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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

slide3

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

slide9
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

slide13
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

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

slide64

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.

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.

slide70

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

slide72

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.

slide74

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.

slide76

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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