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Update in Hospital Medicine 2011. Michael Hwa, MD Assistant Clinical Professor UCSF Division of Hospital Medicine. Update in Hospital Medicine 2011. Brad Sharpe, MD Associate Chief. Michelle Mourad, MD Director of DHM Quality. Update in Hospital Medicine. VS.

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Update in hospital medicine 2011

Update in Hospital Medicine 2011

Michael Hwa, MD

Assistant Clinical Professor

UCSF Division of Hospital Medicine


Update in hospital medicine 20111

Update in Hospital Medicine 2011

Brad Sharpe, MD

Associate Chief

Michelle Mourad, MD

Director of DHM Quality

Update in Hospital Medicine

Update in Hospital Medicine


Update in hospital medicine 2011

VS.

Update in Hospital Medicine


Update in hospital medicine 20112

Update in Hospital Medicine 2011

  • Updated literature since Summer 2010

  • Process:

  • Collaborative review of journals

    • ▪ Including ACP J. Club, J. Watch, etc.

  • Three hospitalists ranked articles

    • ▪ Definitely include, can include, don’t include

  • Update in Hospital Medicine

    Update in Hospital Medicine


    Update in hospital medicine 20113

    Update in Hospital Medicine 2011

    • Chose articles based on 3 criteria:

    • Change your practice

    • Modify your practice

    • Confirm your practice

    • Hope to not use the words

      • ▪ Markov model, Kaplan-Meier, Student’s t-test

  • Focus on breadth, not depth

  • Update in Hospital Medicine

    Update in Hospital Medicine


    Update in hospital medicine 20114

    Update in Hospital Medicine 2011

    • Major reviews/short takes

    • Case-based format, multiple choice ?’s

    • Audience Participation…Please!

    Update in Hospital Medicine

    Update in Hospital Medicine


    Syllabus bookkeeping

    Syllabus/Bookkeeping

    • No conflicts of interest

    • Handouts available

      • ▪ Key slides

  • Final presentation via email: [email protected]

  • Feedback also appreciated!

  • Update in Hospital Medicine

    Update in Hospital Medicine


    Update in hospital medicine 2011

    Update in Hospital Medicine


    Update in hospital medicine 2011

    Case

    A 65 year-old man with a history of HTN and diabetes was admitted for CAP. On hospital day 5 he develops a fever, abdominal pain, and diarrhea.

    He appears ill and has a WBC of 22,000 and acute renal failure (Cre 2.2 mg/dL). A C diff test comes back positive.

    What is the optimal initial treatment?

    Update in Hospital Medicine

    Update in Hospital Medicine


    What is the optimal initial treatment

    What is the optimal initial treatment?

    • Fidaxomicin PO

    • Vancomycin PO

    • Metronidazole PO

    • Vancomycin IV

    • Did someone order a stool transplant?

    Update in Hospital Medicine


    Management clostridium d ifficile

    Management Clostridium difficile

    Question:What is the optimal management of Clostridium difficile infection?

    Design:Expert panel development of practice guideline; based on updated evidence

    ▪ SHEA: Society for Healthcare Epidemiology of America

    ▪ IDSA: Infectious Diseases Society of America

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431.


    Clostridium difficile

    Clostridium difficile

    • Origin?

    Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431. Heinlen L, et al. Am J Med Sci. 2010;340:247.

    Update in Hospital Medicine


    Update in hospital medicine 2011

    Of the people here at the conference, what percentage are colonized with C diff (assume none have been hospitalized recently)?

    • 90%

    • 50%

    • 10%

    • 2%

    • 0%

    • Geez, I can’t believe I just licked my fingers.


    Clostridium difficile1

    Clostridium difficile

    • Origin

      • “it is on you, not in you”

    • Testing

      • “if the stool is not loose, the test is no use”

    • Severe C diff

      • WBC > 15,000 or

      • Acute renal failure (Cr 1.5x normal)

    Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431. Heinlen L, et al. Am J Med Sci. 2010;340:247.

