Updates in Hospital Medicine 2013

1. Updates in Hospital Medicine2013 Kendall Rogers, MD CPE FACP SFHM Associate Professor and Chief Division of Hospital Medicine University of New Mexico School of Medicine

2. Disclosures No disclosures to report.

3. Acknowledgements • Michelle Mourad • Hospital Medicine Journal Club • Anthony Worsham, Sheila Modi, and Jens Langsjoen

4. Updates in Hospital Medicine 2013

5. Updates in Hospital Medicine 2013 • Articles From Late 2012 and 2013 • Process: • Reviewed and stole from SHM Update in Hospital Medicine 2013 • Reviewed all articles presented at Division of Hospital Medicine Journal Club • CME collaborative review of journals • ▪ Including ACP J. Club, J. Watch, etc.

7. 1 in 5 hospitalized patients get a foley, up to half are inappropriate • 26% will develop bacteriuria, and 24% of those will develop CAUTI • 13,000 deaths per year to CAUTI • Annual direct medical costs between $340 to $370 million

8. As many as 71% of hospitalized patients on GI prophylaxis without indication • Strong correlation between PPI use and pneumonia and C. Diff infections • PPI not recommended for adult patients in non-ICU settings with fewer than 2 risk factors for bleeding

9. A restrictive approach with Hgb cutoff of 7 g/dL has shown improved outcomes • Holds true to AMI, GI bleed, and surgical patients • Cost of blood $700-900 per unit and carries infectious and noninfectious adverse reactions

10. Study showed only 12.6% of patients on non-ICU required telemetry and only 7% received modified management due to telemetry • Telemetry • Is resource intensive • Does not alter management • Can lead to additional testing • Increased length of stay in ED • Reduced hospital throughput • A false sense of security

11. Studies show no difference in readmit rates, transfers to ICU, LOS, rates of adverse events, or mortality when frequency reduced • Charges estimated at $150/patient/day • Hospital acquired anemia shown to have worse outcomes

13. What didn’t make it on SHM: • Don’t presume a patient to be full code on admission, have a code status discussion with all patients to confirm.

14. Other Choosing wisely lists pertinent to hospital medicine

16. Other Choosing Wisely Lists: • ACP • In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI) • In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test. • Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.

17. Other Choosing Wisely Lists: • Palliative Medicine • Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding. • Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment. • Don't leave an implantable cardioverter-defibrillator (ICD) activated when it is inconsistent with the patient/family goals of care.

18. Other Choosing Wisely Lists: • Neuro • Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms. • GI • For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals.

19. Other Choosing Wisely Lists: • Radiology • Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability. • Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.

20. Other Choosing Wisely Lists: • Geriatrics • Don't use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia. • Avoid using medications to achieve hemoglobin A1c<7.5% in most adults age 65 and older; moderate control is generally better. • Don't use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium. • Don't use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

21. Other Choosing Wisely Lists: • Echocardiography • Avoid transesophageal echocardiography (TEE) to detect cardiac sources of embolization if a source has been identified and patient management will not change. • Nuclear Cardiology • Don't perform cardiac imaging as a pre-operative assessment in patients scheduled to undergo low- or intermediate-risk non-cardiac surgery.

22. Other Choosing Wisely Lists: • Nephrology • Avoid nonsteroidal anti-inflammatory drugs (NSAIDs) in individuals with hypertension or heart failure or CKD of all causes, including diabetes. • Nuclear Medicine • Avoid using a computed tomography angiogram to diagnose pulmonary embolism in young women with a normal chest radiograph; consider a radionuclide lung study (“V/Q study”) instead.

23. Other Choosing Wisely Lists: • Vascular Medicine • Don’t do work up for clotting disorder (order hypercoagulable testing) for patients who develop first episode of deep vein thrombosis (DVT) in the setting of a known cause. • Don’t reimage DVT in the absence of a clinical change. • Avoid cardiovascular testing for patients undergoing low-risk surgery.

