Update in Hospital Medicine 2018-2019 VS. Brad Sharpe, MD SFHM - - PowerPoint PPT Presentation

6/19/2019 1

Update in Hospital Medicine 2018-2019

Brad Sharpe, MD SFHM Alfred Burger, MD SFHM

Update in Hospital Medicine

VS. Year in Review 2019

Year in Review

• Updated literature
• April 2018 – April 2019

Process:

• CME collaborative review of journals

▪ Including ACP J. Club, J. Watch, etc.

• Independent analysis of article quality

Year in Review

Year in Review 2019

Chose articles based on 3 criteria:

1) Change your practice 2) Modify your practice 3) Confirm your practice

• Hope to not use the words:
• Student’s t-test, meta-regression, Mantel-Haenszel

statistical method, etc.

• Focus on breadth, not depth

6/19/2019 2

Year in Review

Year in Review 2019

• Major reviews/short takes
• Case-based format
• Multiple choice questions
• Promote retention

Year in Review

Year in Review 2019

• Major reviews/short takes
• Case-based format
• Multiple choice questions
• Promote retention

Year in Review

Syllabus/Bookkeeping

• No conflicts of interest
• Final presentation

available by email: sharpeb@medicine.ucsf.edu

Year in Review

6/19/2019 3

Update in Hospital Medicine

Case Presentation

You are the attending and hearing about a holdover admission from the nightfloat. She describes a 53 year-old man with a history of hypertension, injection drug use (heroin), and homelessness who presented with two days of left leg redness and pain. He also had subjective fever and chills and the pain was so severe he was unable to ambulate.

Update in Hospital Medicine

Case Presentation

On examination, he had a temperature of 38.7oC, heart rate of 118 beats per minute, and an initial blood pressure of 84/45 mmHg (improved to 116/70 mmHg with fluids). Oxygen saturation was normal. There were no murmurs and his lungs were clear. There was redness, warmth, and pain of the left leg from the ankle to the mid-thigh without purulence. His white blood cell count was 14,000 x 109/L, sodium 133mg/dL, and creatinine 1.7mg/dL.

Update in Hospital Medicine

Case Presentation

The resident states she thinks this is cellulitis and started treatment with intravenous fluids and vancomycin. She states, “You know, he’s pretty sick so I thought about nec fasc. His LRINEC score is 5 so I wasn’t that worried. But then I wondered, how good is the LRINEC score at ruling out nec fasc?” How do you respond to her question about the LRINEC score?

How do you respond to her question about the LRINEC score?

A. It has high specificity and high sensitivity – we can trust it. B. It has high sensitivity but not great specificity; it can help us rule it out. C. It’s sensitivity isn’t that good – we shouldn’t use it to rule out nec fasc.

• D. What is the LRINEC score?

E. How good do you think the LRINEC score is at ruling out nec fasc?

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

It has high specificity and... It has high sensitivity but... It’s sensitivity isn’t that ... What is the LRINEC score? How good do you think t..

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:10

6/19/2019 4

Update in Hospital Medicine

Necrotizing Fasciitis

Question: What is the diagnostic accuracy of the exam, imaging, and LRINEC score in necrotizing fasciitis? Design: Systematic review/meta-analysis; all studies of exam, imaging, or LRINEC score to diagnose nec fasc;

Update in Hospital Medicine

Fernando SM, et al. Ann Surg.2019;269:58-65.

Update in Hospital Medicine

Necrotizing Fasciitis

Question: What is the diagnostic accuracy of the exam, imaging, and LRINEC score in necrotizing fasciitis? Design: Systematic review/meta-analysis; all studies of exam, imaging, or LRINEC score to diagnose nec fasc;

Update in Hospital Medicine

Fernando SM, et al. Ann Surg.2019;269:58-65.

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

Results

Fernando SM, et al. Ann Surg.2019;269:58-65.

Sensitivity Specificity Fever (> 38.0oC) Hypotension

(SBP < 90mmHg)

Bullae LRINEC ≥ 6 LRINEC ≥ 8

• Total of 23 studies, 21 to > 400 patients
• Only findings with > 3 studies

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

Results

Fernando SM, et al. Ann Surg.2019;269:58-65.

Sensitivity Specificity Fever (> 38.0oC) 46.0% 77.0% Hypotension

(SBP < 90mmHg)

Bullae LRINEC ≥ 6 LRINEC ≥ 8

• Total of 23 studies, 21 to > 400 patients
• Only findings with > 3 studies

6/19/2019 5

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

Results

Fernando SM, et al. Ann Surg.2019;269:58-65.

Sensitivity Specificity Fever (> 38.0oC) 46.0% 77.0% Hypotension

(SBP < 90mmHg)

21.0% 97.7% Bullae LRINEC ≥ 6 LRINEC ≥ 8

• Total of 23 studies, 21 to > 400 patients
• Only findings with > 3 studies

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

Results

Fernando SM, et al. Ann Surg.2019;269:58-65.

Sensitivity Specificity Fever (> 38.0oC) 46.0% 77.0% Hypotension

(SBP < 90mmHg)

21.0% 97.7% Bullae 25.2% 95.8% LRINEC ≥ 6 LRINEC ≥ 8

• Total of 23 studies, 21 to > 400 patients
• Only findings with > 3 studies

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

Results

Fernando SM, et al. Ann Surg.2019;269:58-65.

