NEW APPROACHES IN INPATIENT MEDICINE THAT MIGHT CHANGE YOUR PRACTICE - - PowerPoint PPT Presentation

NEW APPROACHES IN INPATIENT MEDICINE THAT MIGHT CHANGE YOUR PRACTICE

Jack Chase, MD FAAFP FHM

Director of Operations, UCSF Family Medicine Inpatient Service San Francisco General Hospital Assistant Clinical Professor UCSF Dept. of Family and Community Medicine

Presentation Goal & Objectives

• Discuss recent innovations which may

impact family medicine across the continuum

• f care
• Highlight selected evidence
• Give links to resources for point-of-care use

Disclosures & Acknowledgements

• No disclosures
• Appreciation to Tracy Minichiello (UCSF) for

teaching on anticoagulation at UCSF Hospital Medicine Update, and to Steven Cohn MD (Miami) & Nick Fitterman MD (Hofstra) for teaching on steroids in CAP at SHM National Conference.

What’s Pnew in Pneumonia?

• Mr. Lattimore, a 67 yo man,

comes to the office with 3 days of productive cough, dyspnea and fever

• PMHx: weekly wound clinic

visits for venous stasis

• CURB-65 = 1 (~2% mortality)

You elect to give

• utpatient treatment with

close follow-up

Questions?

• What kind of

pneumonia is this?

• What antibiotics to

prescribe?

• Duration of therapy?
• Other EBM

treatments?

Healthcare Associated Pneumonia

• 2005 & 2007 ATS/IDSA guideline: different

treatments for CAP, HCAP, HAP, VAP

• based on microbiology studies and assumption that each

diagnosis has distinct organisms, drug susceptibility, etc.

• 2016 IDSA guidelines remove HCAP
• Studies: HCAP ≈ CAP flora
• Risk for MDR organisms ≈ patient-specific factors (not

simply interaction with healthcare)

Why does it matter?

• Empiric treatment for community-living patients with

pneumonia irrespective of recent healthcare exposure

• Shorter courses (5 days) of antibiotics are effective
• New IDSA CAP guidelines coming Summer, 2017!
• Validated MDR organism risk screen, ?new antibiotic recs

OP (uncomplicated) macrolide OR doxycyline OP (comorbidities)* respiratory FQ or β-lactam + macrolide Inpatients (non-ICU) Ceftriaxone + macrolide OR doxycycline

‘Roid rage!

• 2005 & 2007 IDSA guidelines: no

recommendation on corticosteroids in pneumonia

• Consider in septic shock and non-responders to

antibiotics

• 2015: new meta-analysis in Annals of Internal

Medicine evaluates corticosteroids in CAP

Steroids for CAP?

• Meta-analysis of 13 placebo-controlled RCT’s

among inpatients with CAP (N > 2000):

• Decreased mortality (NNT 38, sCAP: NNT 7)
• Lower risk of ARDS (NNT 38)
• Decreased need for mechanical ventilation (NNT 38)
• Decreased length of stay (1-2.9 days less)

Benefit most evident among patients with severe CAP

• Steroids appear to benefit hospitalized patients

with severe CAP (eg. hospitalized in ICU)

• Start early! (within 36 hours)
• No consensus on dosing. Trials used short course ≈

COPD exacerbation (eg. prednisone 40mg QD x 5 days)

• Post-discharge patients may be finishing steroids

Why does it matter?

Pneumonia Prevention

• ACIP 2015 immunization guidelines
• Adults > 65 yo and 19-64 with comorbidities* should

receive two phase pneumococcal immunization

*Comorbidities: diabetes mellitus, chronic lung or heart disease, tobacco use, alcoholism, chronic liver disease or cirrhosis, functional asplenia, cerebrospinal fluid leaks, or cochlear implant.

• Reduce PPI use (RR 1.5 for CAP, most prominent in first month
• f use). No increase RR with H2B’s.

13-valent pneumococcal conjugate vaccine (PCV13; Prevnar 13)

→ 12 months →

23-valent pneumococcal polysaccharide vaccine (PPSV23; Pneumovax 23)

SOFA’s and CVP’s and CVC’s? Oh my!

• Ms. Cortez, a 37 yo

woman with DM2, drops in to the office with dysuria, flank pain, fever and vomiting. VS: T39C, 96/54, P126, R26, O2 Sat 98% Exam: ill, +R CVAT

Questions?

• Next

management steps?

• Location of

care?

• Risk of adverse
• utcomes?