    Update in Hospital Medicine


    Clostridium difficile2

    Clostridium difficile

    • Origin

      • “it is on you, not in you”

    • Testing

      • “if the stool is not loose, the test is no use”

    • Severe C diff – WBC>15k or Cr > 1.5x

    • Treatment – Vanco for severe, metronidazole all others, 10-14 days

    Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431. Heinlen L, et al. Am J Med Sci. 2010;340:247.

    Update in Hospital Medicine


    Management clostridium d ifficile1

    Management Clostridium difficile

    Question:What is the optimal management of Clostridium difficileinfection?

    Design:Expert panel development of practice guideline; based on updated evidence

    Conclusion: Cdiff is spread by us; only send the test (once) on loose stool;

    Severe C diff (WBC, Cr) should be treated w/ Vancomycin; duration of tx 10-14 days

    Comment: Expert guideline, most evidence moderate to good; a common disease, follow the guidelines

    Wash your hands!!!

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431.


    What is the optimal initial treatment1

    What is the optimal initial treatment?

    • Fidaxomicin PO

    • Vancomycin PO

    • Metronidazole PO

    • Vancomycin IV

    • Did someone order a stool transplant?

    Update in Hospital Medicine


    Short take c diff antibiotic exposure

    Short Take: C diff & Antibiotic Exposure

    • In a retrospective cohort study including 10,154 hospitalizations there was a dose-dependent increase in the risk of C diff associated with:

      • Number of antibiotics

      • Cumulative antibiotic dose

      • Days of antibiotic exposure

    • Hospitalized patients who received 5 or more antibiotics were 10x more likely to develop C diff.

    Update in Hospital Medicine

    Update in Hospital Medicine

    Stevens V, et al. CID;2011;53:42.


    Case continued

    Case Continued

    The patient gets PO vancomycin and IVFs and remains on the floor. You wash your hands.

    Your resident is reviewing his medication list and notices that he is not on anything for “GI prophylaxis” (no PPI, H2 blocker, etc.).

    “Shouldn’t he be on some sort of GI prophylaxis?”

    Update in Hospital Medicine

    Update in Hospital Medicine


    What do you do for gi prophylaxis for this patient

    What do you do for GI prophylaxis for this patient?

    Nothing

    Start a PPI

    Start an H2 blocker

    Tums. Tums. Tums. Tums.

    You’re staring at your Nexium pen, racking your brain, trying to remember what that rep told you at last night’s Purple PillTM dinner

    Update in Hospital Medicine

    Update in Hospital Medicine


    Acid suppression nosocomial gi bleeding

    Acid-Suppression & Nosocomial GI Bleeding

    Question:For non-ICU inpatients, do PPIs or H2 blockers lower the incidence of nosocomial UGIB?

    Design: Observational cohort study; 79,287 adult inpatients; compared PPI or H2 blocker usage to no therapy.

    Update in Hospital Medicine

    Update in Hospital Medicine

    Herzig, SJ et al. Arch Int Med. 2011;171:991


    Results

    Results

    * With propensity scoring

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Herzig, SJ et al. Arch Int Med. 2011;171:991


    Results1

    Results

    * With propensity scoring

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Herzig, SJ et al. Arch Int Med. 2011;171:991


    Results2

    Results

    • Incidence of nosocomial UGIB: 0.29%

    • Incidence of clinically significant UGIB: 0.22%

    * With propensity scoring

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Herzig, SJ et al. Arch Int Med. 2011;171:991


    Results3

    Results

    • Incidence of nosocomial UGIB: 0.29%

    • Incidence of clinically significant UGIB: 0.22%

    * With propensity scoring

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Herzig, SJ et al. Arch Int Med. 2011;171:991


    Acid suppressive nosocomial gi bleeding

    Acid-Suppressive & Nosocomial GI Bleeding

    Question:For non-ICU inpatients, do PPIs or H2 blockers lower the incidence of nosocomial GI bleeding?

