By Jaleesa Baulkman the fall and spring seasons and usually peaked was to get RSV, they’re not going to have nearly late December to mid-February. However, there’s the same amount symptoms as the 9-month-old. ounger children may be vulnerable to been an offseason spike in the common illness Dr. Harrison said delaying RSV in children was the reemergence of common respiratory this year, with nearly 2,000 confirmed cases each never an option before because it’s a virus that’s viruses such as influenza and respiratory week of July. almost impossible to avoid. syncytial virus (RSV) as COVID-19 restric- Richard J. Webby, PhD, of the infectious dis- “Hopefully, the mask means that if you get tionsY wane, experts say. The impact eases department at St. Jude Children’s exposed, instead of getting a million virus parti- could be detrimental. Research Hospital, Memphis, said that, al- cles from your classmate or your playmate, you The COVID-19 pandemic and the though RSV transmits more easily during may only get a couple thousand,” Dr. Harrison implementation of preventative mea- the winter, the virus is able to thrive during explained. “And maybe that’s enough that you can sures such as social distancing, travel this summer because many children have fight it off or it may be small enough that you get restrictions, mask use, and sheltering limited immunity and are more vulnerable a mild infection instead of a severe infection.” in place, reduced the transmission to catching the virus than before. Popula- A summer surge of RSV has also occurred in of respiratory viruses, according to tion immunity normally limits a virus to Australia. A study published in Clinical Infectious the Centers for Disease Control and circulating under its most favorable condi- Diseases (2020 Sep 24. doi: 10.1093/cid/ciaa1475) Prevention. However, because older Dr. Harrison tions, which is usually the winter. However, found that Western Australia saw a 98% reduc- infants and toddlers have not been because there are a few more “susceptible tion in RSV cases. This suggests that COVID-19 exposed to these bugs during the pandemic, they hosts,” it gives the virus the ability to spread restrictions also delayed the RSV season. are vulnerable to suffering severe viral infections. during a time when it typically would not. Dr. Webby said the lapse in preventive measures “[We’ve] been in the honeymoon for 18 months,” “Now we have a wider range of susceptible kids against COVID-19 may also affect this upcoming flu said Christopher J. Harrison, MD, professor of because they haven’t had that exposure over the season. Usually, around 10%-30% of the population pediatrics and pediatric infectious diseases at past 18 months,” said Dr. Webby, who is on the gets infected with the flu each year, but that hasn’t Children’s Mercy Hospitals and Clinics in Kansas World Health Organization’s Influenza Vaccine happened the past couple of seasons, he said. City, Mo. “We are going to be coming out of the Composition Advisory Team. “It gives the virus Although a severe influenza season rebound honeymoon and the children who didn’t get sick more chances to transmit during conditions that this winter is a possibility, Australia continues to are going to start packing 2 years’ worth of infec- are less favorable.” experience a historically low flu season. Dr. Har- tions into the next 9 months so there’s going to Dr. Harrison said that, if children continue rison, who said the northern hemisphere looks at be twice as many as would be normal.” to take preventative measures such as wearing what’s happening in Australia and the rest of the The CDC issued a health advisory in June for masks and sanitizing, they can delay catching the “southern half of the world because their influen- parts of the southern United States, such as Texas, RSV – which can be severe in infants and young za season is during our summer,” hopes this is an the Carolinas, and Oklahoma, encouraging broad- children – until they’re older and symptoms won’t indication that the northern hemisphere will also er testing for RSV – a virus that usually causes be as severe. experience a mild season. mild, cold-like symptoms and is the most common “The swelling that these viruses cause in the However, there’s no indication of how this up- cause of bronchiolitis and pneumonia in children – trachea and the bronchial tubes is much bigger coming flu season will hit the United States and among those who test negative for COVID-19. Vir- in proportion to the overall size of the tubes, so it there isn’t any guidance on what could happen tually all children get an RSV infection by the time takes less swelling to clog up the trachea or bron- because these historically low levels of respirato- they are 2 years old, according to the CDC. chial tube for the 9-month-old than it does of a ry viruses have never happened before, Dr. Web- In previous years, RSV usually spread during 9-year-old,” Dr. Harrison said. “So if a 9-year-old by explained. Bronchitis the leader at putting children in the hospital

By Richard Franki most common primary diagnosis Top ve principal diagnoses for inpatient stays, ages 0-17 years MDedge News in girls, with a rate of 176.7 stays per 100,000, and the second-leading diag- Depressive disorders ore children admitted to nosis overall, although the rate was hospitals in 2018 had acute less than half that (74.0 per 100,000) Acute bronchitis Mbronchitis than any other in boys. Two other respiratory condi- Pneumonia Females diagnosis, according to a recent re- tions, asthma and pneumonia, were Asthma port from the Agency for Healthcare among the top five for both girls and Epilepsy, convulsions Research and Quality. boys, as was epilepsy, they reported. About 7% (99,000) of the 1.47 mil- The combined rate for all diagnoses lion nonmaternal, nonneonatal hos- was slightly higher for boys, 2,051 per Acute bronchitis pital stays in children aged 0-17 years 100,000 vs. 1,922 for girls, based on data Asthma involved a primary diagnosis of acute from the National Inpatient Sample. Pneumonia Males

bronchitis in 2018, representing the “Identifying the most frequent ews

Epilepsy, convulsions N

leading cause of admissions in boys primary conditions for which page d Depressive disorders e

(154.7 stays per 100,000 population) tients are admitted to the hospital MD and the second-leading diagnosis in is important to the implementation 0306090120150180 girls (113.1 stays per 100,000), Kimber- and improvement of health care de- Rate per 100,000 population ly W. McDermott, PhD, and Marc Roe livery, quality initiatives, and health mer, MS, said in a statistical brief. policy,” said Dr. McDermott, IBM Note: Based on 2018 National Inpatient Sample data for nonneonatal, nonmaternal admissions. Depressive disorders were the Watson Health. Source: Agency for Healthcare Research and Quality September 2021 | 10 | The Hospitalist CLINICAL Early heparin treatment linked to lower COVID-19 mortality

By Tara Haelle COVID-19 patients, and guidance for heparin were treated with LMWH 61%). There was also no significant the home care of COVID-19 patients 4,000 IU, or 6,000 IU if their body difference in use of a venturi mask arly treatment with from the World Health Organization mass index was above 30 kg/m2. This (35% vs. 28%), noninvasive ventila- low-molecular-weight hepa- doesn’t mention heparin treatment was reduced to 2,000 IU if estimated tion (13% vs. 14%), or intubation (5% rin (LMWH) reduces the risk at all, he said. glomerular filtration rate (eGFR) vs. 8%). for death in patients with To examine the benefits of early dropped below 30 mL/min. None of However, rates of death were ECOVID-19, a retrospective cohort heparin – whether administered at the patients had previously received significantly lower in patients who study shows. home or in the hospital – Dr. De Vito heparin. received early heparin than in those Heparin could reduce the risk for and colleagues looked at a cohort Median age was slightly younger who did not (13% vs. 25%; P < .0001). blood clots, Andrea De Vito, MD, of of older adults with COVID-19 who for patients who received early hep- There was a trend toward shorter the unit of infectious diseases at were evaluated or treated at an Ital- arin than for those who did not (76.8 hospital stays for patients treated the University of Sassari (Italy) said ian university hospital. vs. 78.5 years). with early heparin, but the differ- during his online presentation of “Some patients were hospitalized Other demographic characteristics, ence was not significant (median, 10 the findings at the 31st European immediately after symptoms onset; such as sex and body mass index, vs. 13 days; P = .08). Congress of Clinical Microbiology & other people preferred to call their were similar in the two groups, as Researchers also conducted a sep- Infectious Diseases. general practitioner and started the were rates of comorbidities, such arate analysis of 219 COVID-19 pa- “Several studies try to describe treatment at home,” Dr. De Vito said. as hypertension, cardiovascular dis- tients who received LMWH at home, the role played by coagulopathies “Other people were hospitalized for ease, diabetes, chronic obstructive regardless of when during their dis- in COVID-19 death,” but the mech- worsening of symptoms later in the pulmonary disease, kidney disease, ease course they received it. These anism causing them is still unclear, course of the disease.” and neurologic conditions. Also simi- patients were significantly less Dr. De Vito explained. Of the 734 patients, 296 received lar were the frequency of symptoms likely to be hospitalized than were Some guidelines have suggested heparin within 5 days of the onset (such as fever, cough, and shortness patients who did not receive LMWH heparin as a treatment for hospi- of symptoms or a positive COVID-19 of breath) and rates of treatment at home (odds ratio, 0.2; P < .0001). talized COVID-19 patients, but few test. Of the remaining 438 patients, with remdesivir or steroids. Comparatively, early heparin have looked at nonhospitalized 196 received LMWH treatment later Rates of hospital admission were treatment had a greater effect on patients. In fact, the National In- during the disease course, and the not significantly different between the risk for death and the risk for stitutes of Health discourages the rest never received LMWH. patients who received early hepa- hospitalization than did other fac- use of heparin in nonhospitalized All patients who received early rin and those who did not (65% vs. tors.

“Reflecting over the past decade of practicing medicine, I have a great appreciation for the immense responsibility and influence our words and actions carry. It is our duty to create an environment centered around empathy. Empathic listening allows us to learn about our patients and understand the key events that led to their hospitalization. In Puerto Rico, we value hospitality, respect, and empathy in an unrushed spirit. Patients are immediately receptive to a clinician who genuinely listens to their concerns. Being present for patients has always felt organic.”

— Ivonne Marie Peña, MD Together, We Are

Ivonne Marie Peña, MD the Power of Care. SHM Member – 6 years We invite you to join our SHM family. hospitalmedicine.org/join

the-hospitalist.org | 11 | September 2021 Patient experience Continued from page 1 COVID-19 to experience many of the same restric- in areas such as communication, responsiveness Declining HCAHPS scores last year could tions imposed by the pandemic. of staff, information about their diagnosis, medi- easily be explained by what was going on with “A lot of the care hospitalists provide involves cations, and discharge – and if they would recom- COVID-19, Dr. Patel said. “But we want our patient touch, sitting down, and looking at the patient eye mend the hospital to others. experience to be seamless. We have to put our- to eye, on the same level,” said Dr. Patel, a practic- Surveys can be done by mail, phone, or inter- selves in the patient’s shoes. For them, it’s about ing hospitalist at Frederick (Md.) Health Hospital. active voice recognition and are offered in seven whether they felt they were treated well or not. “That had to take a back seat to infection control.” different languages. They can be administered by We had to reinvent ourselves and find new ways Meanwhile, lengths of stay were longer for the hospital itself or by an approved survey ven- to compensate for the limitations imposed by the patients with COVID-19, who dor. They are sent between 48 hours and 6 weeks pandemic,” he said. were often very sick and alone after the patient’s hospital discharge. “We also recognized that our No. 1 job as a in their hospital rooms for pro- Nationwide results from HCAHPS survey group is to take care of our doctors, so that they longed periods, sometimes on have been published since 2008 in a searchable, can take care of their patients. We provided mechanical ventilation, isolat- comparable format on the consumer-focused quarantine pay, implemented a buddy system for ed without the support of their government website Hospital Compare (https:// doctors, used CME dollars to pay for COVID edu- families. Health care providers tinyurl.com/8dhr8b7m). The data have been used cation, and if they felt ill, we said they needed to tried to minimize time spent in a value-based incentive purchasing program stay home, while we paid their shift anyway,” he at the bedside because of viral since 2012. Hospital Compare also incorporates said. “When you do that kind of thing and engage Dr. Patel exposure risks. Nobody really measures of quality such as mortality, readmis- them in your mission, frontline hospitalists can knew how to treat patients’ sion, and hospital-acquired infection rates as well help to improve quality of care, decrease costs, severe respiratory distress, especially at first. “So as process measures such as how well facilities and increase patient safety.” we basically threw the kitchen sink at it, follow- provide recommended care. ing the evolving [Centers for Disease Control and Starting in 2016, overall hospital quality has been A sacred encounter Prevention] guidelines, and hoped it would work,” encapsulated in a Star rating, which summarizes a For Sarah Richards, MD, a hospitalist with Ne- he explained. variety of measures across seven areas of quality braska Medicine in Omaha, what happens in the “When we saw our patient experience scores into a single number from one to five for each hos- hospital room between the hospitalist and the plummeting across the division, we said, ‘This is pital. One of those seven areas is patient experience. patient is a sacred encounter. not good.’ We could see that we weren’t spending Hospitals may choose to ask additional ques- “It’s about relationship and as much time at the bedside, and our patients tions of their own along with the HCAHPS sur- trust,” she said, noting that it’s were lonely and scared.” There was also greater vey, to gather additional, actionable quality data hard to capture all of that in fragmentation of care, all of which impacted pa- for internal purposes. Internal surveys with re- survey data. It might be better tients’ experience in partnering hospitals. sults closer to real time, instead of the months-to- expressed in words: “ ‘How are Dr. Patel and his team spearheaded a number years lag in posting HCAHPS scores, enable the things going for you?’ To me, of processes across their partner hospitals to help hospital to respond to issues that emerge. that’s the real patient experi- patients and their families get the information ence. When I talk with physi- they needed and understand what was happening It’s not just the scores Dr. Richards cians about patient experience, during their treatment. “At that moment, real-time “A lot of leaders in the hospital business will tell I start with why this matters. feedback was essential,” he explained. “We imple- you ‘It’s not about the scores,’ ” Dr. Patel related. We know, for example, that when patients trust mented the TED protocol – Teach back, Empathy, “But you need scores to tell how your practice is us, they are more likely to engage with their care and ‘Double-backing,’ which means spending a doing. It’s a testament to the kind of care you are and adhere to the treatment plan.” shorter visit on morning rounds but going back providing as a hospital medicine program. These Dr. Richards said standard hospital quality to the patient’s bedside for a second daily visit at are important questions: Did your doctor listen to surveys can be a blunt tool. The HCAHPS survey, the end of the shift, thereby establishing a second you, communicate in ways you understood, and conducted around a week after the hospitaliza- touch point.” Teach back is a strategy of asking pa- treat you with courtesy?” Scores are scores, he tion, has a low response rate, and returns are tients to repeat back in their own words what they said, but more importantly, are patients getting not representative of the demographic served in understood the doctor to be saying about their care. the information they need? Do they understand the hospital. “The inpatient data are not always The group developed ID buttons – called “Suttons” what’s going on in their care? helpful, but this is what we have to work with. or Sound Buttons – with a larger picture of the “You have to look at the scores and ask, what One choice hospitals have is for the leadership to doctor’s smiling face pinned to their medical gowns. can we do differently to impact patient experi- choose not to use the data for individual bonuses, The hospitalists started scheduling Zoom calls with ence? What are we doing wrong? What can we recognition, or discipline, since the questions ask families from the ICU rooms of COVID-19 patients. do better? If the scores as a collective experience patients about the care they received collectively “We employ clinical performance nurses as collabo- of hospitalized patients are plummeting, it must from all of their doctors,” she said. rative influencers. They visit patients’ bedsides and mean they’re not feeling good about the care they But as hospitalists have worked longer shifts work with staff on improving patient experience,” are receiving, and not recognizing what we’re try- under more stress while wearing PPE – which Dr. Patel said. “And we printed thank-you cards with ing to do for them.” makes it harder to communicate with their the doctor’s name, photo, and an individualized patients – there is a dynamic that has emerged, message for their patients.” Together these tech- which deserves more study. “I think doctors niques measurably improved patient experience gave it their all in the pandemic. I’m a hospital- scores across partnering hospitals. ist, and people told me I’m a hero. But did that change my impact at work (on patient experi- What is patient experience? ence)?” she said. Evaluated by the Agency for Healthcare Research Dr. Richards sits on SHM’s Patient Experience