Evolution of sepsis

SIRS Early Goal Directed Therapy Surviving Sepsis Campaign Process Trial

Bone RC et al. Chest 1992 Rivers et al. NEJM 2001 Partnership (IHI, SCCM, ESICM), 2003-present ProCESS Investigators. NEJM 2014 ACCP/SCCM consensus conference Open, randomized, partially blinded, single center trial Expert meta-analytic guideline of existing publications Randomized, multi-center trial in tertiary hospitals

• Defined SIRS, sepsis,

severe sepsis, septic shock

• SIRS = two or more
• f: T > 38°C or <

36°C; HR > 90; R > 20

• r PaCO2 < 32; WBC

> 12K or < 4K or > 10% bands

• Sepsis = SIRS +

infection

• Aggressive & early

treatment (IVF, Abx, lactate, CVC for CVP & scVO2, transfusions & vasopressors)

• ↑ oxygen delivery

via hemodynamics

• ↓ mortality vs

standard care by 15%.

• Comprehensive EBM
• n diagnostic and

treatment considerations

• Emphasis on early

recognition and treatment

• Popularized sepsis

bundle

• EGDT = protocol-

based standard therapy = usual care in severe sepsis

• Common elements =

early IVF, broad spectrum Abx, lactate and ↑ perfusion

qSOFA and Prognosis

• Quick Sepsis Related Organ Failure Assessment;

Seymour et al, JAMA 2016

• Retrospective analysis of 1.3 million EHR encounters

in 12 hospitals in Pennsylvania

• 3 variable tool (GCS < 15, RR >22, SBP < 100) = risk
• f poor outcome in patients with suspected infection
• utside the ICU
• Score > 2 = ↑ ICU LOS & 3-14x mortality

• qSOFA = 3-item risk assessment tool in sepsis
• More predictive than SIRS → who is at high risk?
• Clinical handoffs (eg. from office to ED)
• Prognostication to pts/families re: severity of illness
• Key treatment elements from prior studies:
• Give broad spectrum antibiotics and fluids ASAP
• Lactate & volume/perfusion assessment guides IVF +

interventions

Why does it matter?

Anticoagulation in transition

• Mr. Tran, a 72 yo man with atrial

fibrillation and HTN is scheduled for partial thyroidectomy for a non-toxic goiter. CHA2DS2-VASC: 2 (2.2% CVA/yr) HAS-BLED: 1 (~1% major bleeding/yr) Meds: warfarin, HCTZ

Questions?

• Perioperative

anticoagulation?

• Bleed risk vs

thrombosis risk?

• Efficacy and

choice of agent?

To Bridge or Not to Bridge?

• Randomized, double blind RCT of 1884

patients at multiple US sites

• Mean CHADS2 score = 2.3, ie. low-moderate

risk for CVA; multiple exclusions including for mechanical valves, recent CVA or embolism

• Compared perioperative treatment: LMWH vs

placebo in patients with AF on chronic warfarin treatment

Rechenmacher and Fang, JACC 2015

Bridge Trial Results

• No bridging = bridging in prevention of arterial

thromboembolism (ie. CVA) over 30 days of follow-up among patients with AF at low-moderate CVA risk.

• Bridging increased major bleeding (OR 3.6).
• N.B. Rate of arterial thromboembolism was low (0.3-

0.4%) and very few high risk patients – patients at high risk for CVA should be considered for bridging on a case-by-case basis.

Ok, I’ll stop bridging in low-moderate risk AF. Tell me some good news…

• Meta-analysis of 4 RCT’s (2014) comparing warfarin to

direct-acting oral anticoagulants (DOAC’s) in treatment of non-valvular AF.

• 71,000+ patients, median follow-up 1.8-2.8 years
• DOAC’s significantly reduced all-cause mortality (NNT =

132), vascular mortality (NNT = 189) and bleeding mortality (NNT = 313).

• DOAC’s = reduced mortality, more non-life threatening

GIB, fewer fatal intracranial hemorrhages vs warfarin.

• Evidence that direct-acting oral anticoagulants are

superior to warfarin in reducing mortality.

• Using scoring, eg. CHA2DS2-VASC and HAS-BLED allows

patient-specific risk:benefit analysis of anticoagulation

• Avoid perioperative anticoagulant bridging in low and

most moderate risk AF patients

• Anticoagulation Forum/Centers of Excellence – point-of-

care resource for anticoagulation management.

Why does it matter?

Longevity and evidence-based decisions

• Ms. McGillicuddy, your 92 yo

primary care patient, is hospitalized for progressive weakness and malnutrition. The hospitalist calls you to talk with the patient and her family about care planning.

• PMHx: COPD on 2L home
• xygen, CAD s/p PCI and

DES 16 years ago, HFrEF, mild dementia, HTN, HLP,

• steoporosis, DJD/OA
• Medications: ASA, aricept,

plavix, atorvastatin, Vit D, Calcium, metoprolol, furosemide, spironolactone, senna, tylenol

• SHx: Lives with in-home caregiver, uses assistance for

eating, toileting and dressing. Decreased oral intake in past 6 months.

