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Update in Hospital Medicine 2010

Update in Hospital Medicine 2010. Kendall M. Rogers, MD, CPE, FACP, FHM Associate Professor Chief – Section of Hospital Medicine. Procedural Core Competencies. Question: Do hospitalists routinely perform the nine inpatient procedures designated as “core competencies?”

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Update in Hospital Medicine 2010

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  1. Update in Hospital Medicine2010 Kendall M. Rogers, MD, CPE, FACP, FHM Associate Professor Chief – Section of Hospital Medicine

  2. Procedural Core Competencies • Question: Do hospitalists routinely perform the nine inpatient procedures designated as “core competencies?” • Design: national mailed survey in 2004 • Subjects: 1059 ACP members identified as hospitalists by having >10 clinical hours per week and >40% of time in hospital based activity Thakkar, et al. Procedures Performed by Hospitalist and Non-hospitalist General Internists. JGIM 2010; Volume 25, Number 5, 448-452,

  3. Procedures • electrocardiogram interpretation • chest X-ray interpretation • arthrocentesis • thoracocentesis • abdominal paracentesis • lumbar puncture • central line placement • endotracheal intubation • ventilator management Thakkar, et al. Procedures Performed by Hospitalist and Non-hospitalist General Internists. JGIM 2010; Volume 25, Number 5, 448-452, d

  4. Procedural Core Competencies • Question: Do hospitalists routinely perform the nine inpatient procedures designated as “core competencies?” • Design: national mailed survey in 2004 • Subjects: 1059 ACP members • Results: 17% respondents classified as hospitalists, 11% performed all nine procedures (compared to 3% of non-hospitalists) • Conclusion: Hospitalists do not regularly perform the procedures listed as core competencies, raises questions about credentialing Thakkar, et al. Procedures Performed by Hospitalist and Non-hospitalist General Internists. JGIM 2010; Volume 25, Number 5, 448-452,

  5. EMR -> higher cost, longer LOS • Question: Do EMRs decrease costs and shorten length of stays? • Design: retrospective review of administrative data • Subjects: 300 California hospitals • Conclusion: hospitals with EMRs had higher costs and longer lengths of stay. Performance improved with time.

  6. Leapfrog Group Report on CPOE Evaluation Tool Results June 2008 to January 2010 214 Hospitals used the Leapfrog evaluation tool for their CPOE systems

  7. Types of Things Tested • Therapeutic Duplication • Example: Codeine AND Tylenol #3. • Single and Cumulative Limits • Example: Ten-fold excess dose of Methotrexate. • Allergies and Cross Allergies • Example: Penicillin prescribed for patient with documented Penicillin allergy. • Contraindicated Route of Administration • Example: Tylenol to be administered intravenously. • Drug-Diagnosis Interactions • Example: Nonspecific beta blocker in patient with asthma. • Contraindications/Dose Limits Based on Age and Weight • Example: Adult dose of antibiotic in a newborn. • Contraindications/Dose Limits Based on Lab Studies • Example: Normal adult dose regimen of renally eliminated medication in patient with elevated creatinine. • Contraindications/Dose Limits Based on Radiology Studies • Example: Medication prescribed known to interact with iodine to be used as contrast medium in ordered head CT exam.

  8. Results of Adult & Pediatric Medication Orders

  9. Results of Adult & Pediatric Medication Potentially Fatal Orders

  10. What’s the data say? • Longstanding data from chart review gives us numbers on ADE’s (Brennan 1991) • IT systems make queries on quality and patient safety measures faster and easier but have their own biases (Bates 1994) • Initial data on CPOE shows decreases in adverse events (Bates 1998, Evans 1992) • CPOE introduces it’s own errors (Koppel 2005) • Fragmentation of data and problems with human computer interface

  11. Concerns are Realized • Overall in hospital mortality rate rises from 2.80% to 6.57% after CPOE implementation

  12. Or Not???? • Overall in hospital mortality rate drops from 1.008% to 0.716% after CPOE implementation

  13. Leapfrog Recommendations • Collaboration over competition • Require testing of systems • Systems are not ‘plug and play’ • Evaluation tool available • This should be part of meaningful use • Test and develop CDS for more than medication administration