25. Now on with the cases!

26. Case 1 76 y.o. patient with COPD, chronic venous insufficiency, previous C. difficile. One day history of fever, chills… Pulse 120 BP 94/60 T 102.4 RR 28 WBC 18,000 with 18% bands Lactate 3

27. Is there another symptom or sign that helps predict bacteremia?

28. Predicting bacteremia based on nurse-assessed food consumption at the time of blood culture. Patients meeting entry criteria n = 1179 Exclude: Other causes of decreased oral intake IVH/NPO, n=194 N/G tube feeding, n=134 n = 851 Blood Culture + n = 122 Blood Culture – n = 729 True positive cultures well-defined True Positive n = 75 Komatsu T et al. J Hosp Med 2012; 7:702-205

29. Komatsu T et al. J Hosp Med 2012; 7:702-205

30. Komatsu T et al. J Hosp Med 2012; 7:702-205

31. The Case continues….. + Blood cultures: MRSA 48 hours into hospitalization: Still febrile, BPs labile and lowish

32. Is daptomycin better than vancomycin for MRSA bacteremia?

33. Daptomycin versus vancomycin for bloodstream infections due to methicillin-resistant Staphylococcus aureus with a high vancomycin minimum inhibitory concentration: a case-control study. Design: Single center, retrospective MRSA blood culture isolates with vancomycin minimum inhibitory concentration less than or equal to 2 Moore CL et al. Clin Infect Dis 2012; 54:51-8.

34. Moore CL et al. Clin Infect Dis 2012; 54:51-8.

35. Moore CL et al. Clin Infect Dis 2012; 54:51-8.

36. On with the case! Our patient is treated and discharged but then returns to the ED increased cough and SOB. Initially on BiPAP, now on NC. His labs are only notable for a BUN of 35 and a creatinine of 1.9. He has diffuse loud wheezes on exam and is difficult to arouse. Afebrile BP: 135/85 Pulse: 110 O2 sat: 94% on 4L NC

37. Case Presentation “The patient has a monitored floor bed upstairs and is just waiting for your admitting orders.”

38. Where do you think the patient should be admitted? • Need an ABG before triage to the floor • Regular floor on telemetry • His age, pulse, BUN and altered mental status identify risk for bad outcomes on the floor • Needs the ICU • Sounds like an “obs” patient to me

39. Is there an easy risk score that can predict poor outcomes in acute COPD?

40. Validation of a Novel Risk Score for Severity of Illness in Acute Exacerbations of COPD Design: Validation of a risk score for pts with acute COPD admitted to hospital, retrospective cohort 34,699 patients > 40 years old, acute exacerbations of COPD. Ability of the BAP-65 score to predict outcomes, LOS and cost. B – BUN >25 A – AMS P – Pulse >109 >65 year old Shorr AF, et al. Chest. 2011;140(5):1177-1183.

41. BAP-65 score for COPD risk B – BUN >25 A – AMS P – Pulse >109 >65 year old Shorr AF, et al. Chest. 2011;140(5):1177-1183.

42. Conclusion: BAP-65 can be useful in initial triage to predict MV and mortality. Better at identifying patients with low risk, who are safe for floor. Comment: Measurements all present on an initial assessment, but may leave out other key information that could improve triage. BAP-65 score for COPD risk Shorr AF, et al. Chest. 2011;140(5):1177-1183.

43. Where do you think the patient should be admitted? • Need an ABG before triage to the floor • Regular floor on telemetry • His age, pulse, BUN and altered mental status identify risk for bad outcomes on the floor • Needs the ICU • Sounds like an “obs” patient to me

44. Where do you think the patient should be admitted? • Need an ABG before triage to the floor • Regular floor on telemetry • His age, pulse, BUN and altered mental status identify risk for bad outcomes on the floor • Needs the ICU • Sounds like an “obs” patient to me

45. Our case continues... We start prednisone, Azithromycin and admit him to the ICU, where he is intubated for 2 days due to progressive hypercarbia and extubated on hospital day #3 and he is moved to the floor. Two days later his WBC rises to 24, and we are a little worried this isn’t just the steroids. Nurse states pt having loose stools that smell like C. Diff

46. Should you believe her? Can you tell C. Difficile simply by its smell?

47. Using a dog’s superior olfactory sensitivity to identify Clostridium difficile in stools and patients: proof of principle study • Beagle trained to identify the smell of C.difficile in stool samples and sit or lie down with a positive result. • Performance was tested on 100 stool samples & 300 patients (30 cases and 270 controls). Bomers, MK et al. BMJ; 2012:345, 7-9

49. Bomers, MK et al. BMJ; 2012:345, 7-9

50. Bomers, MK et al. BMJ; 2012:345, 7-9