Update in Hospital Medicine 2010

Transcription

1 2010 Bradley Sharpe, MD UCSF Division of Hospital Medicine Romsai Boonyasai, MD, MPH Johns Hopkins Department of Medicine Anneliese Schleyer, MD University of Washington Dept. of Medicine Sponsored by the SGIM Academic Hospitalist Taskforce

2 2010 Present updated literature since April 2009 Process: CME collaborative review of journals Including ACP J. Club, J. Watch, etc. Four hospitalists ranked articles Definitely include, can include, don t include Removed articles covered by others

3 2010 Chose articles based on 2 criteria: 1) Change or impact your practice 2) Change or impact your teaching Hope to not use the words Markov model, Kaplan-Meier, Student s t-test Focus on breadth, not depth

4 2010 Major reviews/short takes Chance to ask questions Case-based format Hospitalist? Inpatient attending?

5 Syllabus/Bookkeeping Handouts available today Key slides Final presentation will be posted

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7 Case Presentation A 67 year-old woman with a history of HTN presents with syncope. She is generally healthy and lives alone. On the day of admission she was cooking dinner and the next thing she knew, she woke up on the floor of her kitchen. In addition to taking a complete history and performing a physical exam, what tests should you order?

8 Which diagnostic test is the highest-yield and most cost-effective in this patient with syncope? A. Head CT B. Telemetry for 24 hours C. EKG D. Troponin I E. Transthoracic echocardiogram (TTE) F. Orthostatic vital signs G. Tilt-table testing (Although you really don t even know what it is, how it is done, or when to order it, you think it makes you sound smarter to order it)

9 Diagnostic Tests in Syncope Question: Design: What are the highest-yield and most costeffective diagnostic tests in elderly patients w/ syncope? Retrospective cohort study; 2100 pts; All > 65 yo. Noted studies ordered, if tests made diagnosis/changed management Wanted to determine cost per positive test Mendu ML, et al. Arch Intern Med. July 2009;169:1299.

10 Results 53% of patients had a diagnosis for syncope Most common causes: vasovagal, orthostasis Mendu ML, et al. Arch Intern Med. 2009;169:1299.

11 Results Tests Frequency Obtained (%) EKG 99 Telemetry 95 Cardiac Enzymes 95 Echocardiogram 39 Head CT 63 EEG 8 Orthostatic Vitals 38 Affected Diagnosis Affected Management Mendu ML, et al. Arch Intern Med. 2009;169:1299.

12 Results Tests Frequency Obtained (%) Affected Diagnosis (%) Affected Management (%) EKG Telemetry Cardiac Enzymes Echocardiogram Head CT EEG Orthostatic Vitals Mendu ML, et al. Arch Intern Med. 2009;169:1299.

13 Results Tests Frequency Obtained (%) Cost per + test - $ (affect dx or tx) EKG 99 1,020 Telemetry Troponin I alone 95 4,813 Echocardiogram 39 6,272 Head CT 63 24,881 EEG 8 32,973 Orthostatic Vitals 38 17

14 Diagnostic Tests in Syncope Question: What are the best and most cost-effective tests in elderly patients w/ syncope? Design: Retrospective cohort study; pts > 65 yo. Noted diagnostic yield, cost per test; Conclusion: Orthostatic vitals - the best test; EKG, tele, and troponin I high-yield, low cost; Others should be based on history, exam, etc. Comments: Retrospective design, confounders, cost est. Probably should not use shotgun approach ACC: echo, stress test, for unexplained syncope ACP guidelines: only hx, exam, EKG up front Mendu ML, et al. Arch Intern Med. 2009;169:1299.

15 Which diagnostic test is the highest-yield and most cost-effective in this patient with syncope? A. Head CT B. Telemetry for 24 hours C. EKG D. Troponin I E. Transthoracic echocardiogram (TTE) F. Orthostatic vital signs G. Tilt-table testing (Although you really don t even know what it is, how it is done, or when to order it, you think it makes you sound smarter to order it)

16 Case Presentation Her history and exam are not revealing, her EKG is sinus with no evidence of ischemia, and her troponin I is negative. She is admitted for telemetry and observation. The next morning (senior resident s day off), she develops rapid atrial fibrillation (HR 150s). Her blood pressure is stable but she has palpitations. Your July intern calls you and asks...

17 (Gulp) I ve I never managed rapid afib before, what do we give her to control the rate? A. Intravenous amiodarone. B. Intravenous digoxin. C. Intravenous diltiazem. D. Intravenous metoprolol. E. Do you have the pager number for the CCU resident?

18 Rate Control Rapid Atrial Fibrillation Question: Design: What is the optimal treatment for rate control in uncomplicated rapid afib? Open-label RCT, 150 pts; Presented to ER, symp rapid afib (HR>120); uncomplicated Compared 3 groups: Outcomes: 1) IV diltiazem Rate < 90bpm 2) IV digoxin 3) IV amiodarone Symptoms Siu C, et al. Crit Care Med. July 2009;37(7):2174.