    Design: Observational cohort study, 79,287 adult inpatients; compared PPI or H2 vs. nothing

    Conclusion: PPI or H2 blockers reduced bleeding. Incidence of nosocomial UGIB out of the ICU very low.

    Comments:Retrospective, administrative data

    Supports guidelines against routine usage of acid-suppressive medications outside the ICU.

    Update in Hospital Medicine

    Update in Hospital Medicine

    Herzig, SJ et al. Arch Int Med; 2011;171:991


    What do you do for gi prophylaxis for this patient1

    What do you do for GI prophylaxis for this patient?

    Nothing

    Start a PPI

    Start an H2 blocker

    Tums. Tums. Tums. Tums.

    You’re staring at your Nexium pen, racking your brain, trying to remember what that rep told you at last night’s Purple PillTM dinner

    Update in Hospital Medicine

    Update in Hospital Medicine


    Short take proton pump inhibitors

    Short Take: Proton Pump Inhibitors

    • In case-control studies, PPIs are associated with:

    • 2x increased risk of nosocomial C. diff infection

    • A 1.4x increased risk of C. diff recurrence after treatment

    • Increased incidence of both community (3x) and hospital-acquired pneumonia (1.3x)

    Arch Intern Med. 2010;170:747-748, 772-778, 784-790

    Sarkar M. Ann Intern Med. 2008;149:391

    Shoshana J, JAMA, 2009; 301:2120

    Update in Hospital Medicine


    Case 1 summary

    Case 1 Summary

    • Start

      • Considering that antibiotic exposure increases the risk for C diff.

      • Treating severe C diff (WBC > 15,000, Cr 1.5x baseline) with vancomycin.

      • Treating C diff for 10-14 days.

      • Washing your hands!!!

  • Stop

    • Sending C diff tests on non-diarrheal stool.

    • Prescribing “GI prophylaxis” for non-ICU patients.

  • Update in Hospital Medicine


    Case presentation

    Case Presentation

    A 60 year old man with severe necrotizing pancreatitis requires mechanical ventilation and pressors. On hospital day 3 you note a new infiltrate on CXR, fever, and increasing WBC.

    The ICU pharmacist says, “I think IDSA guidelines recommend linezolid over vancomycin for VAP.”

    You wonder, what is the optimal antibiotic regimen for this patient with suspected MRSA VAP?

    Update in Hospital Medicine

    Update in Hospital Medicine


    Vancomycin versus linezolid how would you respond

    Vancomycin versus Linezolid, how would you respond?

    No change. Vancomycin is superior to linezolid.

    Maybe the pharmacist is right, I think there is evidence that linezolid is superior

    Doesn’t matter, they have similar efficacy

    I think it’s time for an ID consult

    Psssh…Vanco? Linezolid? It’s time to release the Tiger! (tigecycline)

    Update in Hospital Medicine

    Update in Hospital Medicine

    Walkey AJ, et al. Chest;2011;139:1148.


    Linezolid versus glycopeptides for suspected mrsa nosocomial pna

    Linezolid versus Glycopeptides for suspected MRSA Nosocomial PNA

    Question:In patients with suspected MRSA nosocomial pneumonia, is linezolid superior to vancomycin?

    Design: Meta-analysis of 8 RCTs of linezolid versus vancomycin

    Update in Hospital Medicine

    Update in Hospital Medicine

    Walkey AJ, et al. Chest;2011;139:1148.


    Results4

    Results

    Update in Hospital Medicine

    Update in Hospital Medicine

    Walkey AJ, et al. Chest;2011;139:1148.


    Results5

    Results

    Update in Hospital Medicine

    Update in Hospital Medicine

    Walkey AJ, et al. Chest;2011;139:1148.


    Results6

    Results

    Update in Hospital Medicine

    Update in Hospital Medicine

    Walkey AJ, et al. Chest;2011;139:1148.


    Results7

    Results

    Update in Hospital Medicine

    Update in Hospital Medicine

    Walkey AJ, et al. Chest;2011;139:1148.