and Quality and endorsed by the National Qual- s Special Interest Group (SIG), which was tasked ician ity Forum, HCAHPS hospital quality surveys ask s with providing tools to help mitigate the effects hy patients (or their family members, who may be P of the pandemic. These include a fact sheet, ound

the ones completing the survey) 29 well-tested S “Communication Tips for 5 Common Conun- questions about the recent hospital stay and how Hospitalists at Frederick (Md.) Health Hospital drums in the COVID-19 Pandemic” (https://ti- they experienced it. Nineteen of those questions created “thank you” cards that they gave to nyurl.com/dakvbtza), and a downloadable pocket explore critical aspects of the patient’s experience patients at the end of their stays. Continued on following page September 2021 | 12 | The Hospitalist

01_12_13HOSP21_9.indd 12 8/23/2021 12:04:40 PM COVID Tachycardia may be distinct marker for long COVID

By Marcia Frellick much attention has been paid to cas- longer, the authors report. be raised and a head-up tilt test es of clotting and perimyocarditis in “Systematic investigations suggest or at least an active standing test achycardia is commonly patients after COVID, little attention that 9% of post–acute COVID-19 syn- should be performed,” he said. reported in patients with has been paid to tachycardia, despite drome patients report palpitations at If POTS is confirmed, he said, post–acute COVID-19 syn- case reports that show palpitations six months,” the authors write. patients should be offered a heart drome (PACS), also known are a common complaint. The findings also shed light on po- rate–lowering drug, such as low- Tas long COVID, authors report in “We have diagnosed a large num- tential tests and treatments, he said. dose propranolol or ivabradine. a new article. The researchers say ber of patients with postural ortho- “Physicians should be liberal in Compression garments, increased tachycardia syndrome should be static tachycardia syndrome [POTS] performing a basic cardiological fluid intake, and a structured reha- considered a distinct phenotype. and other forms of COVID-related workup, including an ECG, echocar- bilitation program also help. The study by Marcus Ståhlberg, tachycardia at our post-COVID out- diography, and Holter ECG moni- Researchers think the mechanism MD, PhD, of Karolinska University patient clinic at Karolinska Universi- toring in patients complaining of underlying the tachycardia is au- Hospital, Stockholm, and colleagues ty Hospital and wanted to highlight palpitations and/or chest pain,” Dr. toimmune and that primary SARS- was published online in The Amer- this phenomenon,” he said. Ståhlberg said. CoV-2 infections trigger formation ican Journal of Medicine (2021. doi: Between 25% and 50% of patients “If orthostatic intolerance is also of autoantibodies that can activate 10.1016/j.amjmed.2021.07.004). at the clinic report tachycardia and/ reported – such as vertigo, nausea, receptors regulating blood pressure Dr. Ståhlberg said that, although or palpitations that last 12 weeks or dyspnea – suspicion of POTS should and heart rate.

Continued from previous page sponsiveness, fall rates, and sepsis rates.1 “None patients who reported to the emergency depart- card (https://tinyurl.com/22b2xrze) called “The 5 of that should be surprising. Not having family ment but met certain criteria for discharge. They Rs of Cultural Humility.” present just ups the ante. Any hospital patients would be sent home with daily nursing visits Also on the SIG is Mark Rudolph, MD, SFHM, could benefit from an advocate sitting next to and 24-hour virtual access to hospitalists. Vituity Sound Physicians’ chief experience officer, whose them, helping them to the bathroom, and keeping hospitalists also worked more closely with emer- job title reflects a growing, systematic attention them from falling out of bed,” Dr. Rudolph said. gency departments to provide emergency psychi- to patient experience in U.S. “In the past year, we have placed a premium on atric interventions for anxious patients, and with hospitals. “Most clinicians are communicating with these patients with kind- primary care physicians. Patient care navigators familiar with the surveys and ness and compassion, to help them understand helped to enhance transitions of care. In addition, the results of those surveys,” what’s happening to them,” he said. Out of neces- their hospitalist team added personalized pic- he said. “People in our field sity, hospitals have had to rejigger their processes, tures over their gowns so patients could see the can get frustrated with the which has led to more efficient and better care, hospitalists’ faces despite PPE. surveys, and have a lot to say although the jury is still out on whether that will Another Vituity innovation was virtual round- about the quality of the scores persist post pandemic. ing, with iPads in the patient’s room and the phy- themselves – what is actually sician in another room. “I did telerounds at our Dr. Rudolph being measured. Is the patient Communicating with compassion Redwood City hospital with patients with COVID upset because the coffee was Swati Mehta, MD, a hospitalist at Sequoia Hospi- who were very lonely, anxious, and afraid because cold, or due to a bad clinical experience? Is it tal in Redwood City, Calif., and director of quality they couldn’t have family visitors,” Dr. Mehta said. about the care they received from the hospitalist, and performance and patient experience at Vi- Telerounds offered greater protection and safety or the physical setting of the hospital?” tuity, a physician-owned and -led multispecialty for both providers and patients, reduced the need partnership, said COVID-19 was a wake-up call for for PPE, and improved collaboration with the Doing the right thing hospitalists. There have been successful models nursing team, primary care providers, and families. To be a patient hospitalized with an acute illness for enhancing hospitalized patients’ experience, A recent perspective published in the New is a form of suffering, Dr. Rudolph said. “We know but it took the challenges of COVID-19 for many England Journal of Medicine suggests that the patient experience in the hospital since March hospitalists to adopt them. Zoom family conference may offer distinct ad- of 2020 has been frightening and horrible. These “Early in 2020, our data analysis showed emerg- vantages over in-person family conferences.3 It people are as sick as can be. Everything about the ing positive trends, reflecting our patients’ appre- allows for greater participation by primary care experience is horrible. Every effort you can make ciation for what doctors were doing in the crisis clinicians who knew the patient before the cur- to reduce that suffering is important. If you are and awareness of the challenges they faced. But rent hospitalization and thus might have import- a patient in the hospital and don’t know what’s after that uptick, global measures and national ant contributions to discharge plans. happening to you, that’s terrifying.” data showed drops for health care organizations The pandemic stimulated many hospitals to He encourages hospitalists to look beyond the and providers. Patients’ expectations were not be- take a closer look at all areas of their service scores or the idea that they are just trying to ing met. We needed to respond and meet patients delivery, Dr. Rudolph concluded. “We’ve made improve their scores. “Look instead at the actual where they were at. We needed to do things dif- big changes with a lot of fearlessness in a short content of the questions around communication. ferently,” she said. amount of time, which is not typical for hospitals. The competencies addressed in the survey ques- Keeping patients well informed and treating We showed that the pace of innovation can be tions – listening and explaining things clearly, for them with respect are paramount – and more faster if we lower the threshold of risk.” example – are effective guides for patient experi- important than ever – as reflected in Dr. Mehta’s ence improvement efforts. You can be confident “6H” model to promote a human connection be- References 2 you’re doing the right thing for the patient by tween doctors and patients. As chair of SHM’s 1. Silvera GA et al. The influence of COVID-19 visitation restric- focusing on these skills, even if you don’t see im- Patient Experience SIG, she led the creation of tions on patient experience and safety outcomes: A critical role mediate changes in survey scores.” COVID-19–specific communication tips for hospi- for subjective advocates. Patient Experience Journal. 8(1). doi: 10.35680/2372-0247.1596. Hospitals that did not allow visitors had worse talists based on the 6H model. 2. Mehta S. How to truly connect with your patients: Introducing clinical outcomes and patient experience ratings, “I’m very committed to treating patients with the ‘6H model.’ The Hospitalist. 2020 Aug 14. https://tinyurl.com/ and recent research confirms that, when family compassion,” she said. tn8bavrx. visitors are not allowed, outcomes are worse in For Vituity, those approaches included making 3. Lee TH. Zoom family meeting. N Engl J Med. 2021 Apr areas such as patient ratings of medical staff re- greater use of the hospital at home model for 29;384(17):1586-7. the-hospitalist.org | 13 | September 2021 CLINICAL Top 10 things to know about the AHA ACLS 2020 updates Plus, how things differ in a COVID-19 cardiac arrest case

By Jessica Nave Allen, MD, FHM less clear but it is reasonable to give It is reasonable to use physiolog- the first dose after initial defibrilla- 6 ical parameters such as arterial ere are the most import- tion attempts have failed. Currently blood pressure or end-tidal CO2 ant take-aways from the the shockable rhythms algorithm has (EtCO2) to monitor CPR quality. Goal 2020 American Heart As- the first dose of epinephrine given EtCO2 is greater than 10 but ideally sociation Guidelines for after the second shock. greater 20 mm Hg, so if you’re not HCardiopulmonary Resuscitation and reaching that ideal goal, push harder Emergency Cardiovascular Care.1 Giving medications intravenous- and/or faster! Of note, to use arterial 4 ly is preferred over intraosseous blood pressure monitoring you must There were no changes to the 2015 (IO) cannulation because of some have an arterial line in place and to 1 cardiac arrest algorithms. small observational studies that get adequate EtCO2 monitoring, the showed worsened outcomes with IO patient must be intubated with an

The 2020 adult bradycardia al- delivery. Try to get an IV if possible, EtCO2 monitor attached. 2 gorithm increased the atropine but can still use IO if necessary. Cen- dose to 1 mg (from 0.5-1 mg) but tral venous catheters are still not The need for intubation and the maintains the same frequency of recommended during a code unless 7 ideal timing are still unknown. dosing as every 3-5 minutes with no other access can be obtained. The American Heart Association Dr. Allen is assistant professor of max dose of 3 mg. recommends either bag valve mask medicine in the division of hospital Double sequential defibrilla- or an advanced airway. medicine at Emory University, Epinephrine was reaffirmed. 5 tion in refractory VF, which is Atlanta. 3 Specifically, give epinephrine as the application of two sets of pads In pregnant patients who develop soon as possible in nonshockable using two defibrillators to provide 8 cardiac arrest, focus on high-qual- rhythms (pulseless electrical activity defibrillation either in rapid suc- ity CPR and relief of aortocaval com- Intubate as early as possible by and asystole). In shockable rhythms cession or at the same time, is not pression through left lateral uterine 3 someone highly experienced and (ventricular fibrillation and pulseless recommended because of lack of displacement while the patient is place the patient on a ventilator ventricular tachycardia), the timing is evidence. supine. This means that someone with HEPA filter while undergoing on the team stands on the left side resuscitation. This decreases aero- of the patient and cups the uterus, solization risk. pulling it up and leftward. Alterna- tively, if standing on the right of the Use a mechanical CPR device if patient, push the uterus left and up- 4 possible. This results in less peo- ward off of the maternal vessels. ple needed in the room.