  14. Meaningful Use • Difficult to define • Difficult to police • Nobody wants to miss out on the opportunity • We should make a true effort and not strive to be just good enough to get ARRA funds

  15. CMS Carrot For Achieving Stages of Meaningful Use • Stage I (2011-2012) • Capturing health info and using it effectively • Stage II (2013-2014) • Continuous QI and information exchange • Stage III (2015) • Improvements in quality, safety and efficiency with a focus on decision support • Patient access and improving population health • Hospitals can receive up to 4 years of incentive payments but start missing out if no meaningful use by 2013 since only paying up until 2016

  16. After 2016……The Stick • Decrement in Medicare and Medicaid payment if not meeting meaningful use criteria.

  17. Timeline and compensation slide for hospitals not EP’s • Important Dates • 2013 • Have to start by then to take full advantage of HITECH funds • 2016 • Have to be done by then to avoid CMS penalties

  18. Stage I: Core Objectives and Measures

  19. Stage I: Menu Objectives and Measures

  20. Meaningful Use as part of Maintenance of Certification (MOC) "Aligning MOC and meaningful use of HIT will help to facilitate physicians' knowledge, skill, and use of HIT and in turn can improve physician performance and patient outcomes,“ -Kevin B. Weiss, MD American Board of Medical Specialties president and CEO.

  21. Geriatric Evaluation Units • Question: Do geriatric evalaution and management units • Design: systematic review and meta-analysis • Primary Outcome: mortality, functional decline, readmission, institutionalization, LOS • Conclusion: significant effect in favor of GEMU on functional decline at discharge and institutionalization after 1 year

  22. Pre-Operative Medicine Consult • Question: Does pre-operative consultation by medicine improve outcomes? • Design: large retrospective cohort of preoperative IM consultation patients compared to propensity-score matched contemporary cohort • Patients: 269, 866 patients,, >40 yo undergoing major elective non-cardiac surgery between 1994-2004. 38.8% received consult • Primary Outcome: mortality, mean hospital stay, postoperative wound infection Outcomes and Processes of Care Related to Preoperative Medical Consultation.Wijeysundera, Austin, et al. Arch Intern Med. 2010;170(15):1365-1374

  23. Pre-Operative Medicine Consult Outcomes and Processes of Care Related to Preoperative Medical Consultation.Wijeysundera, Austin, et al. Arch Intern Med. 2010;170(15):1365-1374

  24. Pre-Operative Medicine Consult Outcomes and Processes of Care Related to Preoperative Medical Consultation.Wijeysundera, Austin, et al. Arch Intern Med. 2010;170(15):1365-1374

  25. Pre-Operative Medicine Consult Outcomes and Processes of Care Related to Preoperative Medical Consultation.Wijeysundera, Austin, et al. Arch Intern Med. 2010;170(15):1365-1374

  26. Pre-Operative Medicine Consult • Conclusion: medicine consult associated with increased mortality and hospital stay, increase in preoperative pharmacologic interventions and testing Outcomes and Processes of Care Related to Preoperative Medical Consultation.Wijeysundera, Austin, et al. Arch Intern Med. 2010;170(15):1365-1374

  27. “In perioperative medicine, the evidence has shown little clinical benefit and the potential for harm from current practices…The economic climate calls for restrained testing and increased discretion in perioperative medicine. It is time for us to throttle back.” • Ann Intern Med 2010;152:47-51.

  28. Staph Eradication Pre-Op • Question: Does eradication of Staph Aureus nasal carriage reduce post surgical infection rates? • Design: Randomized double-blind placebo-controlled trial of mupirocin nasal ointment + chlorhexidine soap for 5 days • Patients: 917 adults admitted to surgical and medical services with expected LOS 4+ days • Primary Outcome: cumulative incidence of hospital-acquired staph aureus infections N Engl J Med 2010;362:9-17

  29. N Engl J Med 2010;362:9-17

  30. Staph Eradication Pre-Op • Question: Does eradication of Staph Aureus nasal carriage reduce post surgical infection rates? • Design: Randomized double-blind placebo-controlled trial of mupirocin nasal ointment+chlorhexidine for 5 days • Patients: 917 adults admitted to surgical and medical services with expected LOS 4+ days • Primary Outcome: cumulative incidence of hospital-acquired staph aureus infections • Conclusion: Early identification and treatment of Staph aureus nasal carriage reduces subsequent associated infections N Engl J Med 2010;362:9-17