19 Results 10 8 Median Time to HR < 90 bpm Hours Diltiazem Digoxin Amiodarone P < for Diltiazem vs. both

20 Results Percent with HR < 90 at 24hrs % Diltiazem Digoxin Amiodarone P < for Diltiazem vs. both

21 Results Lenth of Stay (LOS) 5 4 Days Diltiazem Digoxin Amiodarone P < 0.03 for Diltiazem vs. both

22 Rate Control Rapid Atrial Fibrillation Question: Design: What is the optimal treatment for rapid afib? Open-label RCT, 150 pts; rapid afib (HR>120); uncomplicated Conclusion:Earlier rate control, more rate control, shorter LOS with dilt vs. digoxin or amio; Better symptom relief; side effects same Comments:Small study, did not include β-blockers; Diltiazem prob better w/ uncomplicated afib Supports expert guidelines (ACC/ACP); Apply to afib in the hospital? Siu C, et al. Crit Care Med. July 2009;37(7):2174.

23 (Gulp) I ve I never managed rapid afib before, what do you we give her to control the rate? A. Intravenous amiodarone. B. Intravenous digoxin. C. Intravenous diltiazem. D. Intravenous metoprolol. E. Do you have the pager number for the CCU resident?

24 Case Continued You and the intern rate control her with diltiazem. You get her on a stable oral regimen and the next day you are preparing to discharge her (her rhythm control to be managed as an outpatient). When discussing her anticoagulation, your upstart, enthusiastic medical student eagerly thrusts his hand in the air and asks:

25 Do you think dabigatran is better than warfarin in atrial fibrillation? A. Dabigatran is equal to warfarin for efficacy and safety but is hepatotoxic. B. Dabigatran has similar stroke rates but less bleeding compared to warfarin in afib. C. Dabigatran has lower stroke rates but at a cost of increased bleeding compared to warfarin. D. Listen, squirt, why don t you go and look that up and tell us about it tomorrow?

26 Dabigatran for Atrial Fibrillation Question: Design: Is dabigatran non-inferior compared to warfarin in atrial fibrillation? Partially blinded, RCT, 18,113 pts; Afib with 1 risk factor for stroke; 1) Dabigatran 110mg BID 2) Dabigatran 150mg BID 3) Adjusted dose warfarin Connolly SJ, et al. NEJM. Sept 2009;361:1139.

27 Dabigatran for Atrial Fibrillation Median follow-up 2 years Warfarin pts therapeutic 64% of the time Dabig 110mg Dabig 150mg Warfarin Stroke/ Embolism Major Hemorr. Net Benefit Net Benefit = vasc events + major bleed + death

28 Dabigatran for Atrial Fibrillation Median follow-up 2 years Warfarin pts therapeutic 64% of the time Stroke/ Embolism Dabig 110mg 1.53% Dabig 150mg 1.10%* Warfarin 1.69% Major Hemorr. Net Benefit * P < 0.001

29 Dabigatran for Atrial Fibrillation Median follow-up 2 years Warfarin pts therapeutic 64% of the time Stroke/ Embolism Major Hemorr. Dabig 110mg 1.53% 2.71%* Net Benefit Dabig 150mg 1.10%* 3.11% Warfarin 1.69% 3.36% * P < 0.001

30 Dabigatran for Atrial Fibrillation Median follow-up 2 years Warfarin pts therapeutic 64% of the time Stroke/ Embolism Major Hemorr. Net Benefit Dabig 110mg 1.53% 2.71%* 7.09% Dabig 150mg 1.10%* 3.11% 6.91%* Warfarin 1.69% 3.36% 7.64% No increased risk of hepatotoxicity Increased risk dypepsia (11% vs 6%) Slight increased risk of MI and GI bleed * P < 0.001

31 Dabigatran for Atrial Fibrillation Question: Design: Is dabigatran non-inferior compared to warfarin in atrial fibrillation? Partially blinded, RCT, 18,113 pts; Afib with 1 risk factor for stroke; Conclusion:Both doses dabigatran non-inferior; 110mg same clot risk, less bleeding; 150mg dose decreased clot risk, same bleeding Comments:Dabigatran better or equal to warfarin; Need to watch dyspepsia + MI (inc 0.2%); Await FDA approval; no change in practice Connolly SJ, et al. NEJM. Sept 2009;361:1139.

32 Do you think dabigatran is better than warfarin in atrial fibrillation? A. Dabigatran is equal to warfarin for efficacy and safety but is hepatotoxic. B. Dabigatran has similar stroke rates but less bleeding compared to warfarin. C. Dabigatran has lower stroke rates but at a cost of increased bleeding compared to warfarin. D. Listen, squirt, why don t you go and look that up and report back to us tomorrow?

33 Short Take: Dabigatran for DVT/PE A large (2564 pts), randomized, double-blind trial compared dabigatran (150mg) to warfarin for the treatment of acute DVT or PE (after 9 days of initial parenteral treatment). Overall rates of recurrent embolism and death were similar in both groups (2.4% vs. 2.1%) as were rates of major bleeding. Dyspepsia and discontinuation rates with dabigatran were higher. Schulman S, et al. NEJM. Dec 2009;361:2342.

34 Summary Definitely Consider 1) Use diltiazem instead of digoxin or amiodarone for rate control of uncomplicated atrial fibrillation. 1) Limiting evaluation of syncope in patients 65 yo to history, exam, orthostatics, tele, EKG, troponin I. 2) Using dabigatran instread of warfarin for anti-coagulation in afib and DVT/PE when approved.