Care planning discussion

• Hospitalist recommends a feeding tube and a

GI consult for colon cancer screening.

• The patient wants to “feel better”.
• Her family asks “What’s going to help her at

this point in her life?”

Questions?

• Prognosis?
• Impact on

care planning

www.eprognosis.ucsf.edu

• Prognostication is a primary technique in medicine
• Allows risk:benefit analysis of medical decisions appropriate

for a patient’s stage in life

• Based on “gestalt”, many medical providers routinely
• verestimate both longevity and potential benefit of

interventions

• Patients/families & providers generally support truthful

prognostic disclosure and counseling with emotional support

• ePrognosis = point-of-care tool for evidence-based

prognostication, communication and cancer screening recommendations.

Why does it matter?

• Pneumonia: H CAP + steroids + PCV13 & 23 - PPIs
• Sepsis: > 2 = hospitalize, start IVF and Abx now
• Anticoagulation: + DOACs + risk:benefit scoring
• and Longevity-Informed Care Planning

Review

References: Pneumonia

• Dressler D. Corticosteroids for Hospitalized Community-Acquired Pneumonia — Time to Change

Practice? NEJM Journal Watch, Dec 2015

• Ebell M. CURB-65 And CRB-65 Severity Scores For Community-acquired Pneumonia. Family

Practice Management, 2006.

• Kalil AC et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia:

2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. CID, 2016.

• Kaysin A, Viera AJ. Community-Acquired Pneumonia in Adults: Diagnosis and Management. AFP,

2016.

• Lambert AA et al. Risk of Community-Acquired Pneumonia with Outpatient Proton-Pump Inhibitor

Therapy: A Systematic Review and Meta-Analysis. PLoS One, 2015.

• Mandell LA et al. Infectious Diseases Society of America/American Thoracic Society Consensus

Guidelines on the Management of Community-Acquired Pneumonia in Adults. CID, 2007.

• Siemieniuk RA et al. Corticosteroid Therapy for Patients Hospitalized with Community -Acquired
• Pneumonia. Annals Int Med, 2016.
• Uranga A et al. Duration of Antibiotic Treatment in Community -Acquired Pneumonia: A Multicenter

Randomized Clinical Trial. Jama, 2016.

References: Sepsis

• Bone, RC et al. Definitions for Sepsis and Organ Failure and Guidelines for

the Use of Innovative Therapies in Sepsis. Chest, 1992.

• Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis

and septic shock. NEJM 2001.

• Seymour CW et al. Assessment of Clinical Criteria for Sepsis For the Third

International Consensus Definitions for Sepsis and Septic Shock (Sepsis -3)

• ProCESS Investigators. A Randomized Trial of Protocol-Based Care for

Early Septic Shock. NEJM, 2014.

• International Guidelines for Management of Severe Sepsis and Septic

Shock: 2012 Surviving Sepsis Campaign. Society for Critical Care Medicine, 2012.

References: Anticoagulation

• Douketis JD et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation.

NEJM 2015.

• Liew A et al. Comparing mortality in patients with atrial fibrillation who are receiving a direct -

acting oral anticoagulant or warfarin: a meta-analysis of randomized trials. J Thromb Haemost, 2014.

• Lip GY et al. Refining clinical risk stratification for predicting stroke and thromboembolism in

atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial

• fibrillation. Chest. 2010.
• Pisters R, et al. A Novel User-Friendly Score (Has-Bled) To Assess 1-Year Risk Of Major

Bleeding In Patients With Atrial Fibrillation: The Euro Heart Survey. Chest. 2010.

• Rechenmacher SJ, Fang JC. Bridging Anticoagulation: Primum Non Nocere. JACC, 2015.
• Sample CHADS2-Vasc2 and HAS BLED calculators: http://www.mdcalc.com/
• Anticoagulation Forum Anticoagulation Centers of Excellence: http://excellence.acforum.org/

References: Prognostication

• Anderson WG et al. A Multicenter Study of Key Stakeholders’ Perspectives on

Communicating with Surrogates about Prognosis in Intensive Care Units. Ann Amer Thor Soc, 2015.

• Baile WF et al. SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the

Patient with Cancer. The Oncologist, 2000.

• Christakis NA, Lamont EB. Extent and determinants of error in physicians' prognoses

in terminally ill patients: A prospective cohort study. West J Med, 2000.

• Glare P. A systematic review of physicians' survival predictions in terminally ill

cancer patients. BMJ 2003.

• Krouss, M et al. Physician Understanding and Ability to Communicate Harms and

Benefits of Common Medical Treatments. JAMA Intern Med, 2016.

• Yourman MC et al. Prognostic Indices for Older Adults: A Systematic Review. JAMA

2012.

• ePrognosis.ucsf.edu

Thank You