    Linezolid versus glycopeptides for suspected mrsa nosocomial pna1

    Linezolid versus Glycopeptides for suspected MRSA Nosocomial PNA

    Question:In patients with suspected MRSA nosocomial pneumonia, is linezolid superior to vancomycin?

    Design: Meta-analysis of 8 RCTs of linezolid versus vancomycin

    Conclusion: RCTs do not support superiority of linezolid over vancomycin

    Comments:Not powered to see difference in MRSA+ PNA. Don’t choose linezolid because of perceived superiority

    Update in Hospital Medicine

    Update in Hospital Medicine

    Walkey AJ, et al. Chest;2011;139:1148.


    Vancomycin versus linezolid how would you respond1

    Vancomycin versus Linezolid, how would you respond?

    No change. Vancomycin is superior to linezolid

    Maybe the pharmacist is right, I think there is evidence that linezolid is superior

    Doesn’t matter, they have similar efficacy

    I think it’s time for an ID consult

    Psssh…Vanco? Linezolid? It’s time to release the Tiger! (tigecycline)

    Update in Hospital Medicine

    Update in Hospital Medicine

    Walkey AJ, et al. Chest;2011;139:1148.


    Case continued1

    Case Continued

    You start the patient on vancomycin and broad GNR coverage for VAP. Despite this, the patient does poorly. Respiratory cultures return as MRSA.

    Why isn’t the patient improving with a susceptible strain of MRSA? Should you change antibiotics?

    Update in Hospital Medicine


    Based on his vancomycin mic and mrsa vap you should

    Based on his vancomycin MIC and MRSA VAP you should:

    • Cont vanco, ensure trough is >15

    • Change over to linezolid

    • Call your ID consultant to better understand the significance of this result

    • Treat with vancomycin and linezolid

    • Wait, didn’t you just tell me it didn’t make a difference? Make up your mind.

    Update in Hospital Medicine


    Vancomycin mic in mrsa pna

    Vancomycin MIC in MRSA PNA

    Question:Do vancomycin MICs predict outcomes for MRSA PNA?

    Design:Observational cohort study, 158 pts, MRSA nosocomial PNA in ICU

    Looking at all cause mortality at 28 days

    Propensity scoring

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Harper SC, et al. CHEST. 2011;170:880.


    Results8

    Results

    32.3% of patients had died by day 28

    Median and mean trough was 14

    Patients were 3 times more likely to die with every 1mg/mL increase in Vancomycin MICs

    Most MRSA isolates had Vancomycin MICs of ≥1.5 mg/ml

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Harper SC, et al. CHEST. 2011;170:880.


    Vancomycin mic in mrsa pna1

    Vancomycin MIC in MRSA PNA

    Question:Do vancomycin MICs predict outcomes for MRSA PNA?

    Design: Observational cohort study, 158 pts, MRSA PNA in ICU

    Conclusion:Mortality increased with increasing vancomycin MICs, including those with MIC in “susceptible” range.

    Comment: Check those vanco MICs, consider alternatives if MIC between 1 and 2mg/mL, especially if patient not doing well

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Harper SC, et al. CHEST. 2011;170:880.


    Based on vancomycin mics of 2 in mrsa pna you should

    Based on Vancomycin MICs of 2 in MRSA PNA you should:

    • Cont vanco, ensure trough is >15

    • Change his antibiotics to linezolid

    • Consult ID to better understand the significance of this result

    • Treat with vancomycin and linezolid

    • Wait, didn’t you just tell me it didn’t make a difference? Make up your mind.

    Update in Hospital Medicine


    Case continued2

    Case Continued

    While you are writing the order to switch to linezolid, the nurse points out his falling urine output, which is now 30cc/hr.

    You realize you can’t remember the last time you used the bathroom… and wonder who’s urine output is better, yours or your patients?

    Update in Hospital Medicine


    Short take uo in icu providers

    Short Take: UO in ICU providers

    Controlled trial comparing the urine output between residents and their patients during a month in the ICU.