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37 Case Presentation A 60 year-old woman with DM and CKD presents to the ED after being found confused in her apartment by a friend. On presentation she is somnolent and oriented only to self. She complains of headache. Her exam is notable for T 38.9 o C, somnolence and nuccal rigidity. Given your high suspicion for acute bacterial meningitis, you perform an LP, start empiric IV antibiotics, and admit her to your service.

38 Should you treat acute bacterial meningitis with steroids as well as antibiotics? A. Of course not. Why on earth would you give steroids in bacterial meningitis? B. Absolutely. Steroids + antibiotics improve survival and decrease neuro sequelae in all patients with acute bacterial meningitis C. Absolutely! The guidelines say to do it and I do whatever guidelines say. D. Maybe. Depends on the patient.

39 Steroids in Acute Bacterial Meningitis Question: Design: What is the effect of adjuvant steroids on short-term mortality and neurologic sequelae in acute bacterial meningitis? Systematic review/meta-analysis, placebocontrolled, randomized trials steroids+abx; 4 trials; 1261 adult/adolescent patients Abx: Amoxicillin (Europe); Ceftriaxone (Vietnam/Malawi) Steroids: Dexamethasone 32-40mg/d (Q6/12 hrsx3-4d) or wgt based Assiri, et al. Mayo Clin Proc 2009;84(5):

40 Results: Pooled Relative Risk of Death (95% CI) Overall 0.81 ( ), I 2 =54%, P=.29 High Income Low HIV Prevalence 0.50 ( ), I 2 =0%, P< ( ), P=.03 In high income countries: NNT to prevent 1 death 12.5 NNT to prevent 1 death from S pneumo 4.8

41 Results: Neurologic sequelae Pooled RR of Neuro Sequelae (95% CI) Overall 0.67 ( ), I 2 =56% High-Income 0.58 ( ), I 2 =0% In high income countries: NNT to prevent 1 neuro sequela: 11

42 Steroids in Acute Bacterial Meningitis Question: Design: What is the effect of adjuvant steroids acute bacterial meningitis? Systematic review/meta-analysis, placebocontrolled, randomized trials Conclusion:Steroids + abx in high-income-low HIV prevalence improve mortality; prevent neurological sequelae Comment: Few trials; more study needed esp in HIV Use steroids with abx if high-income/hiv- Assiri, et al. Mayo Clin Proc 2009;84(5):

43 Should you treat acute bacterial meningitis with steroids as well as antibiotics? A. Of course not. Why on earth would you give steroids in bacterial meningitis? B. Absolutely. Steroids + antibiotics improve survival and decrease neuro sequelae in all patients with acute bacterial meningitis C. Absolutely! The guidelines say to do it and I do whatever guidelines say. D. Maybe. Depends on the patient.

44 Case Continued On hospital day #2, pt is beginning to improve (with abx and 3 doses of steroids so far) but she loses her tenuous peripheral IV access. Your intern eagerly steps forward and orders a peripherally inserted central catheter (PICC) line for access proclaiming PICCs are just so much safer than any central line I put in.

45 What is the risk of thromboembolism (VTE) in inpatients with PICCs? A. Everyone knows that PICC lines don t cause clots B. 0.5% in medical inpatients C. 5% in medical inpatients D. 10% in medical inpatients E. Who cares? UE DVTs and PEs don t really matter anyway!

46 VTE with PICCs Question: Design: What is the in-hospital VTE risk in inpatients with PICCs? What factors predict VTE? Retrospective electronic chart review of consecutive adult gen med inpatients, single university-affiliated community hospital; 954 PICCs; 777 patients Symptomatic patients only Mean age 61; 60% women Lobo, et al. J Hosp Med 2009;4:

47 Results 3.5% developed upper extremity DVT 1% developed pulmonary embolism Rate: 5.10 VTE events/1000 PICC-days Multivariate Model Odds Ratio (95% CI) Hx of VTE (7%) ( ) PICC not central (not SVC/RA) 2.61 ( ) Lobo, et al. J Hosp Med 2009;4:

48 VTE with PICCs Question: Design: What is the in-hospital VTE risk in inpatients with PICCs? What factors predict VTE? Retrospective review of consecutive adult gen med inpatients, single community hospital Conclusion:4.5% had VTE complication; hx VTE and non-central PICC location assoc w/vte Comment: Single site, retrospective study. Verify PICC location upon insertion; consider VTE risk with PICC if VTE hx Lobo, et al. J Hosp Med 2009;4:

49 What is the risk of thromboembolism (VTE) in inpatients with PICCs? A. Everyone knows that PICC lines don t cause clots B. 0.5% in medical inpatients C. 5% in medical inpatients D. 10% in medical inpatients E. Who cares? UE DVTs and PEs don t really matter anyway!

