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Update in Hospital Medicine 2009

Update in Hospital Medicine 2009. Kendall M. Rogers, MD Assistant Professor/Chief – Section of Hopital Medicine. Lecture Outline. Trends in Hospital Medicine Literature Review Conclusions and Challenges. Lecture Outline. Trends in Hospital Medicine Growth of the Specialty Health Reform

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Update in Hospital Medicine 2009

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  1. Update in Hospital Medicine2009 Kendall M. Rogers, MD Assistant Professor/Chief – Section of Hopital Medicine

  2. Lecture Outline • Trends in Hospital Medicine • Literature Review • Conclusions and Challenges

  3. Lecture Outline • Trends in Hospital Medicine • Growth of the Specialty • Health Reform • Quality Measures • Literature Review • Conclusions and Challenges

  4. Lecture Outline • Trends in Hospital Medicine • Literature Review • Clinical • Processes of Care • Conclusions and Challenges

  5. Lecture Outline • Trends in Hospital Medicine • Literature Review • Clinical • Inpatient Glycemic Control • H1N1 • Inpatient Resucitation • Clinical Potpourri • Processes of Care • Conclusions and Challenges

  6. Lecture Outline • Trends in Hospital Medicine • Literature Review • Clinical • Processes of Care • Discharge Processes • IT Tools Potpourri • Processes Potpourri • Conclusions and Challenges

  7. Lecture Outline • Trends in Hospital Medicine • Growth of the Specialty • Health Reform • Quality Measures • Literature Review • Clinical • Inpatient Glycemic Control • H1N1 • Inpatient Resucitation • Clinical Potpourri • Processes of Care • Discharge Processes • IT Tools Potpourri • Processes Potpourri • Conclusions and Challenges

  8. Trends In Hospital Medicine

  9. Lecture Outline • Trends in Hospital Medicine • Growth of the Specialty • Health Reform • Quality Measures • Literature Review • Conclusions and Challenges

  10. Growth of Hospital Medicine Specialty • SHM Estimates >28,000 hospitalists currently • Study of Medicare Data • Percentage of physicians in GIM identified as hospitalists increased from 5.9% in 1995 to 19.0% in 2006 • Percentage of all claims for inpatient services by hospitalists increased from 9.1% to 37.1% from 1995 to 2006 • Odds of receiving care from a hospitalist increased by 29.2% per year from 1997 through 2006 Kuo YF, Sharma G, Freeman JL, Goodwin JS. Growth in the care of older patients by hospitalists in the United States. N Engl J Med. 2009 Mar 12;360(11):1102-12.

  11. Health Reform Impact on Hospitalists • Bundled Hospital Payments • HITECH Funding

  12. Health Reform – Bundled Payments • Care Transitions Project – CMS Pilot • One payment to hospitals and providers for an Acute Care Episode • Current project on ortho and cardiac surgeries • Models also could include post hospital care • Implications • Emphasis on preventing re-admissions and quality advances • Hospital/physician power struggles • Would hospitalists predominantly become employees? • Potential for sharing of cost savings • Would specialist take patients back from hospitalists?

  13. Health Reform – HITECH Funding • Part of the ARRA • 37 Billion to incentivize adoption of EHRs (expect 20 billion in savings) • Payments to begin in 2010 • Penalties begin ~2015 • Demonstrate meaningful use of a certified Electronic Health Record (EHR) • ‘Meaningful use’ • ‘Certified EHR’

  14. HITECH Funding Implications • Is current EHR software ready for ‘primetime’ • Do ‘off the shelf’ systems replicate home grown research? • Should the focus be on adoption or development? • Do we have the expertise to implement? • Does this force a customer base for poorly designed software? • For inpatient EHR, hospitalists are and will be ‘go to’ population for implementation

  15. Hold Harmless Clauses/Non-Disclosure • Health IT venders are virtually liability free even when product implicated in adverse events • Learned intermediaries should identify and correct all software faults • Many contracts also include non-disclosure of defects, even to other users of the same system • JC requires hospitals to report safety quality issues • Non-disclosure is unethical in a healthcare setting • These are NEGOTIABLE – take them out of your contracts Ross Koppel, PhD; David Kreda, BA. Health Care Information Technology Vendors' "Hold Harmless" Clause - Implications for Patients and Clinicians. JAMA. 2009;301(12):1276-1278.