    Doctors were found to be oliguric during 22% of their shifts and “in failure” in 1%.

    Doctors twice as likely than their patients to be oliguric (OR 1.99, CI 1.08 – 3.68)

    Thankfully, mortality among providers was low (0).

    Solomon, et al. BMJ;. 2010;341:6761

    Update in Hospital Medicine

    Update in Hospital Medicine


    Case continued3

    Case Continued

    While going to get a glass of water, you realize that you were planning on discharging that 65 year old woman admitted overnight for CAP.

    The radiology report on the CXR that showed infiltrate says, “consider interval follow up in 4-8 weeks.”

    You wonder, do I really need to get a follow-up chest xray?

    Update in Hospital Medicine


    Short take cxr after pna

    Short Take: CXR after PNA

    Observational cohort following 3398 patients with confirmed CAP followed to determine incidence of and risk factors for new lung cancer.

    Tang, et al. Arch Int Med; 2011;171:1193.

    Update in Hospital Medicine

    Update in Hospital Medicine


    Short take cxr after pna1

    Short Take: CXR after PNA

    Risk factors for lung cancer included: Age >50 (aHR 19), male sex (aHR 1.8) and smoking history (aHR 1.7).

    Looking at pts >50 increases yield to 2.8%.

    Suggests incidence of diagnosing lung cancer after CAP is low and post-treatment CXR not needed in low-risk patients with resolving symptoms

    Tang, et al. Arch Int Med; 2011;171:1193.

    Update in Hospital Medicine

    Update in Hospital Medicine


    Case 2 summary

    Case 2 Summary

    Start

    • Looking at MIC for MRSA nosocomial PNA

    • Hydrating when working those long shifts in the ICU

      Stop

    • Choosing linezolid over vancomycin for suspected MRSA nosocomial PNA based solely on efficacy

    • Getting routine follow-up chest xrays in low risk PNA patients with resolving symptoms

    Update in Hospital Medicine

    Update in Hospital Medicine


    Update in hospital medicine 2011

    Update in Hospital Medicine


    Case presentation1

    Case Presentation

    You are called to see an 88 yo patient in the ED diagnosed with a DVT and a subsegmental PE.

    You find him ambulating, with stable vitals and O2 sat of 98% on room air.

    His physical exam is normal. He asks if he can go home, he doesn’t want to miss his favorite show: DWTS. Can he safely be discharged from the ED?

    Update in Hospital Medicine


    How do you know if he is safe to be treated as an outpatient

    How do you know if he is safe to be treated as an outpatient?

    • A severity score can identify patients at low risk for complications

    • A negative troponin and BNP <100

    • Oxygen saturation and respiratory rate

    • Normal vital signs with exertion

    • Give it up. He’s 88. there’s no way the ED will let him leave.

    Update in Hospital Medicine


    Outpatient vs inpatient pe

    Outpatient vs. Inpatient PE

    Question:Can patients with acute PE be managed as outpatients?

    Design:Randomized non-inferiority trial, 19 EDs; PESI I or II; inpt vs. outpt

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Aujesky D, et al. Lancet. 2011;378:41.


    Pe severity index pesi

    PE Severity Index (PESI)

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Aujesky D, et al. Am J RespirCrit Care Med. 2005;172:1041


    Results9

    Results

    Update in Hospital Medicine


    Results10

    Results

    Update in Hospital Medicine


    Results11

    Results

    Update in Hospital Medicine


    Results12

    Results

    Update in Hospital Medicine


    Outpatient vs inpatient pe1

    Outpatient vs. Inpatient PE

    Question:Can patients with acute PE be managed as outpatients?

    Design:Randomized non-inferiority trial, 19 EDs; PESI I or II; inpt vs. outpt

    Conclusion: Overall, outpt not inferior to inpt; similar rates of recurrent VTE & bleeding; LOS much shorter with outpt treatment

    Comment: Small study, 14 additional exclusion criteria. Likely not ready for prime time

    But, use PESI to consider earlier discharge

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Aujesky D, et al. Lancet. 2011;378:41.