50 Case Continued The patient continues to improve and you start thinking about discharge.

51 Which of the following factors does NOT predict early rehospitalization? A. Medicaid insurance B. Marital status C. High-school education D. Current LOS > 2 days E. Lack of regular physician F. There are no specific factors you know she s going to bounce back

52 Hospital Readmission Prediction Model Question: Design: Which patient-level factors are associated with early re-hospitalization? Prospective observational cohort study; 6 US academic medical centers; adult gen med patients; randomly divided into derivation (2/3) and validation cohorts (1/3) Pts admitted by hospitalist or internist; not PCP Pts discharged to home All-cause readmission from admin data; 30-day post-d/c call Hasan, et al. J Gen Intern Med 2010;25(3):

53 Results 17.5% were readmitted within 30 days Seven factors predicted early readmission: Insurance status Marital status Regular physician Charlson co-morbidity index SF-12 physical component score >1 admission in past year Current LOS > 2 days Hasan, et al. J Hosp Med 2009;4:

54 Results Cumulative risk score >=25 identified 5% with 30%+ readmission risk Admissions in last year and age predicted readmission in pts going to SNFs Hasan, et al. J Hosp Med 2009;4:

55 Hospital Readmission Prediction Model Question: Design: Which patient-level factors are associated with early re-hospitalization? Prospective observational cohort study; 6 US acad medical centers; pts Conclusions: 7 patient factors identify high readmit risk Comment: Many pts screened (almost 2/3) not included in analysis;?generalizability Still: consider patient factors when planning discharge interventions Hasan, et al. J Gen Intern Med 2010;25(3):

56 Which of the following factors does NOT predict early rehospitalization? A. Medicaid insurance B. Marital status C. High-school education D. Current LOS > 2 days E. Lack of regular physician F. There are no specific factors you know she s going to bounce back

57 Case Continued The patient is about to be discharged (your intern worked out a great plan!) but you notice that her creatinine has risen from 1.5 to 1.8 over 48 hours (NightFloat gave her NSAIDs for pain at PICC site). Should you care?

58 Short Take: : Acute Kidney Injury (AKI) and Outcomes Retrospective cohort and case-control study of 735 adult patients with AKI (increase of serum creatinine of >0.3 mg/dl within 48 hours); 5089 controls at a single community teaching hospital Patients with AKI were: 8 x more likely to die in the hospital 5 x more likely to have LOS > 7 days ~5 x more likely to require critical care Barrantes, et al. Mayo Clin Proc. 2009;84(5):

59 Summary Definitely Consider 1) Use steroids with abx in acute bacterial meningitis for high income, non HIV patients 2) Ensure central PICC position upon placement 3) Consider risks for readmission when planning discharge 4) Pay attention to small fluctuations in serum creatinine in hospitalized patients 1) VTE risk in hospitalized patients with PICC who have hx of VTE

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62 Case Presentation A 60 year-old man with COPD, HTN, and chronic back pain is admitted with increasing cough, chest pain, and dyspnea. He is tachypneic and hypoxic on exam. His CXR is clear. Based on your evaluation, you think he has a COPD exacerbation. At some point the patient mentions that his chest pain may be ripping or tearing in nature and maybe radiating to the back. In general, you feel this is unlikely to be PE or aortic dissection but wish you could rule them out easily.

63 What test could you order to rule out PE and aortic dissection? A. MRI of the chest. B. Ultrasound of the lower extremities. C. D-dimer. D. CT scan of the chest. E. Trans-esophageal echocardiogram (TEE) F. Who cares. We probably can t get the test done here anyway. I hate my job.

64 D-dimer in Aortic Dissection Question: Design: Can D-dimer testing aid in the evaluation of acute aortic dissection? Prospective, multi-center, 222 suspected aortic dissection; all D-dimer + other; Patient with < 24 hours of symptoms High suspicion = high enough to image 87 patients with dissection Suzuki T, et al. Circulation. 2009;119:2702.

65 Results Test characteristics for D-dimer < 500 ng/ml Sensitivity Specificity Negative Predictive Value Value Negative LR Suzuki T, et al. Circulation. 2009;119:2702.

66 Results Test characteristics for D-dimer < 500 ng/ml Value Sensitivity 96.6% Specificity 46.6% Negative Predictive Value 95% Negative LR 0.07 True for both type A and type B dissection

67 D-dimer in Aortic Dissection Question: Can D-dimer testing aid in the evaluation of acute aortic dissection? Design: Prospective, multi-center, 222 suspected aortic dissection; all D-dimer + other; Conclusion: D-dimer at a level of 500 ng/ml rule out dissection 95% of the time; Poor specificity (coin toss) Comments: Small study but prospective, international Need more to become standard of care May help if truly low pre-test probability for dissection (or imaging not available) Suzuki T, et al. Circulation. 2009;119:2702.

68 What test(s) ) could you order to rule out PE and aortic dissection? A. MRI of the chest. B. Ultrasound of the lower extremities. C. D-dimer. D. CT scan of the chest. E. Trans-esophageal echocardiogram (TEE) F. Who cares. We probably can t get the test done here anyway. I hate my job.

69 Short Take: : Death in COPD Exac. What causes early (< 24 hrs) death in patients hospitalized with a COPD exacerbation? Autopsies were performed on 43 pts with COPD exacerbation who died within 24 hrs of admission. The main causes of death were cardiac failure (37%), pneumonia (28%), and PE (21%). Zvezdin B, et al. Chest. August 2009; 136:376.

70 Case Continued His D-dimer was slightly elevated but a subsequent CT scan was negative for PE and dissection. You admit the patient and treat him for a COPD exacerbation with bronchodilators, steroids, and antibiotics. Before signing your attending note, You read the final CT report: 1. No evidence of pulmonary embolism. 2. A 1 cm pulmonary nodule; clinical correlation is advised. Curious, a new pulmonary nodule...