AHA released new algorithms for If a patient is NOT intubated 9 opioid overdose given the current 5 but is prone when they arrest, crisis. There is an absence of proven safely turn them supine and per- naloxone benefit in cardiac arrest form resuscitative effort. If a pa- so focus on standard resuscitative tient is intubated and prone when efforts and do not wait for effects of they arrest: If unable to safely turn naloxone before initiating CPR. How- them, place the pads in the AP po- ever, naloxone is still reasonable to sition and perform compressions give if overdose is suspected. over T7-T10 vertebral bodies. Evi- dence for this is extremely limited Clinicians should wait a mini- but comes from a small pilot study 10 mum of 72 hours after return which showed that reverse CPR to normothermia before performing generated a higher mean arterial Data to support your hospitalist multimodal neuroprognostication. pressure, compared with standard This allows for confounding factors resuscitation.3 group’s transition from COVID-19 (that is, meds) to hopefully be re- to the new normal! moved for improved accuracy. References 1. Merchant RM et al. Part 1: Executive Top 5 things that differ in a Summary: 2020 American Heart Association Use data from the 2020 SoHM Report and COVID-19 guidelines for cardiopulmonary resuscitation COVID-19+/PUI cardiac arrest and emergency cardiovascular care. Circula- Addendum to help chart a path forward. case2 tion. 2020 Oct 21;142:S337-57. doi: 10.1161/ Don adequate personal protective CIR.0000000000000918. Order today! equipment prior to entering the 2. Edelson DP et al. Interim guidance for basic 1 and advanced life support in adults, children, hospitalmedicine.org/sohm room. This might create a necessary and neonates with suspected or confirmed delay in care. COVID-19. 2020 Jun 23;141(25):e933-43. doi: 10.1161/CIRCULATIONAHA.120.047463. Use a high-efficiency particulate 3. Mazer SP et al. Reverse CPR: A pilot study of CPR in the prone position. Resuscitation. 2 air (HEPA) filter on all airway 2003 Jun;57(3):279-85. doi: 10.1016/s0300- modalities. 9572(03)00037-6. September 2021 | 14 | The Hospitalist CLINICAL DOACs best aspirin after ventricular ablation: STROKE-VT

By Steve Stiles procedures that involved the retro- than in the aspirin arm,” Dr. Pic- wasn’t the one related to the core grade transaortic approach for ad- cini said. Ablation times averaged hypothesis. And that was the effect atheter ablation has been vancing the ablation catheter, rather 2,095 seconds in the DOAC group, of retrograde access,” Paul A. Fried- around a lot longer for than a trans-septal approach. compared with only 1,708 seconds in man, MD, Mayo Clinic, Rochester, ventricular arrhythmia The retrograde transaortic ap- the aspirin group, probably because Minn., said as an invited discussant than for atrial fibrillation, proach should be avoided in such the preponderance of VT over PVC after Dr. Lakkireddy’s formal pre- Cbut far less is settled about what an- procedures, “whenever it can be ablations for those getting a DOAC sentation of the trial. tithrombotic therapy should follow avoided,” said Dr. Lakkireddy, who was even greater in the aspirin Whether a ventricular ablation ventricular ablations, as there have formally presented STROKE-VT at group. is performed using the retrograde been no big, randomized trials for the HRS sessions and is lead author guidance. on its report published about the Ventricular ablation outcomes, postprocedure DOAC vs. aspirin But the evidence base grew stron- same time in JACC: Clinical Electro- ger this week, and it favors post- physiology (2021 Jul 29. doi: 10.1016/j. Endpoint DOAC Aspirin P value procedure treatment with a direct jacep.2021.07.010). (n = 123) (n = 123) oral anticoagulant (DOAC) over The trial has limitations, but “it’s Stroke 0 6.5% .001 antiplatelet therapy with aspirin for a very important study, and I think TIA 4.9% 17.9% .001 patients undergoing radiofrequency that this could become our standard ews Asymptomatic 24 hours 12.2% 22.8% .03 N ge

(RF) ablation to treat left ventricular of care for managing anticoagula- d cerebral event by MRI 30 days 6.5% 17.9% .006 e (LV) arrhythmias. tion after VT and PVC left-sided MD The 30-day risk for ischemic ablations,” Mina K. Chung, MD, stroke or transient ischemia attack Cleveland Clinic, said as an invited Note: Based on data from the randomized controlled STROKE-VT study. (TIA) was sharply higher for pa- discussant after Dr. Lakkireddy’s Source: JACC Clin Electrophysiol. 2021 Aug 29. doi: 10.1016/j.jacep.2021.07.010 tients who took daily aspirin after presentation. RF ablation for ventricular tachy- How patients are treated with Of the 246 patients assigned to transaortic or trans-septal approach cardia (VT) or premature ventricular antithrombotics after ventricular either aspirin or a DOAC, usually a often depends on the location of the contractions (PVC) in a multicenter ablations can vary widely, some- factor Xa inhibitor, 75% had under- ablation targets in the left ventricle. randomized trial. times based on the operator’s “sub- gone VT ablation and the remain- But in some cases it’s a matter of Those of its 246 patients who re- jective feeling of how extensive the der ablation for PVCs. Their mean operator preference, Dr. Piccini ob- ceived aspirin were also far more ablation is,” Christine M. Albert, MD, age was 60 years and only 18% were served. likely to show asymptomatic lesions MPH, Cedars-Sinai Medical Center, women. None had experienced a “There are some situations where, on cerebral MRI scans performed Los Angeles, not involved in the cerebrovascular event in the previ- really, it is better to do retrograde both 24 hours and 30 days after the study, said during the STROKE-VT ous 3 months. aortic, and there are some cases that procedure. media briefing. The 30-day odds ratio for TIA or are better to do trans-septal. But The findings show the impor- That’s consistent with the guide- ischemic stroke in patients who now there’s going to be a higher bur- tance of DOAC lines, which propose oral anticoagu- received aspirin, compared with a den of proof,” he said. therapy after lation therapy after more extensive DOAC, was 12.6 (95% confidence in- Given the findings of STROKE-VT, ventricular ventricular ablations and anti- terval, 4.10-39.11; P < .001). operators may need to consider that ablation pro- platelets when the ablation is more The corresponding OR for asymp- a ventricular ablation procedure cedures, a set- limited – based more on consensus tomatic cerebral lesions by MRI at 24 that can be done by the trans-septal ting for which than firm evidence – as described hours was 2.15 (95% CI, 1.02-4.54; P = route perhaps ought to be consis- there are no by Jeffrey R. Winterfield, MD, of the .04) and at 30 days was 3.48 (95% CI, tently done that way. evidence-based Medical University of South Caro- 1.38-8.80; P = .008). Dr. Lakkireddy discloses finan- guidelines, “to lina, Charleston, and Usha Tedrow, The rate of stroke or TIA was cial relationships with Boston mitigate the Dr. Lakkireddy MD, MSc, of Brigham and Women’s similar in patients who underwent Scientific, Biosense Webster, Jans- risk of systemic Hospital, Boston, in an accompany- ablation for VT and for PVCs (14% sen Pharmaceuticals, and more. thromboembolic events,” said Dha- ing editorial. vs. 16%, respectively; P = .70). There Dr. Chung had “nothing relevant nunjaya Lakkireddy, MD, Kansas “This is really the first randomized were fewer asymptomatic cerebro- to disclose.” Dr. Piccini discloses City Heart Rhythm Institute, Over- trial data, that I know of, that we vascular events by MRI at 24 hours receiving honoraria or speaking or land Park. Dr. Lakkireddy spoke have on this. So I do think it will be for those undergoing VT ablations consulting fees from Sanofi, Ab- at a media presentation on the guideline-influencing,” Dr. Albert (14.7% and 25.8%, respectively; P = bott, ARCA Biopharma, Medtronic, trial, called STROKE-VT, during the said. .046); but difference between rates Philips, Biotronik, Allergan, Liva- Heart Rhythm Society 2021 Scien- “This should change practice,” attenuated by 30 days (11.4% and Nova, and Myokardia; and research tific Sessions, held virtually and agreed Jonathan P. Piccini, MD, 14.5%, respectively; P = .52). in conjunction with Bayer Health- on-site in Boston. MHS, Duke University, Durham, The OR for TIA or stroke associ- care, Abbott, Boston Scientific, and The risk for stroke and TIA went N.C., also not part of STROKE-VT. ated with the retrograde transaor- Philips. Dr. Friedman discloses con- up in association with several pro- “A lot of evidence in the trial is con- tic approach, performed in about ducting research in conjunction cedural issues, including some that sistent and provides a compelling 40% of the patients, compared with with Medtronic and Abbott; hold- operators might be able to change in story, not to mention that, in my the trans-septal approach in the re- ing intellectual property rights order to reach for better outcomes, opinion, the study probably under- mainder was 2.60 (95% CI, 1.06-6.37; with AliveCor, Inference, Medicool, Dr. Lakkireddy observed. estimates the value of DOACs,” he P = .04). Eko, and Anumana; and receiving “Prolonged radiofrequency abla- said in an interview. “The study tells us it’s safe and honoraria or speaking or consult- tion times, especially in those with That’s because patients assigned indeed preferable to anticoagulate ing fees from Boston Scientific. Dr. low left ventricle ejection fractions, to DOACs had far longer ablation after an ablation procedure. But the Winterfield and Dr. Tedrow had no are definitely higher risk,” as are times, “so their risk was even greater more important finding, perhaps, disclosures. the-hospitalist.org | 15 | September 2021 INTERNATIONAL Ad hoc hospitalist model evolves during India’s COVID surge Hospital administrators recognize the efficiencies

By Jeff Craven project of the Global Change Data them out of the hospital. There was quality,” Dr. Odeti said. “It’s the same MDedge News Lab. When the second wave peaked no need for much efficiency before.” thing in India. It’s borne of necessity, on May 22, more than 4,000 people The first issue during the second but it was [done] at a rapid pace.” year after the start of were dying each day. wave was figuring out which con- the COVID-19 pandemic, “All hospitals [in India] were treat- sultants would care for COVID-19 Problems with patient flow as the United States was ing COVID-19 more than any other patients. As there is no dedicated The next issue was triaging patients getting a reprieve in new acute or chronic disease,” Ramesh specialty for infectious disease in in the hospital based on COVID-19 Acases from its winter surge, the op- Adhikari, MD, MS, SFHM, a hospital- India, the responsibilities fell to in- severity. When the second wave posite was happening in the rest of ist with Franciscan Health in Lafay- ternists and critical care medicine began, hospitals in India ran out of the world. In India, a deadly second ette, Ind., said in an interview. consultants who volunteered. Both beds and experienced staff short- wave hit, crippling the health care Challenges arose in treating are considered small specialties in ages like in many countries. But system in the country for months. COVID-19 in India that ran count- India. They became “makeshift hos- this situation “was unusual for the Yugandhar Bhatt, MBBS, MD, a er to how medicine was usually consultant pulmonologist with performed. Physicians were seeing Yashoda Hospital–Malakpet in more inpatient cases than usual – Hyderabad, India, told this news and more patients in general. The organization that someone looking change, Dr. Adhikari said, forced at his hospital before the pandemic health care providers to think out- – a 400-bed multispecialty care unit side the box.

Even in the U.S. when we started the“ hospitalist model, it started out of necessity. It’s a combination of creating

efficiencies and improving quality. It’s the ac P ia s A

same thing in India. It’s borne of necessity, s mage I Dr. Odeti but it was [done] at a rapid pace. etty G / ” r inge

– would see patients being treated An ‘on-the-fly’ hospitalist model r t for respiratory failure secondary to Patients in India access health care /S exacerbation of chronic obstructive by visiting a hospital or primary onway C pulmonary disease, bronchial asth- health center and then are referred ebecca ma, community-acquired pneumo- out to consultants – specialist doc- R nia, and heart failure. About 30-40 tors – if needed. While India has Medical staff attend to patients with COVID-19 in the emergency ward at patients per day were treated on an universal health coverage, it is a the Holy Family hospital on May 6, 2021, in New Delhi. The country broke outpatient basis, and more than 30 multi-payer system that includes a fresh record with more than 412,000 new cases of COVID-19. people were admitted as inpatients. approximately 37% of the popula- “After [the] COVID-19 surge, our tion covered under the government pitalists” who learned as they went health system,” according to Dr. hospital totally divided into COVID plan, a large number of private and became the experts in COVID-19 Odeti, who is also an editorial board and non-COVID [wards], in which health care facilities and no caps care, treating their own patients member for the Hospitalist. COVID patients occupied 70% of on cost-sharing for the patient. while making themselves available “We never had that issue. There [the] total,” he said. About half of Initiatives like Rashtriya Swasthya for consultations, Dr. Odeti said. were so many patients wanting to COVID-19 patients were in the ICU, Bima Yojana in 2008 and Ayushman While no official hospital medi- come to the hospital, and so there with half of those patients requiring Bharat-Pradhan Mantri Jan Arogya cine model in India exists like in the was this rush.” There was no process supplemental oxygen. Yojana in 2018 have attempted to United States, the second COVID-19 to triage patients to determine who During the first wave in India, close the gap and raise the number surge caused these consultants to needed to stay. “Everybody got put which lasted from May to December of lower-income individuals in India begin thinking like hospitalists. into the hospital,” he said. 2020, 50% of patients who were intu- covered under the government plan Tenets of hospital medicine – like Once it was determined who bated were discharged. The percent- and reduce out-of-pocket spending. team-based treatment across spe- would take care of patients with age of extubated patients decreased Out-of-pocket payments still consist cialties – arose out of necessity COVID-19, access to supplies became to 20% in the second wave, Dr. Bhatt of about 70% of total health expen- during the crisis. “They were trying the primary problem, Dr. Adhikari said. ditures, according to the Common- to implement a hospitalist model be- explained. Lack of oxygen, ventila- The death toll during the second wealth Fund. cause that’s the only way they could tors, and critical medicines like the wave of COVID-19 cases was unlike “There is not much scope for a treat COVID-19,” said Dr. Adhikari, antiviral drug remdesivir were and anything India has seen previously. hospitalist because it’s so cash driv- an editorial advisory board member continue to be in short supply. “I had Between March 1 and June 29, 2021, en,” Shyam Odeti, MD, MS, SFHM, for the Hospitalist. friends who [said] they could not ad- an estimated 19.24 million indi- section chief, hospital medicine, at “Even in the U.S. when we started mit patients because they were wor- viduals were newly infected with the Carilion Clinic in Roanoke, Va., the hospitalist model, it started out ried if their oxygen supply [went] COVID-19 and 241,206 patients died, said in an interview. “For a hospi- of necessity. It’s a combination of low in the middle of the night. They according to Our World in Data, a talist, there is no urgency in getting creating efficiencies and improving will treat the patients who were September 2021 | 16 | The Hospitalist INTERNATIONAL