  16. Quality Measures • Too many too quick?

  17. From Every Direction • National Quality Forum • Joint Commission • Professional Societies • CMS • Leapfrog • Institute for Healthcare Improvement • Core Measures • Institute of Medicine • National Quality Measure Clearinghouse includes 1849 measures

  18. Quality of Evidence • Antibiotics within 4 hours for CAP – Core Measure • Catheter related UTI – Never Event • Tight Glycemic Control in ICU – Leapfrog • Rapid Response Teams – IHI Initiative • Blood Cultures in CAP – Core Measure • In-Hospital Falls – Never Event • Future Measures: • Delirium • C. Difficile • Staph Aureus Bacteremia

  19. Never Events • Criteria: • Common • Costly • Reasonably can be prevented • “Can be consistentlyand effectively prevented through the application of evidence-basedguidelines”

  20. Preventable Falls as a Measure • Common, Costly, Preventable? • 1 in 5 considered preventable • No study has shown technique that prevent injury from falls Inouye, Brown, Tinetti. Medicare Nonpayment, Hospital Falls, and Unintended Consequences. NEJM V 360:2390-2393. 6/4/2009

  21. Inouye, Brown, Tinetti. Medicare Nonpayment, Hospital Falls, and Unintended Consequences. NEJM V 360:2390-2393. 6/4/2009

  22. Potential Unintended Consequences • Decrease in mobility • Resurgencein the use of physical restraints • Restraints • Do not reduce the risk of fallsor related injuries • Do increasedrates of complications including • Immobility • Functional loss • Delirium and agitation • Pressure sores • Asphyxiation and death • Increase the risk of falling or sustaining an injuryfrom a fall Inouye, Brown, Tinetti. Medicare Nonpayment, Hospital Falls, and Unintended Consequences. NEJM V 360:2390-2393. 6/4/2009

  23. Conclusion on Falls • Using a simple measure to try to fix a complex problem • Could result in harming more patients than it helps • Argued to be cost control in the guise of patient safety

  24. Preventable Catheter Related UTI • Common, Costly, Preventable? • Can be prevented 25 – 75% of the time with multimodal strategies • Current Inaction • 56% of hospitals have no system for monitoring which patients had urinary cathetersplaced • 74% not monitoring how long a catheter hadbeen in place • 9% have catheter removal reminderor stop order Saint, Meddings, et al. Catheter-Associated Urinary Tract Infection and Medicare Rule Changes. Annals of IM 6/16/2009. V 150: 877-884.

  25. Potential Unintended Consequences • More Urinalyses and Urine Cultures, Leading to More Antibiotic Treatment of Asymptomatic Bacteriuria • Increased Opportunity for Fraud • Loss of Important Information for Research and Surveillance • Reduced Access for Some High-Risk Patients • Opportunity Costs Saint, Meddings, et al. Catheter-Associated Urinary Tract Infection and Medicare Rule Changes. Annals of IM 6/16/2009. V 150: 877-884.

  26. Potential Benefits • Increased Focus on Catheter-Associated Urinary Tract Infection • Specific Education for Health Care Workers Focusing on Appropriate and Inappropriate Indications for Urinary Catheterization • Increased Focus on Early Catheter Removal • More Focus on Alternatives to Indwelling Catheterization Saint, Meddings, et al. Catheter-Associated Urinary Tract Infection and Medicare Rule Changes. Annals of IM 6/16/2009. V 150: 877-884.

  27. Recommendations for Hospitals to Address the Centers for Medicare Medicaid Services Rule Changes Regarding Catheter-Associated Urinary Tract Infection Saint, S. et. al. Ann Intern Med 2009;150:877-884

  28. Recommendations to Hospitals for CA UTI Prevention • Develop or adopt existing protocols to ensure that indwelling urinary catheters are used only when medically indicated and that they are inserted and maintained using proper technique • Develop systems to promote removal of urinary catheters when they are no longer indicated • Educate clinicians about the appropriate use and interpretation of urinalysis and urine culture

  29. Conclusion on CA UTIs • Perhaps this will do more good than bad • Must monitor its impact

  30. Quality Measures • Must have sufficient evidence to support beyond single study or single institution • Must monitor all intended and unintended consequences • If not achieving higher quality care, should be dropped

  31. Literature Review

  32. Lecture Outline • Trends in Hospital Medicine • Literature Review • Clinical • Inpatient Glycemic Control • H1N1 • Inpatient Resucitation • Clinical Potpourri • Processes of Care • Conclusions and Challenges

  33. Glycemic Control • Poor glucose control increases mortality • We are still doing a bad job at glycemic control • Some of what we thought is not so

  34. Poor sugar control increases mortality • Poor glucose control was associated with a fourfold increase in mortality and major complications following cardiac surgery • Data: retrospective study of 8,000 adults who underwent cardiac surgery between April 1996 and March 2004 • Major Findings • >50% with moderate (200 to 250 mg/dL) to poor (>250 mg/dL) blood glucose control (BGC) were not previously identified as diabetic • Inadequate BGC was associated with in-hospital mortality (good, 1.8%; moderate, 4.2%; poor, 9.6%; adjusted odds ratio: poor versus good BGC, 3.90) Ascione, Rogers, et al. Inadequate Blood Glucose Control Is Associated With In-Hospital Mortality and Morbidity in Diabetic and Nondiabetic Patients Undergoing Cardiac Surgery. Circulation. 2008;118:113-123