71 Prevalence of clinically relevant incidental findings on CT s ordered to diagnose PE? A. Hardly ever. B. Less than 5%. C. About 10%. D. Around 25%. E. Clinical correlation!?!? I ll give you a clinical correlation smart.

72 Incidental CT Scan Findings Question: Design: What is the prevalence of clinically relevant incidental findings on CTAs for PE? Retrospective, cross-sectional, 589 CTA s; Ordered by ED; reviewed final read for PE & non-pe findings; Alternative diagnoses (eg. effusion) Incidental = required clinical or rad follow-up Incidental = less urgent / no follow up Hall, et al. Arch Intern Med. Nov 2009; 169(2):1961

73 Results Findings N % Pulmonary embolism Alternative Dx Incidental = Follow-up Incidental Follow-up Hall, et al. Arch Intern Med. 2009; 169(2):1961

74 Results Findings N % Pulmonary embolism 55 9% Alternative Dx % Incidental = Follow-up % Incidental Follow-up 615 ** Follow-up included 13% with a new nodule, 9% with new lymphadenopathy Hall, et al. Arch Intern Med. 2009; 169(2):1961

75 Incidental CT Scan Findings Question: Design: What is the prevalence of clinically relevant incidental findings on CTAs for PE? Retrospective, cross-sectional, 589 CTA s; Ordered by ED; reviewed final read for findings; Conclusion:Incidental findings common in CTAs for PE; Many require followup new nodules/lad; Did also have alternative diagnoses Comment: Retrospective, single site; But consecutive sampling ~ real world Alternative diagnoses: good CXR? Generally poor with follow-up; radiation; Hall, et al. Arch Intern Med. 2009; 169(2):1961

76 Incidental CT Scan Findings A. Hardly ever. B. Less than 5%. C. About 10%. D. Around 25%. E. Clinical correlation!?!? I ll give you a clinical correlation smart.

77 Case Continued You go in with your team to discuss the new pulmonary nodule with the patient. His wife who you have not met is there. You reach out to shake her hand and she withdraws. So have you? she asks, arms crossed. Umm, ahh... So have you washed your hands? There are signs all over the hospital saying that I should ask you. So have you?

78 Have you washed your hands? A. Sure as you hit the alcohol dispenser on the wall. B. Definitely, before and after each patient contact. C. Of course (as you wipe mustard from lunch on your pants) D. Have you?

79 Improving Hand Hygiene Question: Design: Can a multimodal intervention improve healthcare worker hand hygiene? Hand hygiene intervention 5 hosp units; multimodal intervention over 2 weeks; before/after observations Presented baseline data Education of MDs and RNs Identify MD/RN champions Supplied personal use bottles Saint, et al. Qual Saf Health Care 2009;18:429.

80 Results 3987 provider patient interactions Findings Pre Post p Overall 32% 47% <.001 Nurses 34% 48% <.001 Doctors 28% 47% <.001 MD champion identified, engaged, motivated by baseline Cardiology Unit MDs: Pre: 6.4% Post 3.8 % Saint, et al. Qual Saf Health Care 2009;18:429

81 Improving Hand Hygiene Question: Design: Can a multimodal intervention improve healthcare worker hand hygiene? Hand hygiene intervention 5 hosp units; multimodal intervention over 2 weeks; before/after observations Conclusion:Multimodal intervention can improve adherence; MD champion likely key; Rates still remain poor; Comment: Valuable lessons for all hospitals; System issue or personal responsibility? Change physician behavior? Saint, et al. Qual Saf Health Care 2009;18:429

82 Have you washed your hands? A. Sure as you hit the alcohol dispenser on the wall. B. Definitely, before and after each patient contact. C. Of course (as you wipe mustard from lunch on your pants) D. Have you?

83 Summary Definitely 1) Take seriously non-respiratory illnesses in patients hospitalized with a COPD exacerbation. 2) Appreciate how common important incidental findings are in CT scans for PE. Consider 1) Using d-dimer to rule out aortic dissection. 2) How hard it is to get providers to wash their hands.

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86 Case Presentation Mrs. Q, 65 year-old woman with multiple myeloma, is readmitted to the hospital from the nursing home 1 week after receiving chemo through a port. She complains of cough and malaise for 2 days. Her vitals are: T 39.2, P 96, BP 110/56, R 28, SaO2 94% on 3 L NC. CXR shows a left lower lobe infiltrate. Overnight, the team starts her on Ceftriaxone & Azithromycin.

87 You make the following teaching point about the empiric antibiotics: A. Seems like a reasonable choice B. A more appropriate choice would be to empirically cover her with 2 anti-pseudomonal antibiotics. C. Change her coverage to Vancomycin, Cefepime & Gentamicin until cultures return. D. Sounds good. Don t forget to start nebulizers and lasix too just in case

88 HCAP Guidelines *Empiric abx: cover for MRSA & resistant pseudomonas *Risk factors for HCAP: -Hospitalization >2 days in preceding 90 days -Residence in nursing home or extended care facility -Home infusion therapy (including abx) -Long-term dialysis within 30 days -Home wound care -Family member with multidrug resistant organism -Abx therapy within preceding 90 days -Currently hospitalized >5 days -Immunosuppressive disease and/or therapy -High frequency of abx resistance in community or hospital Am J Respir Crit Care Med. 2005;171:388.