stantly exchanging messages and World Health Organization (J Educ serving as “kind of a friendly sup- Health Promot. 2020;9:190). That port group.” makes telemedicine a unique oppor- In Dr. Odeti’s group chat, physi- tunity for one physician in India to

ac cians helped one another find hos- reach many patients regardless of P ia s

A pital beds for patients who reached location. s out to them. “The first couple of Dr. Adhikari said he helped out his mage I weeks, there was no proper way colleagues in India by performing etty G / r for people to know where [patients] consults for their patients. “They inge r were based. There was no way to were just worried because they did t /S find if this hospital had a bed, so not know where to go, or what to

onway they reached out to any doctors they get,” he said. “I was treating more C

knew,” he said. patients in India than I was actually ebecca R While he said it was emotionally treating here.” Patients who contracted the coronavirus lie in beds while connected to ox- draining, “at the same time, we felt In March 2020, the Indian Min- ygen supplies inside the emergency ward of a COVID-19 hospital on May a responsibility toward colleagues istry of Health and Family Welfare 3, 2021, in New Delhi. in India,” Dr. Odeti said, noting that released telemedicine practice guide- as COVID-19 cases have decreased lines for the country, which relaxed already admitted versus taking new contend with physical violence from in India, the requests have been less regulations on privacy requirements patients. That had caused problems patients and individuals on the frequent. and has been credited in part for for the administrators,” Dr. Adhikari street, Dr. Adhikari added. Work- Because of concerns about trav- giving telemedicine an additional added. place violence was already a concern eling to India during the pandemic boost during the pandemic. “That It is also a source of additional – for years, the Indian Medical Asso- while on a J-1, H-1B, or other visa makes it easy for people to reach out stress for the physicians. Where ciation has cited a statistic that 75% with the United States, directly but also has its own problems,” Dr. patients flow through a hospital of doctors in India have experienced helping friends and family in India Adhikari said. medicine model in the United States, violence at work (Indian J Psychia- seemed out of reach. But many Monitoring of milder COVID-19 a system that might include case try. 2019 Apr;61[Suppl 4]:S782-5). But hospitalists of Indian origin instead cases that don’t require hospitaliza- managers, social workers, pharma- the threat of violence against physi- turned to telemedicine to help their tion can be performed by a nurse cists, physician advocates, and other cians has sharply increased during colleagues. Telemedicine had already who calls every few hours to check professionals to keep a patient’s care the COVID-19 pandemic. Disruptions been steadily growing in India, but on a patient, make recommenda- on track, the physician is the go-to to daily life through lockdowns was accelerated by the pandemic. tions, and text treatment plans. “The “made people fearful, anxious, and The current ratio of doctors to pa- telemedicine platforms are being In response to the sometimes they have found it diffi- tients in India is 0.62 to 1,000 – lower adopted really fast,” Dr. Adhikari cult to access emergency treatment,” than recommendations from the Continued on following page restlessness, irritation, according to a letter published by and despair resulting Karthikeyan Iyengar and colleagues in the Postgraduate Medical Journal from hospitals closing (2020 Aug 19. doi: 10.1136/postgrad- their doors, people have medj-2020-138496). In response to shown their“ frustration the restlessness, irritation, and despair resulting from hospitals clos- by verbally abusing and ing their doors, “people have shown threatening to physically their frustration by verbally abusing and threatening to physically as- assault doctors and other sault doctors and other health care health care workers.” workers,” the authors wrote. Your path to leadership A telemedicine boon in India begins at SHM. person in India for patient care. Back in the United States, hospital- While physicians provide access to ists with family and friends in India medications and remain available to were trying to figure out how to Be Recognized for Promoting Excellence, a patient’s family, those duties be- help. Some were working through come much harder when caring for the day, only to answer calls and Innovation, & Improving the Quality of Patient Care a greater number of patients during WhatsApp messages from loved the pandemic. “That has led to some ones at night. “Everyone knows a Apply for SHM Awards of Excellence unrealistic expectations among the physician or someone who’s your Nominate yourself or a colleague for an patients,” Dr. Adhikari said. colleague, who owns a hospital or Award of Excellence across an array of categories. Dr. Bhatt said “more than half” runs a hospital, or one of the family hospitalmedicine.org/awards of a physician’s time in India is members is sick,” Dr. Adhikari said. spent counseling patients on con- These U.S.-based hospitalists were SHM Class of 2022 Fellows Program cerns about COVID-19. “Awareness burning the candle at both ends, Make 2022 your year by applying to become an SHM Fellow. about the disease is limited from helping with the pandemic in both Applications are now open to all qualifying members of the the patient and patient’s family countries. Physicians in India were hospital medicine team. perspective, as [there is] too much posing questions to U.S. colleagues hospitalmedicine.org/fellows apprehension toward the nature of who they saw as having the most [the] disease,” he added. “Theoretical recent evidence for COVID-19 treat- discussions collected from social ment. Out of the 180 physicians he Apply Today. media” obstruct the physician from trained with in India, Dr. Odeti said executing his or her duties. 110 of the physicians were in a large Physicians in India have had to WhatsApp group chat that was con- the-hospitalist.org | 17 | September 2021 INTERNATIONAL

Continued from previous page hospital setting. Could those skills said. “The platforms were built in no be put to use elsewhere in India af- time.” ter the pandemic? According to NewZoo, a games According to Dr. Bhatt, the patient market data analytics company, care model is likely to revert to the India has 345.9 million smartphone system that existed before. “What- users as of 2019 – the second highest ever the changes, interims of bed number of users in the world after occupancy, cost of ICU will be tem-

China. Dr. Odeti said he believes porary [and] will change to normal,” ac P ia telemedicine will be widely adopted. he said. “But awareness about masks s A

“In India, they are very proactive [and] sanitizing methods will be per- s mage I in accepting these kinds of methods, manent.” etty G so I’m sure they will,” he said. “Gov- Dr. Adhikari believes that not / ernments were trying to do it before utilizing the skills of newly minted tringer the pandemic, because access to care hospitalists in India would be a /S is a problem in India. There are vil- missed opportunity. “This is a silver arooqui lages which are very, very remote.” lining from COVID-19, that hospital F ariha

medicine plays a vital role in the F Reversion to old systems sickest patients, whether it is in Health care worker Shama Shaikh, 53, cares for a patient who has COV- After the peak in late May, new India or the U.S. or anywhere,” he ID-19 in an ICU ward at the government-run St. George hospital on May COVID-19 cases in India began to said. “I think the model of hospital 27, 2021, in Mumbai, India. The nation has experienced a prolonged and decrease, and the second wave medicine should be adopted. It’s not: devastating wave of COVID-19 infections. waned on a national level. Hospitals ‘Should it really be adopted or not?’ began to get the supplies they need- It should be. There is a huge poten- 5 days. “These hospitals right now by their primary care.” ed, beds are available, and patients tial in doing inpatient coordinated are learning the efficient ways of Anecdotally, Dr. Odeti sees pa- aren’t as sick as before, according [care], having people dedicated in doing it: when to send [patients] tients already adapting to having to Dr. Adhikari. The federal govern- the hospital.” out, how to send them out, how to access to a physician for asking ment has begun issuing supplies There are tangible benefits to cre- [perform] service-based practices, questions normally answered by to patients in each state, including ating efficiencies in India’s health creating processes which were non- primary care physicians. “I think COVID-19 vaccines. “The peak for system, Dr. Odeti said. Length of existent before.” primary care will come into play,” the second wave is gone,” he said. stay for sicker patients “was much While he doesn’t personally be- he said. “When I was doing a Zoom What remains is a group of phy- longer” at 10-14 days during the sec- lieve physicians will adopt a full- sicians trained in how to triage ond wave, compared with the Unit- fledged hospitalist model unless the In India, they are very patients and create efficiencies in a ed States, before lowering to around payer structure in India changes, “these people are at an advantage proactive“ in accepting with this extra set of skills,” he said. these kinds of methods… “I think all the knowledge that these people have are going to come in Governments were handy.” trying to do it before the Opportunities for growth pandemic, because access Dr. Odeti sees the potential for the to care is a problem in hospitalist model to grow in India – India. There are villages if not into its own specialty, then in April 7-10, 2022 how critical care consultants handle which are very…remote. Music City Center | Nashville, Tennessee sicker patients and handoffs. ” “The critical care clinician cannot call for patients, they were asking keep the patient from the time they me questions about sciatica. I think are admitted to the ICU until the they are getting comfortable with Present to a National Audience discharge, so there will be a need this technology.” for the transition,” Dr. Odeti said. A hospitalist model could even be at SHM Converge 2022 “In the past, there were not many applied to specific diseases with a capabilities in Indian health systems large population of patients. Hospi- Scientific Abstracts Competition to take care of these extremely sick tal administrators “have seen this patients, and now it is evolving. I for the first time, how efficient Join hospitalists from across the world to think that is one more thing that it could be if they had their own present and discuss emerging science and will help.” hospitalists and actually run it. So clinical cases, share feedback, and make Dr. Adhikari said hospital systems that’s the part that has crossed their valuable professional connections. in India are beginning to realize how minds,” Dr. Adhikari said. “How they having dedicated hospital physi- will apply it going forward, other Don’t miss your chance to participate in one of cians could benefit them. In India, than during the COVID-19 pandemic, the most anticipated events at SHM Converge. “if you’re sick, you go to your doctor, depends on the size of the hospital you get treated, and you disappear,” and the volume of the patients for a Submission Deadline: November 29, 2021 he said. The next time, you may see particular disease.” the same doctor or a completely “You can see in certain areas different doctor. “There’s no system there is large growth for hospital Learn More there, so it’s really hard for hospital medicine. But to rise to the level of shmconverge.org/abstracts medicine as such because patients, the United States and how we do it, when they are very sick, they just India needs bigger health systems to come to the ER. They’re not followed adopt the model,” Dr. Adhikari said. September 2021 | 18 | The Hospitalist COMMENTARY Addressing vaccine hesitancy with patients Break through with empathy and compassion

By Gwendolyn Williams, MD effective. However, throughout gressively among the unvaccinated, history, the work of scientists and and increased hospitalizations, we he COVID-19 pandemic is doctors to create vaccines saved foresee the reoccurrence of over- a worldwide tragedy. In millions of lives and revolutionized whelmed health systems and a con- the beginning there was a global health. Arguably, the single tinued death toll. lack of personal protective most life-saving innovation in the The new paradox we are faced Tequipment, COVID tests, and sup- history of medicine, vaccines have with is that people choose to be- port for health care workers and eradicated smallpox, and protected lieve fiction versus fact, despite patients. As 2020 came to a close, the against whooping cough (1914), diph- the real-life evidence of the severe world was given a glimpse of hope theria (1926), tetanus (1938), influenza health effects and increased deaths with the development of a vaccine (1945) and mumps (1948), polio (1955), related to COVID-19. Do these skep- against the deadly virus. Many measles (1963), and rubella (1969), tics simply have a cavalier attitude world citizens celebrated the scien- toward not only their own life, tific accomplishment and began to but the lives of others? Or, is there breathe a sigh of relief that there This past month, when something deeper? It is not enough was an end in sight. However, the asking“ patients why they to tell people that the vaccines are development and distribution of the proven safe3 and are more widely COVID-19 vaccine revealed a new don’t want the vaccine, available than ever. It is not enough challenge, vaccine hesitancy. I found many have no to tell people that they can die of Community members, young COVID-19 – they already know that. Dr. Williams is vice president of the healthy people, and even critically ill real legitimate health- Emotional pleas to family mem- Hampton Roads (Va.) chapter of the hospitalized patients who have the related reason. … So, how bers are falling on deaf ears. This Society of Hospital Medicine. She fortune of surviving acute illness do we get through to the past month, when asking patients is a hospitalist at Sentara Careplex are hesitant to the COVID-19 vac- why they don’t want the vaccine, I Hospital in Hampton, Va., where cine. I recently cared for a critically unvaccinated? found many have no real legitimate she also serves as vice president of ill young patient who was intubated ” health-related reason and respond the Medical Executive Committee. for days with status asthmaticus, and worldwide vaccination rates with a simple, “I don’t want to.” So, one of the worst cases I’d ever seen. increased dramatically thanks to how do we get through to the un- She was extubated and made a full successful global health campaigns.2 vaccinated? know about the COVID-19 vaccine?”; recovery. Prior to discharge I asked However, there was a paradox of or “Can you tell me more about why if she wanted the first dose of the vaccine success. As terrifying dis- A compassionate approach you feel that way?” As meticulous as COVID-19 vaccine and she said, eases decreased in prevalence, so did We navigate these difficult conver- it sounds, we have to go back to the “No.” I was shocked. This was an the fear of these diseases and their sations over time with the approach basics of patient interviewing. otherwise healthy 30-something- effects – paralysis, brain damage, of compassion and empathy, not It is important to remember that year-old who was lucky enough to blindness, and death. This gave birth hostility or bullying. As health care this is not a debate and escalation survive without any underlying to a new challenge in modern medi- providers, we start by being good to arguments will certainly backfire. infection in the setting of severe cine, vaccine hesitancy – a privilege empathic listeners. Similar to when Think about any time you disagreed obstructive lung disease. A coinfec- of first-world nations. we have advance care planning and with someone on a topic. Did criti- tion with COVID-19 would be disas- Vaccines saved countless lives code status conversations, we can- cizing, blaming, and shaming ever trous and increase her mortality. I and improved health and well-be- not enter the dialogue with our in- convince you to change your beliefs had a long talk at the bedside and ing around the world for decades. tention, beliefs, or formulated goals or behaviors? The likely answer is, asked the reason for her hesitancy. However, to prevent the morbidity for that person. We have to listen “No.” Avoid the “backfire effect”– Her answer left me speechless, “I and mortality associated with vac- without judgment to the wide range which is when giving people facts don’t know; I just don’t want to.” I cine-preventable diseases and their of reasons why others are reluctant disproving their “incorrect” beliefs ultimately convinced her that con- complications, and optimize control or unwilling to get the vaccine – his- can actually reinforce those beliefs. tracting COVID-19 would be a fate of vaccine-preventable diseases torical mistrust, political identity, The more people are confronted worse than she could imagine, and in communities, high vaccination religious reasons, short-term side with facts at odds with their opin- she agreed to the vaccine prior to rates must be achieved. Enter the effects that may cause them to lose ions, the stronger they cling to discharge. This interaction made COVID-19 pandemic, the creation of a day or two of work – and under- those opinions. If you want them to me ponder – “why are our patients, the COVID-19 vaccine, and vaccine stand that for each person their change their mind, you cannot ap- friends, and family members hes- hesitancy. reasons are different. The point is proach the conversation as a debate. itant about receiving a lifesaving The question we ask ourselves to not assume that you know or un- You are having this vaccine discus- vaccine, especially when they are as health care providers is “how do derstand what barriers and beliefs sion to try to meet the other person aware of how sick they or others we convince the skeptics and those they have toward vaccination, but where they are, understand their po- can become without it?” opposed to vaccination to take the to meet them at their point of view sition, and talk with them, and not According to the World Health Or- vaccine?” The answer is complicated. and listen while keeping your own at them, about their concerns. ganization, vaccine hesitancy refers If you are like me, you’ve had many emotions level and steady. As leaders in health care, we have to a delay in acceptance or refusal conversations with people – friends, Identifying the reason for vaccine to be willing to give up control and of vaccines despite availability of patients, family members, who are hesitancy is the first step to getting lead with empathy. We have to show vaccine services. Vaccine hesitancy resistant to the vaccine. Very often the unvaccinated closer to vacci- others that we hear them, believe is complex and context specific, the facts are not well received, and nation. Ask open-ended questions: their concerns, and acknowledge varying across time, place, and those discussions end in argument, “Can you help me understand, what that their beliefs are valid to them vaccines. It is influenced by factors high emotions, and broken rela- is your hesitancy to the vaccine?”; as individuals. Even if you disagree, such as complacency, convenience, tionships. With the delta variant of “What about the vaccine worries this is not the place to let anger, dis- and confidence.1 No vaccine is 100% COVID-19 on the rise, spreading ag- you?”; “What have you heard about/ Continued on following page the-hospitalist.org | 19 | September 2021