    How do you know if he is safe to be treated as an outpatient1

    How do you know if he is safe to be treated as an outpatient?

    • A severity score can identify patients at low risk for complications

    • A negative troponin and BNP <100

    • Oxygen saturation and respiratory rate

    • Normal vital signs with exertion

    • Give it up. He’s 88. there’s no way the ED will let him leave.

    Update in Hospital Medicine


    Case continued4

    Case Continued

    He’s admitted, 2 days later as you’re about to write his DC orders, the patient says, “Oh, by the way, I lost 50lbs recently.”

    He’s an incredibly nice person and so you conclude that he must have cancer.

    A CT scan reveals widely metastatic cancer. Oncology wants to describe the benefits and risks of an experimental chemo regimen which showed improved survival at 4 months, but increased side effects.

    What is the most effective way for the oncologist to explain these risks and benefits?

    Update in Hospital Medicine

    Update in Hospital Medicine


    Update in hospital medicine 2011

    What is the optimal way the oncologist could describe risks and benefits?

    • 0.8% more were alive, 1% more had SE (percentages)

    • 8 in 1000 more were alive, 10 in 1000 more had SE (natural frequencies)

    • 1 in 125 more were alive, 1 in 100 more had SE (variable frequencies)

    • Slightly more patients were alive, but slightly more patients had SE (descriptor)

    • With empathy (eg. “This is a hard decision since, well, you’re pretty much screwed.”)

    Update in Hospital Medicine


    Communicating benefits harms

    Communicating Benefits & Harms

    Question:What is the optimal way to express risks and benefits to patients?

    Design:Randomized on-line survey study; representative national sample of 2944 adults; survey presenting risks in 1/5 ways

    ▪ For 2 hypothetical drugs:

    ▪ Heartburn drug which reduces symptoms

    ▪ Cholesterol medicine reduces an uncommon event

    and has a rare side effect

    Paxcid and Questor . . .

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Woloshin S, et al. Ann Intern Med. 2011;155:87.


    Communicating benefits harms1

    Communicating Benefits & Harms

    • Natural Frequency – rates out of 1000 (2/1000, 500/1000, etc.)

    • Variable Frequency – rates with lowest denominator possible (1/500, 1/2, etc.)

    • Percentages – rounded to whole numbers

    • Percentage + Natural Frequency

    • Percentage + Variable Frequency

    Update in Hospital Medicine

    Woloshin S, et al. Ann Intern Med. 2011;155:87.


    Update in hospital medicine 2011

    Update in Hospital Medicine


    Results13

    Results

    • Combining made no difference

    * p < 0.05

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Woloshin S, et al. Ann Intern Med. 2011;155:87.


    Communicating benefits harms2

    Communicating Benefits & Harms

    Question:What is the optimal way to express risks and benefits to patients?

    Design:Randomized survey; national sample of adults; survey presenting risks in 1/5 ways

    Conclusion: Best comprehension w/ percent format; true for all education levels

    Still 1/3 failed comprehension tests

    Comment: Not real-life, just medication benefit/harm

    Percent format may be best

    But many may still not understand

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Woloshin S, et al. Ann Intern Med. 2011;155:87.


    Update in hospital medicine 2011

    What is the optimal way the oncologist could describe risks and benefits?

    • 0.8% more were alive, 1% more had SE (percentages)

    • 8 in 1000 more were alive, 10 in 1000 more had SE (natural frequencies)

    • 1 in 125 more were alive, 1 in 100 more had SE (variable frequencies)

    • Slightly more patients were alive, but slightly more patients had SE (descriptor)

    • With empathy (eg. “This is a hard decision since, well, you’re pretty much screwed.”)