89 Knowledge of HCAP Guidelines Question: How well do physicians know HCAP guidelines? Design: Cross-sectional survey of 855 respondents at 4 academic medical centers. Queried attitudes towards HCAP guidelines & management of 9 hypothetical cases (2 CAP, 7 HCAP). Seymann, et al. Clin Infect Dis. 2009;49:1868

90 Results Seymann, et al. Clin Infect Dis. 2009;49:1868

91 Results Seymann, et al. Clin Infect Dis. 2009;49:1868

92 Results Specialty/Role # Correct answers to 7 HCAP questions Correct answers to 2 CAP questions Hospitalist faculty IM residents ED faculty ED residents Pulm/CCM faculty Pulm/CCM residents Seymann, et al. Clin Infect Dis. 2009;49:1868

93 Results Seymann, et al. Clin Infect Dis. 2009;49:1868

94 Knowledge of HCAP Guidelines Question: Design: How well do physicians know HCAP guidelines? Cross-sectional survey at 4 medical centers; asked about HCAP guidelines and attitudes; Conclusion: Despite awareness and agreement with HCAP guidelines, physicians may not adhere to them when making clinical decisions. Comment: This study does not evaluate actual practice, but high proportion of incorrect answers suggest a large gap between guidelines & practice. Seymann, et al. Clin Infect Dis. 2009;49:1868.

95 You make the following teaching point about the empiric antibiotics: A. Seems like a reasonable choice B. A more appropriate choice would be to empirically cover her with 2 anti-pseudomonal antibiotics. C. Change her coverage to Vancomycin, Cefepime & Gentamicin. D. Sounds good. Don t forget to start nebulizers and lasix too just in case

96 Case Continued With empiric antibiotics, the patient s fever abates and her breathing improves. However on HD #2 the micro lab calls your team: both sets of admission blood cultures have grown coagulase negative staphylococcus (CONS). Your resident notes that Mrs. Q is already receiving Vancomycin. She then asks you, should we take out her port?

97 Should the port be removed? You respond: A. No, studies show that IV Vancomycin will clear CONS even if the central line stays in. B. No, taking out the port will complicate her chemotherapy regimen. C. Possibly, removing the line may decrease the risk for recurrence of bacteremia. D. Sure! The hospital is behind on charges, so we need all the procedures we can get.

98 Managing Coag-negative Staph Question: Design: In the setting of CONS bacteremia, what is the likelihood of resolution and of recurrence when a central line is retained? Case-control study involving 188 patients at a tertiary-care cancer hospital. Raad, et al. Clin Infect Dis. 2009;49:1187.

99 Results Characteristic Resolution of bacteremia Patients without resolution (n=175) Patients with resolution (n=13) P-value Catheter removed or exchanged Catheter retained 72 6 Raad, et al. Clin Infect Dis. 2009;49:1187.

100 Results Recurrence of bacteremia within 4 months Characteristic Patients without recurrence (n=136) Patients with recurrence (n=17) P-value Catheter removed or exchanged Catheter retained Raad, et al. Clin Infect Dis. 2009;49:1187.

101 Results Raad, et al. Clin Infect Dis. 2009;49:1187.

102 Managing Coag-negative Staph Question: Design: In CONS bacteremia, what is resolution or recurrence when the line is retained? Case-control study of 188 patients at a tertiarycare cancer hospital. Conclusion: Removing central lines for CONS bacteremia is not associated with improved resolution of infection or mortality, but may be associated with decreased risk of recurrence. Comments: Small, case control study is suggestive. However further study is needed. Raad, et al. Clin Infect Dis. 2009;49:1187.

103 Should the port be removed? You respond: A. No, studies show that IV Vancomycin will clear CONS even if the central line stays in. B. No, taking out the port will complicate her chemotherapy regimen. C. Removing the line may decrease the risk for recurrence of bacteremia. D. Sure! The hospital is behind on charges, so we need all the procedures we can get.

104 Case Continued Mrs Q continues to improve and your team is now preparing to discharge her back to her nursing home. Prior to discharge you overhear your resident telling the team to discontinue unnecessary medications including the PPI and also to administer a pneumovax. She also tells the team that if Mrs. Q had been a smoker it would be important to arrange for a follow-up chest X-ray in a 3-4 weeks. You quickly jump in with the following pearls

105 Short Take: : PPI increases risk for HAP Retrospective observational study of 63,878 non-icu admissions showed increased risk for hospitalacquired pneumonia: ~1% increased risk. Outcome Acid suppressive medication (n=32,922) No Acidsuppressive medication Adjusted OR (95% CI) Hospital-acquired PNA ( ) Aspiration PNA ( ) Nonaspiration PNA ( ) Herzig, et al. JAMA. 2009;301(20):2120.

106 Short Take: Pneumovax in nursing homes Double blind RCT of 1006 Japanese nursing home residents comparing 23-valent pneumovax vs. placebo showed ~4.5% decreased risk for pneumococcal pneumonia. NNT=22 Risk of death from pneumococcus declined ~35%. Maruyama, et al. BMJ. 2010;340:c1004.