19to24HOSP21_9.indd 19 8/23/2021 12:07:59 PM COMMENTARY

Continued from previous page appointment, or resentment take a front seat. This is about balance, and high-lighting the autonomy in decision making that the other person has to make a choice. Be humble in these conversations and avoid con- descending tones or statements. We already know that you are a caring health care provider. As hospitalists, we are frontline providers who have seen unnecessary deaths and illness due to COVID-19. You are passionate and motivated because you are committed to your es oath to save lives. However, you g ma have to check your own feelings and I etty

remember that you are not speak- /G

ing with an unvaccinated person to amera C at

make them get vaccinated, but rath- F er to understand their cognitive process and hopefully walk with them you relinquish your intentions. ly. Sharing stories as hospitalists or child or senior care to leave home down a path that provides them Once you know or unveil their caring for many critically ill COVID safely to get vaccinated, or physical with a clarity of options they truly reasons for hesitancy, ask them patients or patients who died alone conditions that are preventing them have. Extend empathy and they will what they would like to see with because of COVID-19, and the trau- from receiving the vaccine. Share see your motivation is rooted in regards to COVID-19 and ending the ma you experienced as a health that being vaccinated protects you good-heartedness and a concern for pandemic. Would they like to get care provider feeling paralyzed by from contracting the virus and their well-being. back to a new normal, to visit family the limitations of modern medicine spreading it to loved ones. Focus on If someone admits to reasons for members, to travel once again, to not against the deadly virus, will only how a fully vaccinated community avoiding vaccination that are not have to wear masks and quarantine? serve to humanize you in such an and country can open up opportu- rooted in any fact, then guide them What do they want for themselves, interaction. nities to heal and connect as a soci- to the best resources. Our health their families, communities, the Building trust will also increase ety, spend time with family/friends care system recently released a country, or even the world? The goal vaccine willingness. This will require in another county or state, hold a COVID-19 fact versus myth handout is to find something in our shared a concerted effort by scientists, newborn grandchild, or even travel called Trust the Facts. This could humanity, to connect on a deeper doctors, and health care systems to outside the United States. be the kind of vetted resource you engage with community leaders and There is no guarantee that you will offer. Guide them to accredited members. To address hesitancy, the be able to persuade someone to get websites, such as the World Health If you are a vaccinated people we serve have to hear those vaccinated. It’s possible the outcome Organization, the Center for Disease local, personal, and relatable stories of your conversation will not result Control, or their local and state de- health“ care provider, your about vaccinations, and how it ben- in the other person changing their partments of health to help debunk words have influence and efits not just themselves, but others mind in that moment. That doesn’t fiction by reviewing it with them. around them in their community. mean that you failed, because you Discuss myths such as,“the vaccine power, and we are obliged As part of the #VaxUp campaign in started the dialogue and planted the will cause infertility,” “the vaccine by our positions to have Virginia, community and physician seed. If you are a vaccinated health will give me COVID,” “the vaccine responsibility for the leaders shared their stories of hesi- care provider, your words have influ- was rushed and is not safe,” “the vac- tancy and motivation surrounding ence and power, and we are obliged cine is not needed if I am young and health of our communities. the vaccine. These are real people by our positions to have responsibili- healthy,” “the vaccine has a micro- Don’t be discouraged. in the community discussing why ty for the health of our communities. chip,” etc. Knowledge is power and getting vaccinated is so important Don’t be discouraged, as it is through disinformation is deadly, but how ” and what helped them make an in- caring, compassionate, respectful, facts are presented will make the level so they start to open up and formed decision. I discussed my own and empathic conversations that biggest difference in how others re- let down walls, and find something hesitancy and concerns and also your influence will make the most ceive them, so remember your role is you both see eye-to-eye on. Know tackled a few vaccine myths. difference in these relationships as not to argue with these statements, your audience and speak to what As vaccinated health care workers you continue to advocate for all hu- but rather to provide perspective serves them. To effectively persuade or community leaders, you are liv- man life. without agreeing or disagreeing. someone to come around to your ing proof of the benefits of getting Respond to their concerns with point of view starts with recogniz- the COVID vaccine. Focus on the References statements such as, “I hear you. … It ing the root of the disagreement positives but also be honest. If your 1. World Health Organization. Report of the sounds like you are worried/fearful/ and trying to overcome it before second shot gave you fevers, chills, SAGE working group on vaccine hesitancy. Oct 2014. https://www.who.int/immunization/sage/ mistrusting about the side effects/ trying to change the person’s mind, or myalgias, then admit it and share meetings/2014/october/1_Report_WORKING_ safety/efficacy of the vaccine. … Can understanding both the logic and how you overcame these expected GROUP_vaccine_hesitancy_final.pdf. we talk more about that?” Ask them the emotion that’s driving their deci- reactions. Refocus on the safety of 2. Hsu JL. A brief history of vaccines: Smallpox where these concerns come from sion-making.4 the vaccine and the fact that it is to the present. S D Med. 2013;Spec no:33-7. PMID: 23444589. – the news, social media, an article, freely available to all people. Maybe 3. Chiu A and Bever L. Are they experimental? word of mouth, friends, or family. Building trust the person you are speaking with Can they alter DNA? Experts tackle lingering Ask them about the information Reminding patients, friends, or doesn’t know where or how to get an coronavirus vaccine fears. The Washington Post. they have and show genuine interest family members that their health appointment to get vaccinated. Help 2021 May 14. https://www.washingtonpost.com/ lifestyle/2021/05/14/safe-fast-vaccine-fear-infer- that you want to see it from their and well-being means a lot to you them find the nearest place to get tility-dna/. perspective. This is the key to com- can also be a strategy to keeping an appointment and identify barri- 4. Huang L. Edge: Turning Adversity into Advan- passionate and empathic dialogue – the conversation open and friend- ers they may have in transportation, tage. New York: Portfolio/Penguin, 2020. September 2021 | 20 | The Hospitalist

19to24HOSP21_9.indd 20 8/23/2021 12:08:54 PM CLINICAL Mental illness admissions: Among top diagnoses for ages 18-44 Depressive disorders in top 5 for men and women

By Richard Franki mental illnesses appearing among diagnosis for men in all three groups for all inpatient stays and all ages in MDedge News the top five nonmaternal diagnoses: and for women in two of three (45- 2018 with a rate of 679.5 per 100,000, Depressive disorders were second at 64 and ≥75), with osteoarthritis first followed by heart failure (347.9), os- ore mental and/or sub- 222.5 stays per 100,000 and bipolar among women aged 65-74 years, teoarthritis (345.5), pneumonia not stance use disorders are and related disorders were fourth they said. related to tuberculosis (226.8), and di- ranked among the top- at 142.0 per 100,000. The leading There was one mental illness abetes mellitus (207.8), based on data five diagnoses for hospi- primary diagnosis in women in 2018 among the top five diagnose s for from the National Inpatient Sample. Mtalized men and women aged 18-44 Depressive disorders were the years than for any other age group, most common mental health diag- according to a recent report from Administrators can use diagnosis-related information nosis in those admitted to hospitals the Agency for Healthcare Research and the 12th most common diagno- and Quality. to“ inform planning and resource allocation, such as sis overall; schizophrenia, in 16th In 2018, schizophrenia spectrum/ optimizing subspecialty services or units for the care of place overall, was the only other other psychotic disorder was the high-priority conditions. mental illness among the top 20, the leading primary diagnosis for investigators said. inpatient stays (251.2 per 100,000 ” “This information can help es- population) in men aged 18-44, was septicemia, which was the most children under age 18 years, as de- tablish national health priorities, while depressive disorders were the common cause overall in the age pressive disorders were the most initiatives, and action plans,” Dr. third-most common (195.0 stays per group at a rate of 279.3 per 100,000, common reason for stays in girls McDermott and Mr. Roemer wrote, 100,000) and alcohol-related disor- the investigators reported. (176.6 per 100,000 population) and and “at the hospital level, admin- ders were fifth at 153.2 per 100,000, There were no mental and/or the fifth most common for boys istrators can use diagnosis-related Kimberly W. McDermott, PhD, and substance use disorders in the top (74.0 per 100,000), said Dr. McDer- information to inform planning Marc Roemer, MS, said in an AHRQ five primary diagnoses for any of mott of IBM Watson Health and Mr. and resource allocation, such as statistical brief. the other adult age groups – 45- Roemer of AHRQ. optimizing subspecialty services or Prevalence was somewhat lower 64, 65-74, and ≥75 – included in the Septicemia was the leading non- units for the care of high-priority in women aged 18-44 years, with two report. Septicemia was the leading maternal, nonneonatal diagnosis conditions.”

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the-hospitalist.org | 21 | September 2021 CLINICAL

Key Clinical Question Should hospitalists use albumin to treat non-SBP infections in patients with cirrhosis? Caution is advised in patients at risk of pulmonary edema

By Aksharananda Rambachan, MD, MPH

patients.7 The primary outcome was Key points 90-day renal failure and the secondary outcome was 90-day survival. • In patients with spontaneous Renal failure was chosen as the pri- bacterial peritonitis, hepato- mary endpoint because of its asso- renal syndrome, and for large ciation with survival in this patient volume paracentesis, albumin Case population. The treatment group had improves outcomes and is rec- A 56-year-old male with hypertension, alcohol use disorder, stage II delayed onset of renal failure, but no ommended by guidelines. chronic kidney disease, and biopsy-proven cirrhosis presents with difference in the development of 90- • In patients with cirrhosis and maGes fever and chills, pyuria, flank pain, and an acute kidney injury con- i day renal failure or 90-day mortality a non-SBP infection, there is etty

cerning for pyelonephritis. Is there a benefit in treating with albumin /G rate. Notably, eight patients (8.3%) in some evidence that albumin in addition to guideline-based antibiotics? the albumin group developed pulmo- may improve renal and circula-