  31. July Effect • Question: Do patient outcomes worsen with new interns in July? • Design: retrospective review of medication errors • Patients: 250,000 deaths attributed to med errors between 1979 and 2006 • Results: 21 of the 28 years studied had fatal med errors spike by 10% only in counties with teaching hospitals. No reduction since 2003. • Conclusion: need for re-evaluation of responsibilities, supervision and education on medication safety Phillips DP & Barker GEC (2010). A July spike in fatal medication errors: a possible effect of new medical residents. Journal of General Internal Medicine; DOI 10.1007/s11606-010-1356-3

  32. ACGME Approves IOM Work Hours • Takes effect July 2011 • Work hours remain at 80 hours • First year residents work days capped at 16 hours • Upper levels may work 24 + 4 hours • Establish minimum times off between shifts • Expand program requirements regarding hand-offs • Suggest napping after 16 hours • Training in fatigue recognition

  33. ICU Mortality on weekends • Question: Is mortality higher for patients admitted on weekends? • Design: meta-analysis of 10 studies • Patients: 135,220 patients • Primary Outcome: • Conclusion: weekend ICU admission linked to 8% higher mortality

  34. Current VTE Rates • Question: Have VTE rates in medical patients improved since national attention and guidelines have been accepted? • Design: retrospective cohort study at 376 hospitals in 2004-2005 • Patients: 351, 535 medical patients >18yo with moderate to high risk of VTE with hospital stay >2 days • Primary Outcome: VTE prophylaxis and ‘standard prophylaxis’ by hospital day 2 • Conclusion: 36% received some prophylaxis with only 11% receiving standard prophylaxis J Gen Intern Med 25(6):489–94

  35. Hierarchy of Reliability Predicted Reliability No protocol (“State of Nature”) Decision support exists but not linked to order writing, or prompts within orders but no decision support Protocol well-integrated (into orders at point-of-care) Protocol enhanced (by other QI and high reliability strategies) Oversights identified and addressed in real time Level 1 40% 50% 2 3 65-85% 4 90% 95+% 5

  36. Med Adherence better with LMWH than heparin • Question: Does once a day LMWH have a higher medical adherence rate than BID or TID unfractionated heparin? • Design: Retrospective chart review • Patients: 250 consecutive patients prescribed LMWH or heparin • Primary Outcome: medical adherence • Conclusion: LMWH 94.9% adherence to TID heparin of 87.8%. More likely to receive all scheduled doses (77% compared to 54%). Patient refusal high on reasons for missed doses Fanikos, Stevens, et al. Adherence to Pharmacological Thromboprophylaxis Orders in Hospitalized Patients. Volume 123, Issue 6, Pages 536-541 (June 2010)

  37. Extended VTE • Question: Does extended prophylaxis after discharge in medical patients? • Design: randomized, double blind, placebo-controlled trial of enox vs placebo • Patients: 6000 patients with decreased mobility and acute illness • Primary Outcome: incidence of VTE to day 28, major bleeding • Conclusion: extended prophylaxis reduced VTE compared to placebo (2.5% vs 4%). Funded by Sanofi and some eligibility criteria changed during trial. Hull RD, Schellong SM, Tapson VF, et al. Extended-Duration Venous Thromboembolism Prophylaxis in Acutely Ill Medical Patients With Recently Reduced Mobility: A Randomized Trial. Ann Intern Med. 2010 Jul 6;153(1):8-18. (Original) PMID: 20621900

  38. VTE Shorts • Silent PE occurs in 32% of patients • Am J Med 2010; 123: 426–431 • Cirrhotics have VTE at similar rates as non-cirrhotics: the elevated INR does not relect protection, although it leads us to prphylax less frequently. • Chest 2010;137:1145-1149 • Med Adherence better with LMWH than heparin • Am J Med 2010; 123: 536-541

  39. MRI for Ischemic Stroke • Question: What is the best diagnostic test for ischemic stroke? • Design: consensus guideline • Recommendation: • Within 12 hours of onset, MRI is superior to CT scan for diagnosing ischemic stroke (in one study MRI vs CT: 83% vs 26%). Consider timing, if delay possible use CT scan. Kidwell, Mohr, et al. Evidence-based guideline: The role of diffusion and perfusion MRI for the diagnosis of acute ischemic stroke: Neurology 2010;75;177-185

  40. 3 Procedures for Stroke • Question: What specific interventions improve stroke outcomes? • Design: retrospective cohort study • Patients: 1487 adult patients admitted with acute ischemic stroke or TIA with neuro symptoms 1998-2003 • Primary Outcome: in hospital mortality, discharge to hospice or SNF. Arch Intern Med. 2010 May 10;170(9):810-2.