107 Short Take: : Cancer after pneumonia Retrospective review of 40,744 patients >65 years old who were discharged from a VA hospital found that ~9% were diagnosed with lung cancer within 300 days of index PNA admission. The findings support concept of follow-up imaging in elderly, high-risk patients. However, investigators could not identify appropriate time frame or imaging technique for follow-up. Mortensen, et al. Am J Med ;123:66.

108 Summary Definitely Consider 1) Monitor for inappropriate empiric antibiotics use in patients with healthcare-associated pneumonia. 2) Discontinue or substitute an H2 blocker for unnecessary PPI s in hospitalized patients. 3) Administer the pneumococcal vaccine to patients who reside in nursing homes. 1) Removing central lines, especially ports, in patients who develop CONS bacteremia. 2) Arranging for follow-up Chest X-rays in elderly patients with pneumonia.

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111 Case Presentation Mid-afternoon your resident runs up to you to share that Mr. Johnson, the 62 year-old man with pancreatitis has developed a dense R-sided hemiparesis and aphasia. The nurse states he was completely normal 4 hours ago. The head CT is negative and he has no contraindications to thrombolysis. What do you do?

112 What do you do? A. At 4 hours it is too late to try thrombolysis all we can do is provide supportive care. B. We can still give thrombolysis at 4 hours it may improve his outcome and won t increase mortality. C. We can try thrombolysis as it may improve his outcome but it will increase his chance of dying. D. Isn t there a Billy Squire song from the 1970 s called Stroke?

113 Thrombolysis in Acute Stroke Question: Is it safe and efficacious to administer tpa 3 to 4.5 hours after acute ischemic stroke? Design: Meta-analysis of RCTs; 4 studies; 1622 pts; Outcomes were functional and mortality Included ECASS-1, ECASS-2, ECASS-3, ATLANTIS Median time to treatment was ~ 4 hrs in all trials Lansberg MG, et al. Stroke. July 2009;40:2438.

114 Thrombolysis in Acute Stroke Outcomes Odds Ratio P value Global outcome measure* Modified Rankin 90-day Mortality * Global odds ratio from 3 individual outcome scales at 90 days Lansberg MG, et al. Stroke. July 2009;40:2438.

115 Thrombolysis in Acute Stroke Outcomes Odds Ratio P value Global outcome measure Modified Rankin day Mortality 1.04 NS Did not report symptomatic ICH generally 2-5x higher with tpa (~7% vs. 2%) Lansberg MG, et al. Stroke. July 2009;40:2438.

116 Thrombolysis in Acute Stroke Question: Is it safe and efficacious to administer tpa 3 to 4.5 hours after acute ischemic stroke? Design: Meta-analysis of RCTs; 4 studies; 1622 pts; Outcomes were functional and mortality Conclusion: tpa in the window for eligible patients improves favorable outcomes at 90 days No increased risk of death; Comments: Should be considered in the hr window Supported by updated AHA guidelines, also published in 2009 But earlier is still better (time is brain) Lansberg MG, et al. Stroke. July 2009;40:2438.

117 What do you do? A. At 4 hours it is too late to try thrombolysis all we can do is provide supportive care. B. We can still give thrombolysis at 4 hours it may improve his outcome and won t increase mortality. C. We can try thrombolysis as it may improve his outcome but it will increase his chance of dying. D. Isn t there a Billy Squire song from the 1970 s called Stroke?

118 Case Continued You decide to administer tpa to the patient. Unfortunately 60 minutes after administration, he arrests. You go to the room as the code is ongoing. As you arrive, Mrs. Johnson and their son arrive as well. They ask if they can go into the room to be present for the resuscitation. Do you allow the patient s family to be present during the resuscitation?

119 Do you allow the family to be present during the resuscitation? A. Yes, I think it is helpful for them to see that everything is being done and they can be there for him. B. No, I think it would be too traumatic for them to see a full code blue. C. Yes, my hospital has an official policy allowing families to be present. D. No, I think having the family there might impair the performance of the code team. E. Hard to come up with an appropriate joke answer for this one. Sorry.

120 Family Presence at Medical Codes Question: Design: Does the presence and behavior of a family witness impact resuscitation? Randomized study, 2 nd /3 rd -year EM residents (n=60); simulated code; VT to VF to asystole to death; Randomized to 3 groups: No family witness A nonobstructive quiet witness A witness with overt grief reaction Fernandez R, et al. Crit Care Med. June 2009;37:1956.

121 Results: Impact on critical actions Critical Actions No witness Quiet Overt grief Time to 1 st compression Time to 1 st shock # of Shocks Time to death Fernandez R, et al. Crit Care Med. June 2009;37:1956.

122 Results: Impact on critical actions Critical Actions Time to 1 st compression Time to 1 st shock No witness Quiet Overt grief * # of Shocks * Time to death * P < 0.001

123 Family Presence at Medical Codes Question: Design: Does the presence and behavior of a family witness impact resuscitation? Randomized study, 2 nd /3 rd -year EM residents (n=60); simulated code; Conclusion:Presence of a family member w/ overt grief impacted performance; Could impact outcomes (time to & # of shocks) Comments:Small study and simulated; Note-social worker present (recommended) Intriguing result future research to examine impact on family, providers, and outcomes? Lansberg MG, et al. Stroke. July 2009;40:2438.