fruttipics nary edema with two deaths. This tory function. led the oversight committee to pre- • Clinicians should be cautious Brief overview of the issue additional indications. However, giv- maturely terminate the study. about albumin use in patients Albumin is a negatively charged hu- en the known benefits of albumin Third and most recently, there was at an elevated risk for develop- man protein produced by the liver. in patients with SBP, there has been a multicenter RCT by Fernández et al. ment of pulmonary edema. Albumin comprises 50% of plasma recent research into treatment of in 2019 of 118 patients.8 The primary protein and over 75% of plasma non-SBP infections, including uri- outcome was in-hospital mortality, oncotic pressure.1 It was first used nary tract infections. with secondary outcomes of circula- patients with bacterial infections at Walter Reed Hospital in 1940 and tory dysfunction measured by plasma found that treatment with albumin subsequently for burn injuries after Overview of the data renin concentration, systemic inflam- reduced systemic inflammation.11 the attack on Pearl Harbor in 1941.2 There have been three randomized mation measured by plasma IL-6 and In summary, the three RCTs Albumin serves several important controlled trials (RCTs) regarding biomarkers, complications including looked at comparable patients with physiologic functions including albumin administration for the acute-on-chronic liver failure (ACLF) cirrhosis and a non-SBP infection maintaining oncotic pressure, endo- treatment of non-SBP infections for and nosocomial bacterial infections, and all underwent similar treat- thelial support, antioxidation, nitro- hospitalized patients with cirrhosis. and 90-day mortality. Between the al- ment protocols with 20% albumin gen oxide scavenging, and buffering All three trials randomized patients bumin and control group, there were dosed at 1.5 g/kg on day 1 and 1.0 g/ and transport of solutes and drugs, to a treatment arm of albumin and no differences in in-hospital mortality kg on day 3. All studies evaluated including antibiotics. In cirrhosis, antibiotics versus a control group (13.1% vs. 10.5%, P > .66), inflammation, mortality in either the primary or albumin is diluted because of sodi- of antibiotics alone. The treatment circulatory dysfunction, or liver se- secondary outcome, and none found um and water retention. There is protocol prescribed 20% albumin verity. However, a significantly higher significant differences in mortality increased redistribution, decreased with 1.5 g/kg on day 1 and 1.0 g/kg proportion of patients in the albumin between treatment and control synthesis by the liver, and impaired on day 3. The most common infec- group had resolution of their ACLF groups. Each study also evaluated albumin molecule binding.3 tions studied were pneumonia and (82.3% vs. 33.3%, P = .003) and a lower and found improvement in renal For patients with liver disease, per urinary tract infection. These RCTs proportion developed nosocomial and/or circulatory function. Fernán- the European Association for the found that albumin administration infections (6.6% vs. 24.6%, P = .007). dez et al. also found increased res- Study of the Liver and the American was associated with improved renal A major weakness of this study was olution of ACLF, fewer nosocomial Association for the Study of Liver and/or circulatory function, but not that patients in the albumin group infections, and reduction in some Diseases, albumin should be ad- with a reduction in mortality. had a higher combined rate of ACLF inflammatory markers. However, all ministered to prevent postparacen- First, there was a single center and kidney dysfunction (44.3% vs. studies had relatively small sample tesis circulatory dysfunction after RCT by Guevara et al. in 2012 of 110 24.6%, P = .02). sizes that were underpowered to large-volume paracentesis, to pre- patients with cirrhosis and infection Beyond these three randomized detect mortality differences. Fur- vent renal failure and mortality in based on SIRS criteria.6 The primary controlled trials, there was a study thermore, randomization did not the setting of spontaneous bacterial outcome was 90-day survival with on the long-term administration of lead to well-matched groups, with peritonitis (SBP), and in the diag- secondary outcomes of renal failure albumin for patients with cirrhosis the treatment group patients in the nosis and treatment of hepatorenal development; renal function at days and ascites. Patients who received Fernández study having higher rates syndrome (HRS) type I to poten- 3, 7, and 14; and circulatory function twice-weekly albumin infusions of ACLF and kidney dysfunction. tially improve mortality.4,5 Beyond measured by plasma renin, aldo- had a lower 2-year mortality rate The data suggest that albumin these three guideline-based indica- sterone, and norepinephrine. Renal and a reduction in the incidence of may be beneficial in improving tions, other uses for albumin for pa- function and circulatory function both SBP and non-SBP infections.9 renal and circulatory function. In tients with liver disease have been improved in the albumin group, but Another long-term study of albumin select patients with ACLF and el- proposed, including treatment of not mortality. In a multivariable administration found similar results evated serum creatinine, albumin hyponatremia, posttransplant fluid regression analysis, albumin was with greater 18-month survival and treatment may be considered. There resuscitation, diuretic unresponsive statistically predictive of survival fewer non-SBP infections.10 A trial has been discussion about the use ascites, and long-term management (hazard ratio, 0.294). looking at inflammation in patients of albumin preferentially in patients of cirrhosis. There has yet to be Second, there was a multicenter without bacterial infections and in with subdiaphragmatic bacterial strong evidence supporting these RCT by Thévenot et al. in 2015 of 193 biobanked samples from cirrhotic infections, most related to increased September 2021 | 22 | The Hospitalist 153257.graphic CLINICAL

inine, an infectious Summary of RCTs for use of albumin in patients with cirrhosis and non-SBP infections process associated IMNG Print Colors Headline for a Bar Graphic Author Study type N Primary Result of Selected Results of Other notable with progressive If a deck headline is needed, use this style. renal failure, and is outcome primary outcome secondary secondary ndings and comments (albumin vs. control) outcomes outcomes not at an elevated Label style and size Fernandez Multicenter 118 In-hospital 13.1% vs. Resolution 82.3% vs. Fewer nosocomial infections baseline risk of de- et al. 2019 RCT mortality 10.5% of ACLF 33.3% in treatment group. Axes number style and size veloping pulmonary (P = .66) (P = .03) Treatment group at baseline edema, albumin had higher rates of ACLF Note: Trade Gothic Medium, 8/11 ush left would be reasonable and kidney dysfunction. Source: Trade Gothic Medium, 8/11 ush left to administer at 1.5 Thévenot Multicenter 193 3-month 14.3% vs. 3-month 70.2% vs. Onset of renal failure et al. 2015 RCT renal 13.5% survival 78.3% reduced in treatment group Style Guide: g/kg on day 1 and failure (P = .88) (P = .16) (29 vs. 11.7 days; P < .001). Keep the background white. 1.0 g/kg on day 3 of 8/96 patients in treatment Use the IMNG colors. Dr. Rambachan is an academic hospitalization. group developed pulmonary Move the entire graph to align the bar labels left at the blue guide bar. edema with two deaths. hospital medicine fellow at the (Resizing may need to be done on the graph to t in the space.) University of California, San Bottom line Guevara Single- 110 3-month 82.6% vs. Creatinine Creatinine In multivariable regression If a deeper or shorter template is needed, adjust in Window > Artboards. Francisco. In certain patients et al. 2012 center RCT survival 80.4% at days reduction analysis, albumin treatment (P = .75) 3, 7, 14 in albumin was associated with reduced (Standard, as shown here, is 28 picas x 20 picas.) with cirrhosis and a group mortality (HR, 0.294; To create the dotted lines if they change, use the clear arrow tool, click non-SBP infection, (P < .05) P = .042). on the line that needs to be changed, use the eyedropper tool, then MDedge News risk of renal failure such as biliary the use of albumin click on the dotted rule provided on the side of the template. and urinary tract infections.12 The to help improve re- Source: Dr. Rambachan authors of these studies also note nal and circulatory tis in cirrhosis. A randomized, controlled study. 10. Caraceni P et al. Long-term albumin that albumin may be more benefi- function is reasonable. There is no J Hepatol. 2012 Oct;57(4):759-65. doi: 10.1016/j. administration in decompensated cirrho- cial in patients with higher baseline evidence that albumin will improve jhep.2012.06.013. sis (ANSWER): An open-label randomised creatinine. Caution is warranted for mortality and caution is warranted for 7. Thévenot T et al. Effect of albumin in cirrhotic trial [published correction appears in Lancet. patients with infection other than spontane- 2018 Aug 4;392(10145):386]. Lancet. 2018 patients with impaired cardiac func- patients at risk for pulmonary edema. ous bacterial peritonitis. A randomized trial. J June;391(10138):2417-29. doi: 10.1016/S0140- tion or poor respiratory status given Hepatol. 2015 Apr;62(4):822-30. doi: 10.1016/j. 6736(18)30840-7. the possibility of pulmonary edema. References jhep.2014.11.017. 11. Fernández J et al. Effects of albumin treat- Finally, the high cost of albumin in 1. Caironi P and Gattinoni L. The clinical use 8. Fernández J et al. Efficacy of albumin treatment on systemic and portal hemodynamics ment for patients with cirrhosis and infections and systemic inflammation in patients with many medical centers is a major lim- of albumin: The point of view of a specialist in intensive care. Blood Transfus. 2009;7(4):259-67. unrelated to spontaneous bacterial peritonitis. decompensated cirrhosis. Gastroenterol- itation of this treatment approach. doi: 10.2450/2009.0002-09. Clin Gastroenterol Hepatol. 2020 Apr;18(4):963- ogy. 2019 July;157(1):149-62. doi: 10.1053/j. 73.e14. doi: 10.1016/j.c gh.2019.07.055. gastro.2019.03.021. 2. Paine CH et al. Albumin in cirrhosis: More Application of data to our than a colloid. Curr Treat Options Gastroen- 9. Di Pascoli M et al. Long-term administration 12. Fasolato S et al. Renal failure and bacte- terol. 2019;17(2):231-43. doi: 10.1007/s11938- of human albumin improves survival in patients rial infections in patients with cirrhosis: Epide- patient 019-00227-4. with cirrhosis and refractory ascites. Liver Int. miology and clinical features. Hepatology. 2019 Jan;39(1):98-105. doi: 10.1111/liv.13968. 2007;45(1):223-9. doi: 10.1002/hep.21443. Our patient has cirrhosis and is acute- 3. Walayat S et al. Role of albumin in cirrhosis: ly presenting with pyelonephritis From a hospitalist’s perspective. J Community and acute kidney injury. He has no Hosp Intern Med Perspect. 2017;7(1):8-14. 2017 Mar 31. doi: 10.1080/20009666.2017.1302704. baseline pulmonary disease or oxygen 4. Runyon BA and AASLD. Introduction to the requirement. His recent transthoracic revised American Association for the Study echocardiogram is reviewed and he of Liver Diseases Practice Guideline [for the] has no evidence of cardiac disease. management of adult patients with ascites Serving those who provide care. due to cirrhosis 2012. Hepatology. 2013 Because he has an elevated creat- Apr;57(4):1651-3. doi: 10.1002/hep.26359. 5. European Association for the Study of the IT’S IN OUR DNA. Liver. EASL Clinical Practice Guidelines for Additional reading the management of patients with decompensated cirrhosis [published correction appears We’re taking the mal out of malpractice insurance. • Bernardi M et al. Albumin in in J Hepatol. 2018 Nov;69(5):1207]. J Hepa- Delivering the best imaginable service and unrivaled decompensated cirrhosis: new tol. 2018 Aug;69(2):406-60. doi: 10.1016/j. rewards is at the core of who we are. As an organization jhep.2018.03.024. founded and led by physicians, we understand the value of concepts and perspectives. 6. Guevara M et al. Albumin for bacterial infec- superior care. Because for us, it’s not just a best practice, Gut. 2020 June;69(6):1127-38. doi: tions other than spontaneous bacterial peritoni it’s in our unique code. Join us at thedoctors.com 10.1136/gutjnl-2019-318843. • Runyon BA and AASLD. Intro- Quiz duction to the revised Ameri- can Association for the Study Which of the following is not a of Liver Diseases Practice guideline-recommended use of al- Guideline [for the] management bumin for patients with cirrhosis? of adult patients with ascites A. Treatment of type 1 hepatore- due to cirrhosis 2012. Hepatol- nal syndrome ogy. 2013 Apr;57(4):1651-3. doi: B. Treatment of spontaneous 10.1002/hep.26359. bacterial peritonitis • Paine CH et al. Albumin in C. To correct plasma albumin cirrhosis: More than a colloid. < 2.5 g/dL in nontransplant Curr Treat Options Gastroen- patients terol. 2019 June;17(2):231-43. doi: D. Post large-volume paracentesis 10.1007/s11938-019-00227-4. Exclusively endorsed by • Walayat S et al. Role of albumin The answer is C. Per the EASL in cirrhosis: From a hospital- and AASLD, A, B, and D are rec- ist’s perspective. J Community ommended. There is not strong Hosp Intern Med Perspect. evidence to support administer- 2017 Mar 31;7(1):8-14. doi: ing albumin to correct low plas- 10.1080/20009666.2017.1302704. ma albumin. the-hospitalist.org | 7845_SHM_Hospitalist_DNA_Sep2021_v2.indd 23 | September 2021 1 7/30/21 9:43 AM CLINICAL Patients with diabetes more likely to be hospitalized, especially with foot infection