  41. 3 Procedures for Stroke • Question: What specific interventions improve stroke outcomes? • Conclusion: 3 interventions where shown to improve primary outcomes: • Attention to swallowing function • DVT prophylaxis • Treatment of hypoxia Arch Intern Med. 2010 May 10;170(9):810-2.

  42. Early TIPS in cirrhosis and varices • Question: Does early use of TIPS decrease mortality in patient with variceal bleeds? • Design: prospective, randomized trial • Patients: 63 cirrhotic patients with variceal bleeds • Primary Outcome: rebleeding in 16 months, survival • Conclusion: rebleeding in 14 control and 1 TIPS pt, survival 61% in control vs 86% in TIPS group. Shorter ICU and hospital LOS for TIPS group. Garcia-Pagan JC, Caca K, Bureau C, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010 Jun 24;362(25):2370-9.

  43. Trental use in cirrhosis • Question: Does use of trental reduce mortality and complications in cirrhotic patients? • Design: randomized, placebo controlled double blind trial • Patients: 335 cirrhosis patients • Primary Outcome: mortality at 2 months, 6 months, and liver related complications • Results: Mortality rates 2 month (16.5% vs 18.2) 6 months (30% vs 31.5%). Complication free rates: 2 months (78.6% vs 63.4%) and 6 months (66.8 vs 49.7) • Conclusion: While trental does not decrease short term mortality in advanced cirrhosis, it reduces complications Lebrec D, Thabut D, et al. Pentoxifylline does not decrease short-term mortality but does reduce complications in patients with advanced cirrhosis. Gastroenterology. 2010 May;138(5):1755-62. Epub 2010 Jan 25.

  44. Probiotics for C. Diff • Question: Do probiotics decrease the chance of developing antibiotic associated diarrhea and of C. Diff, and is it dose dependent? • Design: single-center, randomized, double blind, placebo-controlled dose range study • Patients: 255 patients, 50-70 yrs old, hospitalized at least5 days, antibiotic therapy at least 3 days • Primary Outcome: any diarrhea; C diff toxin + diarrhea Am J Gastroent 2010; 170: 784-290.

  45. d

  46. Probiotics for C. Diff • Question: Do probiotics decrease the chance of developing antibiotic associated diarrhea and of C. Diff, and is it dose dependent? • Design: single-center, randomized, double blind, placebo-controlled dose range study • Patients: 255 patients, 50-70 yrs old, hospitalized at least5 days, antibiotic therapy at least 3 days • Primary Outcome: any diarrhea; C diff toxin + diarrhea • Conclusion: Lactobacillus reduces antibiotic associated diarrhea and C diff colitis in a dose dependent manner Am J Gastroent 2010; 170: 784-290.

  47. C Diff Shorts • Monoclonal Ab treatment in addition to abx for C. diff decreases recurrence from 32% to 8% • N Engl J Med 2010; 362:197-205 • C Diff Spores in air around C diff patients • CID 2010; 50:1450-1457 • Guidelines for treatment of C. Diff • Metronidazole PO for mild to moderate cases • Vancomycin PO for initial episodes of severe • Severe and complicated PO vancomycin and IV metronidazole • ISDA and Society of Healthcare Epidemiology of America

  48. C. Diff and PPIs • Question: Does acid suppression with PPIs increase the risk of developing C diff colitis? • Design: large prospective cohort cmparing acid suppresion on prospective nosocomial C diff risk • Patients: 101,796 adults with LOS >3 days • Primary Outcome: newly positive C diff toxin on hospital day 3+ Arch Intern Med 2010; 170:784-790

  49. Arch Intern Med 2010; 170:784-790

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