124 Do you allow the family to be present during the resuscitation? A. Yes, I think it is helpful for them to see that everything is being done and they can be there for him. B. No, I think it would be too traumatic for them to see a full code blue. C. Yes, my hospital has an official policy allowing families to be present. D. No, I think having the family there might impair the performance of the code team. E. Hard to come up with an appropriate joke answer for this one. Sorry.

125 Short Take: Chest compression A prospective study of 509 out-of-hospital cardiac arrests (VF or VT) examined percent time given chest compressions and outcomes. Increased percent time patients were given chest compressions increased the odds of surviving to hospital discharge (11% increase for each 10% increase in time spent). Christensen J, et al. Circulation. Sept 2009;120:1241.

126 Case Continued Unfortunately the patient does not do well. He is coded for 30 minutes but regains a pulse; intubated and on max pressors he is transferred to the ICU and cooled. Days later he has made no neurologic recovery and remains comatose. You arrange for a family meeting with the patient s wife and son.

127 In the meeting you intend to empathetically explain the situation and: A. Let the family decide what course to take. B. Recommend limitations regarding life support. C. Ask the family if they would like your recommendation regarding life support. D. Refuse to perform CPR if he codes again. E. Tell them, Hey, I think I m going to refer this to one of Obama s death panels.

128 End of Life Recommendations Question: Design: Should physicians recommend limitations of life support to surrogates? Prospective study, 169 surrogate decisionmakers for critically ill patients; Watched videos of simulated family meetings MD recommendation was only difference in 2 videos Then, structured interviews to determine why White DB, et al. Am J Respir Crit Care Med. 2009;180:320.

129 End of Life Recommendations N (%) Preferred 96 (56%) Did not prefer 70 (42%) No preference 4 (2%) White DB, et al. Am J Respir Crit Care Med. 2009;180:320.

130 End of Life Recommendations Question: Should physicians recommend limitations of life support to surrogates? Design: Prospective study, 169 surrogate decisionmakers for critically ill patients; Watched videos of simulated family meetings Conclusion: Over 40% preferred no MD recommendation Felt might make the process harder; felt it could impair the relationship with the MD Comment: No consensus on if we should provide recs Best practice probably to ask if surrogates want a recommendation White DB, et al. Am J Respir Crit Care Med. 2009;180:320.

131 In the meeting you intend to empathetically explain the situation and: A. Let the family decide what course to take. B. Recommend limitations regarding life support. C. Ask the family if they would like your recommendation regarding life support. D. Refuse to perform CPR if he codes again. E. Tell them, Hey, I think I m going to refer this to one of Obama s death panels.

132 Short Take: End-of of-life Conversations Do end-of-life (EOL) conversations impact healthcare costs in the last week of life? In a prospective study of 627 patients with advanced cancer, having EOL conversations at baseline was associated with lower costs in the last week of life. Higher costs in the last week were associated with a worse quality of death. Zhang B, et al. Arch Intern Med. Mar 2009;169:80.

133 Summary Definitely Consider 1) Prioritize chest compressions in any resuscitation. 1) Thrombolysis in eligible patients 3 to 4.5 hours after acute ischemic stroke. 2) The consequences of allowing family members to be present at resuscitations. 3) Asking families and surrogates if they would like your opinion regarding limiting care. 4) The cost consequences of not having EOL conversations in patients with advanced cancer.

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135 Summary Definitely Consider 1) Use diltiazem instead of digoxin or amiodarone for rate control of uncomplicated atrial fibrillation. 1) Limiting evaluation of syncope in patients 65 yo to history, exam, orthostatics, tele, EKG, troponin I. 2) Using dabigatran instread of warfarin for anti-coagulation in afib and DVT/PE when approved.

136 Summary Definitely Consider 1) Use steroids with abx in acute bacterial meningitis for high income, non HIV patients 2) Ensure central PICC position upon placement 3) Consider risks for readmission when planning discharge 4) Pay attention to small fluctuations in serum creatinine in hospitalized patients 1) VTE risk in hospitalized patients with PICC who have hx of VTE

137 Summary Definitely 1) Take seriously non-respiratory illnesses in patients hospitalized with a COPD exacerbation. 2) Appreciate how common important incidental findings are in CT scans for PE. Consider 1) Using d-dimer to rule out aortic dissection. 2) How hard it is to get providers to wash their hands.

138 Summary Definitely Consider 1) Monitor for inappropriate empiric antibiotics use in patients with healthcare-associated pneumonia. 2) Discontinue or substitute an H2 blocker for unnecessary PPI s in hospitalized patients. 3) Administer the pneumococcal vaccine to patients who reside in nursing homes. 1) Removing central lines, especially ports, in patients who develop CONS bacteremia. 2) Arranging for follow-up Chest X-rays in elderly patients with pneumonia.

139 Thank you! Thank you to Ben Taylor (UAB) who helped with the selection, formulation, and construction of this Update in Hospital Medicine.

140 2010 Bradley Sharpe, MD UCSF Division of Hospital Medicine Romsai Boonyasai, MD, MPH Johns Hopkins Department of Medicine Anneliese Schleyer, MD University of Washington Dept. of Medicine Sponsored by the SGIM Academic Hospitalist Taskforce