By Liam Davenport Black-White differences in glycemic markedly for foot infection.” socioeconomic status, and have control, access to care, and beliefs “These new data further highlight worse cardiometabolic health than eople with diabetes are at around vaccines.” the need for public health interven- participants without diabetes. increased risk of hospital- Overall, their findings – coupled tions to prevent type 2 diabetes, and Over an average follow-up of 23.8 ization for infection, as well with recent data showing that dia- for preventive health care in people years, there were 4,229 incident as infection-related mortal- betes is an important risk factor for with diabetes, including access to hospitalizations for infection, at Pity, shows a large U.S. study that adverse outcomes with COVID-19 in- diabetes medications and support an overall rate of 15.9 per 1,000 per- suggests the risk is even higher in fection – paint “a common picture,” and to vaccinations to prevent in- son-years. younger and Black individuals. Dr. Fang said. fection,” added Dr. Hartmann-Boyce, Individuals with diabetes at base- Michael Fang, PhD, Johns Hopkins “People with diabetes are much who is a senior research fellow in line had a higher rate of hospitaliza- University, Baltimore, and colleagues more susceptible to infection-related health behaviors. tions than those without, at 25.4 per studied more than 12,000 partici- complications, including COVID-re- Diabetes is thought to be associ- 1,000 person-years versus 15.2 per pants in a community cohort study lated hospitalization and mortality,” ated with susceptibility to infection 1,000 person-years. who were followed for an average of which suggests people with diabetes via mechanisms such as impaired After sociodemographic charac- 24 years, between 1987-1989 and 2019. “may need to be especially cautious.” neutrophil functioning and humoral teristics, socioeconomic status, and Participants with diabetes faced a immune responses, and studies have cardiometabolic risk factors were 67% increase risk of infection-relat- Adds to existing literature; shown a link with both common considered, this equated to a hazard ed hospitalization, compared with amputations begin with and rare infections. ratio for hospitalization with any those without diabetes. infections However, the authors point out infection of 1.67 (P < .001). Of particular note, the risk of Robert A. Gabbay, MD, PhD, chief that “most” of those included “small The risk of hospitalization for any hospitalization with foot infection scientific and medical officer for clinical populations and were infection was significantly higher was almost sixfold higher for people the American Diabetes Association, cross-sectional or had short fol- with diabetes than those without. said the study low-up.” The research, published in Diabe- “does add to the Guidelines for diabetes manage- People with diabetes tologia on Aug. 4 (2021. doi: 10.1007/ existing litera- ment, they note, also “pay less at- are“ much more s00125-021-05522-3), also suggests ture by having tention” to infectious diseases than that diabetes may be associated followed a larger they do to the prevention of micro- susceptible to infection- with a 72% increased risk of infec- number of people and macrovascular complications. related complications, tion-related mortality, although the over time and absolute numbers were small. linking them to ARIC data mined for infections including COVID-related Dr. Fang explained to this news serious complica- in those with diabetes hospitalization and organization that they focused on Dr. Gabbay tions from infec- The team analyzed data from the mortality. infection-related hospitalization and tions.” ongoing U.S. community-based Ath- mortality “because these are com- “Sadly, we have seen this play out erosclerosis Risk in Communities ” prehensively tracked in administra- in real-time during the COVID-19 (ARIC) study. for younger patients with diabetes, tive data and ... are the most severe pandemic.” The National Heart, Lung, and defined as aged less than 55 years types of outcomes.” “One of the sobering bits of data Blood Institute–sponsored cohort (P = .005), and for Black patients (P < However, this is probably just the is the significant health disparities was composed of adults aged 45-64 .001). tip of the iceberg, as people with dia- that exist in Black Americans and years from four U.S. communities, While the increased risk was gen- betes are “likely at increased risk for the fact that foot infections remain recruited between 1987 and 1989 for erally consistent across infection milder infection too,” which can have a significant problem,” he said in an clinical examinations, medical inter- types, it was markedly increased for a “significant adverse impact on peo- interview. views, and laboratory tests, repeated foot infection, at a hazard ratio of ple’s well-being and quality of life.” “Given that amputation rates for over five more visits up to 2018-2019. 5.99 (P < .001). As a result of their findings, the [Black Americans] are three times For the current analysis, the team Overall, there were few deaths due authors call for “broader guidance higher than White Americans, am- included 12,739 individuals with a to infection in the study, at just 362. on infection prevention and man- putations begin with infections,” Dr. mean age of 54.5 years, of whom The risk of infection mortality was agement” in people with diabetes. To Gabbay added, noting the ADA “has 54.3% were female and 24.7% were nevertheless significantly increased achieve this, Dr. Fang said, “we need been taking a strong stand to pre- Black. in people with diabetes, at an adjust- to better understand why diabetes is vent amputations and address the Patients were defined as having ed hazard ratio of 1.72 (P < .001). associated with an increased risk of inequities in health that exist.” diabetes if their baseline fasting Dr. Fang has reported being sup- infection-related complications.” Jamie Hartmann-Boyce, PhD, blood glucose was greater than or ported by a grant from the National “One likely factor is glycemic con- from the University of Oxford, U.K., equal to 7 mmol/L, or nonfasting Institutes of Health/National Heart, trol: Emerging research suggests who was not involved in the study, glucose was greater than or equal Lung, and Blood Institute. Dr. Selvin patients with diabetes with better commented that diabetes is a “well- to 11.1 mmol/L, they self-reported a has reported being supported by glycemic control may be at signifi- known risk factor for worse out- diagnosis of diabetes by a physician, grants from the National Institutes cantly lower risk of infection-related comes from all kinds of infection,” or they were taking glucose-low- of Health/National Heart, Lung, and complications.” which is why they “are prioritized ering medication at the first study Blood Institute and National Insti- He continued that, in younger pa- for flu vaccination every year.” visit. The researchers weren’t able to tutes of Health/National Institute of tients, a factor for worse outcomes She told this news organization distinguish between type 1 and type Diabetes and Digestive and Kidney could be that “diabetes tends to be that the current study “further 2 diabetes. Diseases. Dr. Selvin is an associate more aggressive when it emerges confirms that people with diabetes In total, 1,485 individuals had di- editor for Diabetologia and had no early in life,” while in Black patients are more likely to be hospitalized abetes at baseline. They were more role in the peer review of the man- “there is research highlighting for infection of any type and most likely to be older, Black, have a low uscript. September 2021 | 24 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

Concord :25 Boston

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

MASSACHUSETTS Director of Clinical Operations Hospitalist Service

Find out why so many top physicians are practicing at Emerson Hospital. At Emerson Hospital you will find a desirable place to About Concord, MA and Emerson Hospital practice, strong relationships with academic medical centers, superb quality of life, top rated school districts, competitive financial packages and more… Emerson Hospital Emerson Hospital is seeking a full or part time Director of Clinical provides advanced medical services to Operations to join our well-established team of 12 attending more than 300,000 people in over physicians and 3 nurse practitioners. The hospitalist service 25 towns. We are a 179 bed hospital provides care to patients on the general inpatient medical service as with more than 300 primary care doctors and specialists. well as patients admitted to the behavioral health and transitional Our core mission has always been care units. to make high-quality health care accessible to those that live and work • Board Certification in Internal Medicine in our community. While we provide • Full or part time, will also work clinically as an attending physician most of the services that patients will • Responsibilities include: recruiting, oversight of budget and ever need, the hospitals strong clinical collaborations with Boston’s academic payroll, quality improvement initiatives related to inpatient care medical centers ensures our patients • Three plus years’ experience required as an attending physician have access to world-class resources • Experience preferred in both leadership and quality improvement for more advanced care. • Work in collaboration with the Medical Director of Hospital Medicine • Report to the Chief Medical Officer

For more information please contact:

Diane Forte Willis 324722 Director of Physician Recruitment and Relations 978-287-3002, [email protected]

Not a J-1 of H1B opportunity EMERSONHOSPITAL.ORG TT0521 September 2021 | 25 | The Hospitalist 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: From the hospital to the • Hospital Medicine was established at Ochsner in 1992. We have a stable 50+ member group. home and everything • 7 on 7 off block schedule with exibility in-between, Vituity • Dedicated nocturnists cover nights hospitalists deliver and • Base plus up to 40 K in incentives coordinate superior care. • Average census of 14-18 patients • E-ICU intensivist support with open ICUs at the community hospitals • EPIC medical record system with remote access capabilities • Dedicated RN and Social Work Clinical Care Coordinators • Community based academic appointment Hospitalists Needed • The only Louisiana Hospital recognized by U.S. News and World Report Distinguished Hospital for Clinical Excellence award in 3 medical specialties Seeking board eligible/certified IM • Co-hosts of the annual Southern Hospital Medicine Conference and FP physicians with inpatient • We are a medical school in partnership with the University of Queensland providing experience in the following areas: clinical training to third and fourth year students. Arizona, California, Illinois, • Leadership support focused on professional development, quality improvement, and Indiana, Michigan, Missouri, Oregon, and South Carolina. academic committees & projects • Opportunities for leadership development, research, resident and medical student Competitive income plus annual teaching profit sharing bonus with • Skilled nursing and long term acute care facilities seeking hospitalists and mid-levels premium benefits. with an interest in geriatrics • Paid malpractice coverage and a favorable malpractice environment in Louisiana Impact change at the local level. • Generous compensation and bene ts package Ochsner Health is a system that delivers health to the people of Louisiana, Mississippi and National network of support for urgent clinical and non-clinical the Gulf South with a mission to Serve, Heal, Lead, Educate and Innovate. Ochsner Health needs that includes crisis support, is a not-for-pro t committed to giving back to the communities it serves through preventative equipment supplies, and burnout. 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 HM Administrative Fellowship, globe in 2019, providing the latest medical breakthroughs and therapies, including digital leadership opportunities and medicine for chronic conditions and telehealth specialty services. Ochsner Health is a national training available. 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 Up to $150,000 sign-on bonus thousands of healthcare professionals annually. Ochsner Health is innovating healthcare for select locations. 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 Why Vituity? 4,500 providers are working to reinvent the future of health and wellness in the region. To For nearly 50 years, Vituity has been learn more about Ochsner Health, please visit www.ochsner.org. To transform your health, a catalyst for positive change in please visit www.ochsner.org/healthyyou. healthcare. As a physician-led and -owned multispecialty partnership, Interested physicians should apply to: our 5,000 doctors and clinicians care https://ochsner.wd1.myworkdayjobs.com/en-US/OchsnerPhysician/job/ for nearly 8 million patients each year across 450 practice locations and nine New-Orleans---New-Orleans-Region---Louisiana/Hospital-Medicine-Sourcing-Requisition acute care specialties. Learn about ---all-regions_REQ_00022186 our innovative solutions to healthcare Sorry, no opportunities for J1 applications. challenges at vituity.com. Ochsner is an equal opportunity employer and all qualified applicants will receive consideration for employment without Explore Jobs regard to race, color, religion, sex, national origin, sexual orientation, disability status, protected veteran status, or any vituity.com/careers other characteristic protected by law. 318930 Questions? [email protected]

To learn more, visit www.the-hospitalist.org and click “Advertise” or contact Linda Wilson • 973-290-8243 • [email protected] 313447

the-hospitalist.org | 26 | September 2021 Make your next smart move. Visit shmcareercenter.org.

Inspiring Health. Empowering Careers.

Find fulfillment with Franciscan! Our close-knit, collaborative hospitalist teams are growing across Indiana. Franciscan Health is seeking BOARD CERTIFIED/BOARD ELIGIBLE INTERNAL MEDICINE OR FAMILY MEDICINE HOSPITALISTS to meet the growing demand of our stable, established hospitalist programs at locations throughout Indiana.

With 13 hospitals, Franciscan Health is one of the largest Catholic health care systems in the Midwest. Of our 260+ locations, many are nationally recognized Centers of Health Care Excellence. Franciscan Health takes pride in providing compassionate, comprehensive care for our patients and the communities we serve

Our facilities have earned Centers of Excellence designations, five-star quality awards and top rankings in our state and nationwide.

LET US TELL YOU MORE ABOUT FRANCISCAN HOSPITALIST OPPORTUNITIES !

844-FPN-DOCS (376-3627) [email protected] jobs.franciscanhealth.org

324722 September 2021 | 27 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

Hospitalist Opportunities at Atlantic Health System

Atlantic Health System is seeking a full time Hospitalists and Nocturnist to join our dynamic team in Hackettstown (Warren county) and Newton (Sussex county) New Jersey. Both Hackettstown Medical Center and Newton Medical Center are award winning community hospitals. The Hospitalist is responsible for the provision of in-patient Internal Medicine services to patients under their care within the Medical Center. • Open ICU with 24-hour Intensivist Telemedicine support. • Need for strong competent physicians to run RRT and codes. • Advanced Practice Nursing support • Designated Observation Unit • Flexible scheduling Powered by a workforce of almost 17,000 team members and 4,800 affiliated physicians dedicated to building healthier communities, Atlantic Health System serves more than half of the state of New Jersey including 11 counties and 4.9 million people. The system offers more than 400 sites of care, including seven hospitals: Morristown Medical Center in Morristown, NJ, Overlook Medical Center in Summit, NJ, Newton Medical Center in Newton NJ, Chilton Medical Center in Pompton Plains, NJ, Hackettstown Medical Center in Hackettstown, NJ, Goryeb Children’s Hospital in Morristown, NJ, and Atlantic Rehabilitation Institute in Madison, NJ. We are confident that you will find success within Atlantic Health System, which has been named for the 13th year in a row to Fortune’s “Top 100 Best U.S. Companies to Work For” list. Comprehensive health benefits package and competitive salary • Competitive base salary, incentives and bonus. • CME & Tuition Reimbursement • Relocation assistance and professional liability coverage • Work/Life Balance • Live and work within a short drive of New York City, Poconos, Philadelphia. To learn more about this opportunity please contact Ritu Vedi at [email protected] or feel free to call me at 973-521-2210.

325035

Day Hospitalist, Admission Hospitalist and Nocturnist Opportunities

POSITIONS IN THE GREATER ST. LOUIS AREA Mercy Clinic is actively recruiting Day Hospitalists, Admission Hospitalists and Nocturnists to join our established groups on-campus at two of our Mercy Hospital locations in the Greater St. Louis Metropolitan Area. Qualified candidates can be IM or FM trained and should be available to start in 2021. Opportunities Offer: • Integrated health system with competitive base salary, quarterly bonus, and incentives • $25,000 Commencement Bonus • Providing clinical services at one hospital location • Ability to moonlight at other Mercy Hospitals in St. Louis and surrounding area • Eligibility for sponsorships of H1B Visas • Comprehensive benefits including health, dental, vacation and $5000 annual CME allowance • Relocation assistance and professional liability coverage Locations include Mercy Hospital South in South St. Louis To advertise in and Mercy Hospital Jefferson in Festus. Both locations have quick and easy access to downtown St. Louis and local The Hospitalist or the amenities.. Journal of Hospital Medicine Become a part of our legacy and help us build a healthier future. CONTACT: For more information, please contact: Joan Humphries | Director, Physician Recruitment Linda Wilson Office: 314-364-3821 973.290.8243 [email protected] | careers.mercy.net [email protected] AA/EEO/Minorities/Females/Disabled/Veterans 325241 the-hospitalist.org | 28 | September 2021 Make your next smart move. Visit shmcareercenter.org.