  35. Glycemic Control Poor • Setting: U.S. academic medical centers • Data:1,718 patients discharged from 37 academic medical centers between July 1 and Sept. 30, 2004. • Main Findings: • 84.6% of patients received insulin on day 2 • Recent HgA1C and admission CBG being done varied widely • >70% of patients who received subcutaneous insulin had glucose levels higher than 180 mg/dL on days 1, 2, and 3 • Improved with IV insulin than with subcutaneous insulin, but only 50% of ICU patients had received it on day 1 Boord, Greevy, Braithwaite, et al. Evaluation of hospital glycemic control at US Academic Medical Center. Journal of Hospital Medicine 2009;4:35-44.

  36. Tight Glycemic Control • Background • 2001, Van den Berghe et al reported a reduction in morbidity and mortality with intensive insulin therapy (IIT) in surgical ICU patients • Professional organizations issued guidelines calling for tight control • Hospitals around the world changed their protocols to work toward intensive insulin therapy in ICU patients • Since 2001, further studies have failed to reproduce the same dramatic benefit of IIT N Engl J Med. 2001;345(19):1359-67

  37. Intensive Insulin Therapy • RCT in tertiary-care teaching hospital in Saudi Arabia • Randomized to IIT or conventional insulin therapy (CIT). Protocols to maintain glucose levels of 80 to 110 mg/dL and 180 to 200 mg/dL • The primary endpoint ICU mortality • No statistically significant difference in ICU mortality • (13.5% for IIT vs. 17.1% for CIT; P=0.30). • The adjusted hypoglycemia rate was 6.8 (per 100 treatment days) with IIT and 0.4 with CIT • (P<0.0001) • Patients with hypoglycemia had higher ICU mortality • (23.8% vs. 13.7%, P=0.02) Arabi Y, Dabbagh O, Tamim H, et al. Intensive versus conventional insulin therapy: a randomized controlled trial in medical and surgical critically ill patients. Crit Care Med. 2008;36(12):3190-3197.

  38. Intensive Insulin Therapy • Bottom line: • Well-designed study failed to show a survival benefit with IIT use in the critical-care setting • Hypoglycemic more common in ITT • Hypoglycemia related to higher mortality Arabi Y, Dabbagh O, Tamim H, et al. Intensive versus conventional insulin therapy: a randomized controlled trial in medical and surgical critically ill patients. Crit Care Med. 2008;36(12):3190-3197.

  39. Intensive Insulin Therapy • Meta-analysis of 29 RCT with 8,432 patients comparing tight glycemic control (goal <150) to ‘usual care’ • Tight glucose control in critically ill patients had no significant effect on hospital mortality rates • Increased the risk for severe hypoglycemia (<40) • (13.7% risk for tightly controlled patients versus 2.5% for usual care patients) Wiener, Larson,. Benefits and Risks of Tight Glucose Control in Critically Ill Adults: A Meta-analysis. JAMA. 2008;300(8):933-944.

  40. NICE – SUGAR • Open Label RCT, Multinational • 6104 critically ill patients • Intensive infusion (81-108 mg/dL) vs “Conventional” control (144 – 180 mg/dL) • 90 day survival – primary end point NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009 Mar 26;360(13):1283-97.

  41. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009 Mar 26;360(13):1283-97.

  42. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009 Mar 26;360(13):1283-97.

  43. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009 Mar 26;360(13):1283-97.

  44. NICE - SUGAR ITT vs CGC 90 day mortality 27.5% vs 24.9% Severe hypoglycemia 6.8% vs 0.5% Glucose control (median) 107 vs 141 mg/dL Insulin infusion 97% vs 69% No difference – 30 day mortality, ICU days, hospital days, days of mechanical ventilation, days of renal replacement, organ failures Number needed to harm of 38 NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009 Mar 26;360(13):1283-97.

  45. What NICE SUGAR does not prove • Tight glycemic control without increased episodes of hypoglycemia worsens or improves mortality

  46. Review what we know • Poor glycemic control is bad • Multi-disciplinary protocol driven care is effective • Current targets should be lower than 180 and prevention of hypoglycemia • Develop and use protocols for subcutaneous insulin (basal bolus) for non-critical ill patients and IV insulin for critically ill patients

  47. At UNM • Paper based basal bolus protocol implemented, education to nursing staff and MDs, multi-disciplinary team • Medicine SAC Floor looking at Patient Day Averages                             July 2008        July 2009 CBG Median            161                144 CBG Mean              176                158 Percent CBG <70      9.6                 5.4 Percent CBG >299   21.6                10.9 >10% Improvement ~50% Reductions

  48. H1N1- Inpatient Implications • Vaccination of healthcare workers • Respiratory Precautions • Healthcare workers • Contingency Plans • Screening/Treatment

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