    Update in Hospital Medicine


    Case continued5

    Case Continued

    The patient decides against chemotherapy. You bring up hospice and the wife tells you,

    “I know he doesn’t have long, and I know he wouldn’t want to be hooked up to machines, but if he gets sicker I think he and I would feel better that he come to the hospital and get care.”

    How do you respond?

    Update in Hospital Medicine

    Update in Hospital Medicine


    Update in hospital medicine 2011

    How do you respond to the wife?

    • Most patients with advanced cancer pass in the hospital, we’d make every effort to make him comfortable.

    • If he decides to pass at home, he would suffer less, but it may be emotionally harder on you

    • If he decides to pass at home, he would suffer less, and it might ease your suffering

    • It’s really up to you and your family as to what you are comfortable with.

    • I don’t know. Have you talked with our “death panel” yet?

    Update in Hospital Medicine


    Place of death

    Place of Death

    Question:Is location where a pt dies associated with quality of life and caregiver psychiatric illness?

    Design:Prospective, multi-site study; pts w/ advanced cancer, identified caregiver

    1) Interview patient & caregiver at baseline

    2) Caregiver interview 2 weeks after death

    3) Caregiver interview 6 months later

    ▪ Asked about QOL, physical, psychological stress

    ▪ Assessed caregiver psychiatric illness

    ▪ Controlled for confounders (cancer, caretaker illness, etc.)

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Wright AA, et al. J ClinOnc. 2010;28:4457.


    Update in hospital medicine 2011

    • Hospital or ICU death – assoc. 5x increased chance of PTSD and prolonged grief in caretakers

    Update in Hospital Medicine


    Place of death1

    Place of Death

    Question:Is the place of death associated with pt. quality of life and caregiver psychiatric illness?

    Design:Prospective, multi-site survey study; pts w/ advanced cancer, identified caregiver

    Conclusion: Most pts. died at home; ICU or hosp. death assoc. with worse QOL, increased distress

    Caregiver psychiatric illness increased in ICU or hospital death

    Comment: Not randomized. Can use in counseling patients/families

    Update in Hospital Medicine

    Update in Hospital Medicine

    Update in Hospital Medicine

    Wright AA, et al. J ClinOnc. 2010;28:4457.


    Update in hospital medicine 2011

    How do you respond to the wife?

    • Most patients with advanced cancer pass in the hospital, we’d make every effort to make him comfortable.

    • If he decides to pass at home, he would suffer less, but it may be emotionally harder on you

    • If he decides to pass at home, he would suffer less, and it might ease your suffering

    • It’s really up to you and your family as to what you are comfortable with.

    • I don’t know. Have you talked with our “death panel” yet?

    Update in Hospital Medicine


    Case 3 summary

    Case 3 Summary

    • Start

      • Using PESI score to help determine early discharge in patients with PE.

      • Using percentages to describe risks and benefits of treatment.

      • Counseling on the benefits to both patient and caregiver of home hospice

    Update in Hospital Medicine


    Case 2 summary review

    Case 2 Summary: Review

    Start

    • Looking at MIC for MRSA nosocomial PNA

    • Hydrating when working those long shifts in the ICU

      Stop

    • Choosing linezolid over vancomycin for suspected MRSA nosocomial PNA based solely on efficacy

    • Getting routine follow-up chest xrays in low risk PNA patients with resolving symptoms

    Update in Hospital Medicine

    Update in Hospital Medicine


    Case 1 summary review

    Case 1 Summary: Review

    • Start

      • Considering that antibiotic exposure increases the risk for C diff.

      • Treating severe C diff (WBC > 15,000, Cr 1.5x baseline) with vancomycin.

      • Treating C diff for 10-14 days.

      • Washing your hands!!!

  • Stop

    • Sending C diff tests on non-diarrheal stool.

    • Prescribing “GI prophylaxis” for non-ICU medical patients.

  • Update in Hospital Medicine


    Update in hospital medicine 20115

    Update in Hospital Medicine 2011

    Michael Hwa, MD

    [email protected]

    UCSF Division of Hospital Medicine


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