Washington University School of Medicine is seeking full-time hospitalists, nocturnists and oncology Hospitalist Opportunities hospitalists for our expanding program at Barnes-Jewish Gorgeous Lakes, Ideal Climate, Award-winning Downtown Hospital and Barnes-Jewish West County Hospital. MD/ DO, internal medicine board certification or eligibility, and Inspire health. Serve with compassion. Be the difference. eligibility for licensure in the state of Missouri required. • Comprehensive • Teaching opportunities Prisma Health is a not-for-profit health company and the largest healthcare liability insurance available system in South Carolina. With nearly 30,000 team members, 18 acute and (no tail required) • Competitive base salary specialty hospitals, 2,947 beds and more than 300 outpatient sites with nearly • 403b Retirement, • Health, dental, vision 2,000 physicians, Prisma Health serves more than 1.2 million unique patients with match • Professional allowance OFFERING • Flexible, block schedule • Bonus eligibility annually in its 21-county market area that covers 50% of South Carolina. Barnes-Jewish Hospital is a 1,300-bed Level-I trauma Prisma Health’s goal is to improve the health of all South Carolinians by center serving the St. Louis metropolitan and outlying areas. enhancing clinical quality, the patient experience and access to affordable It is ranked as one of the nation’s top hospitals by US News & care, as well as conducting clinical research and training the next generation World Report. of medical professionals. This position is not J-1 eligible. All qualified applicants will receive consideration for employment without regard to sex, Greenville, South Carolina is a beautiful place to live and work and is located race, ethnicity, protected veteran, or disability status. on the I-85 corridor between Atlanta and Charlotte and is one of the fastest Interested candidates should apply: growing areas in the country. Ideally situated near beautiful mountain ranges, facultyopportunities.wustl.edu Select “Internal Medicine” and see “Hospitalist”. beaches and lakes, we enjoy a diverse and thriving economy, excellent quality of life and wonderful cultural and educational opportunities. Check out all that Greenville, SC has to offer! #yeahTHATgreenville

Ideal Candidates: • BC/BE Internal Medicine Physicians 325605 • IM procedures highly desired, but not required. Simulation center training & bedside 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: next job today! Nocturnist, Laurens County Hospital • $342K base salary with $40K incentive bonus and CME stipend Up to $40K sign on bonus for a 4 year commitment visit SHMCAREERCENTER.ORG • Nocturnist, Baptist Easley Hospital • $340K base salary with $10K incentive bonus and CME stipend • Up to $40K sign on bonus for a 4 year commitment as a Nocturnist

Please submit a letter of interest and CV to: Natasha Durham, Physician Recruiter, [email protected], ph: 864-797-6114 318938

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

September 2021 | 29 | The Hospitalist COMMENTARY

PHM Fellows New fellowship, no problem Using a growth mindset to tackle challenges in a new program

By Daniel Herchline, MD, to others, which can lead to ambigu- provement, and medical education. MSED ous expectations and disruptions to From initial stages of idea devel- normal workflows. Furthermore, as- opment through the final steps of rowth mindset is a sessing and evaluating new fellows manuscript submission and peer re- well-established phenom- may prove difficult as a result of view, fellows will undoubtedly nav- enon in childhood educa- these unclear expectations and gen- igate a plethora of challenges and tion that is now starting eral uncertainties. Using the growth setbacks along the way. Program di- Gto appear in health care education mindset can help both PHM fellows rectors and other core faculty mem- literature.1 This concept empha- and program directors take a de- bers can promote a growth mindset sizes the capacity of individuals to liberate approach to the challenges culture by honestly discussing their change and grow through experi- and uncertainty that may accompa- own challenges and failures in ca- ence and that an individual’s basic ny the creation of a new fellowship reer endeavors in addition to giving qualities can be cultivated through program. thoughtful constructive feedback. hard work, open-mindedness, and One of the challenges new PHM Fellows should routinely practice help from others.2 fellows may encounter lies within explicitly identifying knowledge Growth mindset opposes the con- the structure of the care team. Res- and skills gaps that represent areas cept of fixed mindset, which implies ident and medical student learners for potential improvement. But intelligence or other personal traits may express consternation that the perhaps most importantly, fellows are set in stone, unable to be funda- new fellow role may limit their own must strive to see all feedback and Dr. Herchline is a pediatric mentally changed.2 Individuals with autonomy. In addition, finding the perceived failures not as personal hospitalist at Cincinnati Children’s fixed mindsets are less adept at right balance of autonomy and su- affronts or as commentaries on Hospital Medical Center and coping with perceived failures and pervision between the attending-fel- personal abilities, but rather as recent fellow graduate of the critical feedback because they view low dyad may prove to be difficult. opportunities to strengthen their Children’s Hospital of Philadelphia. these as attacks on their own abil- However, using the growth mindset scholarly products and gain valu- During fellowship, he completed ities.2 This oftentimes leads these may allow fellows to see the inher- able experience for future endeav- a master’s degree in medical individuals to avoid potential chal- ent benefits of this new role. ors. education at the University of lenges and feedback because of fear Fellows should seize the oppor- Not all learners will come Pennsylvania. His academic of being exposed as incompetent tunity to discuss the nuances and equipped with a growth mindset. interests include graduate medical or feeling inadequate. Conversely, differing approaches to difficult So, what can fellows and program education, interprofessional individuals with a growth mindset clinical questions, managing a team directors in new programs do to collaboration and teamwork, and embrace challenges and failures as and interpersonal dynamics, and develop this practice and mitigate quality improvement. learning opportunities and identify balancing clinical and nonclinical some of the inevitable uncertainty? feedback as a critical element of responsibilities with an experienced To begin, program directors should growth.2 These individuals maintain supervising clinician, issues that think about how to create cultures provides a new perspective that a sense of resilience in the face of are often less pressing as a resident. of growth and development, as the prioritizes learning and emphasizes adversity and strive to become life- The fellow role also affords the op- fixed and growth mindsets are not improvement potential. long learners. portunity to more carefully observe just limited to individuals.3 Program Embodying this approach re- As the field of pediatric hospital different clinical styles of practice to directors can strive to augment this quires patience and practice. Being medicine (PHM) continues to rapidly subsequently shape one’s own pre- process by committing to solicit part of a newly created fellowship evolve, so too does the landscape of ferred style. feedback for themselves and ac- represents an opportunity to learn PHM fellowships. New programs are Finally, fellows should employ a knowledging their own vulnerabili- from personal challenges rather opening at a torrid pace to accom- growth mindset to optimize clinical ties and perceived weaknesses. than leaning on the precedent set by modate the increasing demand of time by discussing expectations Fellows must have early, honest previous fellows. And although fel- residents looking to enter the field with involved stakeholders prior to discussions with program direc- lows will often face uncertainty as with new subspecialty accredita- rotations and explicitly identifying tors and other stakeholders about a part of the novelty within a new tion. Most first-year PHM fellows in goals for feedback and improve- expectations and goals. Program program, they can ultimately suc- established programs enter with a ment. Program directors can also directors should consider creating ceed by practicing the principles of clear precedent to follow, set forth help stakeholders including fac- lists of “must meet” individuals Dweck’s Growth Mindset: embracing by fellows who have come before ulty, residency programs, medical within the institution that can help challenges and failure as learning them. For PHM fellows in new pro- schools, and other health care pro- fellows begin to carve out their experiences, seeking out feedback, grams, however, there is often no fessionals on the clinical teams pre- roles in the clinical, educational, and pursuing the opportunities beaten path to follow. pare for this transition by providing and research realms. Deliberately among ambiguity. Entering fellowship as a first- expectations for the fellow role and crafting a mentorship team that will year PHM fellow in a new program by soliciting questions and feedback encourage a commitment to growth References and blazing one’s own trail can be before and after fellows begin. and improvement is critical. Seeking 1. Klein J et al. A growth mindset approach to intriguing and exhilarating given One of the key tenets of the out growth feedback, particularly in preparing trainees for medical error. BMJ Qual Saf. 2017 Sep;26(9):771-4. doi: 10.1136/bmjqs- the unique opportunities available. growth mindset is actively seek- areas that prove challenging, should 2016-006416. However, the potential challenges ing out constructive feedback and become common practice for fellows 2. Dweck C. Mindset: The New Psychology of for both fellows and program direc- learning from failures to grow and from the onset. Success. New York: Ballantine Books; 2006. tors during this transition cannot be improve. This can be a particularly Most importantly, fellows should 3. Murphy MC and Dweck CS. A culture of understated. The role of new PHM useful practice for fellows during reframe uncertainty as opportunity genius: How an organization’s lay theory shapes people’s cognition, affect, and behavior. Pers fellows within the institutional the course of their scholarly pur- for growth and progression. See- Soc Psychol Bull. 2010 Mar;36(3):283-96. doi: framework may initially be unclear suits in clinical research, quality im- ing oneself as a work in progress 10.1177/0146167209347380. September 2021 | 30 | The Hospitalist COMMENTARY

CEO Corner Never prouder to be a hospitalist

By Eric E. Howell, MD, MHM • Need to help other colleagues? financial impacts, to name a few. Check. As the pandemic slogged on, have been a proud hospitalist • Need to reprogram the EMR? our Wellbeing Task Force came up for more than 20 years, and yet Check. with innovative support measures, I have never been prouder to be • Need a new way to teach residents including a check-in guide for hos- a hospitalist than now. The pan- and students on the wards? Check. pitalists and fellow health care Idemic has been brutal, killing more • Need a whole new unit – no, workers and dedicated wellness than 620,000 Americans as of this wait – a new hospital wing? No, sessions complete with a licensed writing. It has stretched the health scratch that – a whole new COVID therapist for members. All the while, care system, its doctors, nurses, and hospital in a few weeks? Check. (I despite the restrictions and hurdles other providers to the limit. Yet we personally did that last one at the the pandemic has thrown our way, will get through it, we are getting Baltimore Convention Center!) SHM members keep meeting and through it, and hospitalists deserve collaborating through virtual chap- a huge portion of the credit. For me and many hospitalists like ter events, committee work, Special According to the Centers for Dis- me, it is as if the last 20 years were Interest Groups, and our annual ease Control and Prevention, there prep work for the pandemic. conference, SHM Converge. Thank have been over 2.5 million COVID-19 Here at SHM, we know the pan- you to the countless members who hospitalizations. In my home state of demic is hard work – exhausting, donated their time to SHM, so that Maryland, between two-thirds and even. SHM has been actively fo- SHM could support hospitalists and three-quarters of hospitalized COVID cused on supporting hospitalists their patients. patients are cared for on general med- during this crisis so that hospital- For the past few months, we have ical floors, the domain of hospitalists. ists can focus on patients. Early been slowly transitioning into a new Dr. Howell is the CEO of the When hospitals needed COVID units, in the pandemic, SHM quickly phase of the pandemic. The medi- Society of Hospital Medicine. hospitalists stepped up to design and pivoted to supply hospitalists with cal miracles that are the COVID-19 staff them. When our ICU colleagues COVID-19 resources in their fight vaccines have made that possible. needed support, especially in those against the coronavirus. Numer- Don’t get me wrong; as I write, the serve, and will put protocols in place early dark days, hospitalists stepped ous COVID-19 webinars, a COVID Delta variant has a tight grip on to limit potential spread of the virus in. When our outpatient colleagues addendum to the State of Hospital the nation, and “breakthrough” in- at any SHM events as needed. were called into the hospital, hospi- Medicine Report, and a dedicated fections of the fully vaccinated are For those chapters that are able talists were there to help them on COVID issue of the Journal of Hos- making headlines. What data are and willing to meet in person safely, board. When the House of Medicine pital Medicine were early and suc- available show that the vaccinated SHM is happy to provide the visit- was in chaos because of COVID-19, cessful information dissemination remain extremely well protected ing faculty. Our Board of Directors hospitalists ran toward that fire. Our strategies. from hospitalization and death due and other SHM leaders are also previous 20+ years of collective expe- As the world – and hospitalists to COVID-19. (I’ll take a sore throat starting to meet with members in rience made us the ideal specialty to – dug in for a multiyear pandemic, over those other two any day.) Al- person. With added protection and manage the inpatient challenges over SHM continued to advance the care though I am still careful, masking careful planning, our own Leader- the last 18 months. of patients by opening our library of up indoors and following the most ship Academy will take place as an educational content for free to any- recent CDC guidelines, as someone in-person event at Amelia Island in • Need a new clinical schedule by one. Our Public Policy Committee fully vaccinated, I am reasonably Florida this October, where we can Sunday? Check. was active around both COVID-19– comfortable traveling again. In learn, network, and even decom- • Need help with new clinical proto- and hospitalist-related topics: immi- August, I went to the Atlanta and press. We also can’t wait for SHM cols? Check. gration, telehealth, well-being, and Baltimore Chapter meetings, both Converge 2022 in Nashville, where held in person. I was able to interact we hope to reunite with many of personally with fellow, masked-up you after 2 years of virtual confer- hospitalists, and it was incredibly ences. rewarding. We still must remain Our response to the pandemic, a vigilant and do all we can to prevent once-in-a-century crisis where our us from further backtracking and own safety was at risk, where doing increasing the stress on health care the right thing might mean death or workers around the country; after harming loved ones, our response of all, they have sacrificed and contin- running into the fire to save lives is ue to sacrifice. Yet, I can’t help but truly inspiring. The power of care – remain optimistic that this pandem- for our patients, for our family and ic will begin to ease, allowing more friends, and for our hospital medi- opportunities for us to rebuild our cine community and the community personal and professional lives. at large – is evident more now than No matter in what direction the ever. coronavirus takes us, SHM will There have always been good continue to pivot to meet our mem- reasons to be proud of being a hos- bers’ needs. Looking ahead, we have pitalist: taking care of the acutely ill, started planning for more in-person helping hospitals improve, teaching maGes

I education and networking events. young doctors, and watching my

eTTy We will continue to actively mon- specialty grow by leaps and bounds, /G itor data to ensure the safety of to name just a few. But I’ve never empura

T our members and the patients they been prouder than I am now. the-hospitalist.org | 31 | September 2021 HOSP_32.indd 1 8/11/2021 12:58:05 PM