Sensitivity Specificity Fever (> 38.0oC) 46.0% 77.0% Hypotension

(SBP < 90mmHg)

21.0% 97.7% Bullae 25.2% 95.8% LRINEC ≥ 6 68.2% 84.8% LRINEC ≥ 8

• Total of 23 studies, 21 to > 400 patients
• Only findings with > 3 studies

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

Results

Fernando SM, et al. Ann Surg.2019;269:58-65.

Sensitivity Specificity Fever (> 38.0oC) 46.0% 77.0% Hypotension

(SBP < 90mmHg)

21.0% 97.7% Bullae 25.2% 95.8% LRINEC ≥ 6 68.2% 84.8% LRINEC ≥ 8 40.8% 94.9%

• Total of 23 studies, 21 to > 400 patients
• Only findings with > 3 studies

6/19/2019 6

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

Results

Fernando SM, et al. Ann Surg.2019;269:58-65.

Sensitivity Specificity Gas on X-ray Computed Tomography (CT)

• Total of 23 studies, 21 to > 400 patients
• Only findings with > 3 studies

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

Results

Fernando SM, et al. Ann Surg.2019;269:58-65.

Sensitivity Specificity Gas on X-ray 48.9% 94.0% Computed Tomography (CT)

• Total of 23 studies, 21 to > 400 patients
• Only findings with > 3 studies

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

Results

Fernando SM, et al. Ann Surg.2019;269:58-65.

Sensitivity Specificity Gas on X-ray 48.9% 94.0% Computed Tomography (CT) 88.5% 93.3%

• Total of 23 studies, 21 to > 400 patients
• Only findings with > 3 studies

Necrotizing Fasciitis

Question: What is the diagnostic accuracy of the exam, imaging, and LRINEC in nec fasc? Design: Systematic review/meta-analysis; all studies

• f exam, imaging, or LRINEC score

Conclusion: Fever, hypotension, bullae make nec fasc more likely LRINEC has poor sensitivity; air on x-ray is specific, CT is the best test Comments:Limited data, no history features No easy way to rule out nec fasc; LRINEC is not sensitive; lactate might be helpful

6/19/2019 7

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

• A. It has high specificity and high sensitivity –

we can trust it.

• B. It has high sensitivity but not great specificity;

it can help us rule it out.

• C. It’s sensitivity isn’t that good – we shouldn’t

use it to rule out nec fasc.

• D. What is the LRINEC score?
• E. How good do you think the LRINEC score is

at ruling out nec fasc?

How do you respond to her question about the LRINEC score?

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

• A. It has high specificity and high sensitivity –

we can trust it.

• B. It has high sensitivity but not great specificity;

it can help us rule it out.

• C. It’s sensitivity isn’t that good – we

shouldn’t use it to rule out nec fasc.

• D. What is the LRINEC score?
• E. How good do you think the LRINEC score is

at ruling out nec fasc?

How do you respond to her question about the LRINEC score?

Year in Review

Case Presentation

She responds, “Hmm, thanks. Maybe with the fever and hypotension we should get a CT scan – what do you think?” You agree and she orders the CT scan. Fortunately, it is negative and so likely this is just severe cellulitis. The nightfloat leaves to get some sleep. While reviewing the notes you notice some concerning language in the ED resident’s note.

Year in Review

Case Presentation

The note describes the patient’s “narcotic abuse,” documents in quotes that the patient had “pain all over,” and describes his girlfriend “lying in bed with him with her shoes on asking for a bus token.” You wonder if this type of language might bias providers to have more negative attitudes toward the patient or impact the treatment of pain.

6/19/2019 8

Short Take: Stigmatizing Language

• A vignette study involving housestaff and

students

• Randomized to read two notes about a patient

with sickle cell pain crisis

• Notes had “stigmatizing” vs. neutral language
• Cast doubt on patient’s pain
• Unnecessary indicators of lower SE status
• Comments on uncooperativeness
• “Narcotic dependent,” “substance abuse”

Goddu AP , et al. J Gen Intern Med 33(5):685–91

Year in Review

Short Take: Stigmatizing Language

• Exposure to the note with “stigmatizing”

language was associated with:

• More negative attitudes toward the patient
• Less aggressive pain management

Goddu AP , et al. J Gen Intern Med 33(5):685–91

Year in Review

Case Presentation

You make this a teaching opportunity for the team and encourage everyone to use more neutral language. You and the team go to see and examine the

• patient. Before going in the room, you and

the team review the data and notice the patient is now on 6 liters of nasal cannula with an oxygen saturation of 99%. You remember the original oxygen saturation was normal and wonder why he is now on

• xygen.

Update in Hospital Medicine

Case Presentation

You ask the nurse, “Did he desat’? Is that why he is on 6 liters?” “Nah,” she responds, “I just put it on for comfort.” What do you think about the nurse’s comment about oxygen for comfort?

Year in Review

6/19/2019 9 What do you think about the nurse’s comment about oxygen for comfort?

A. Patients (without hypoxia) report increased comfort with 2-6 liters of supplemental O2. B. There is no benefit or harm to giving patients supplemental O2 for comfort. C. Supplemental O2 may increase mortality in hospitalized patients.

• D. Supplemental oxygen improves wound

healing in skin and soft tissue infections. E. Who cares what I think. The nasal cannula probably isn’t even in his nose. I hate my job.

Year in Review

P a t i e n t s ( w i t h

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a r e s w h a t I t h i n k . . . .

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Liberal vs. Conservative O2

Question: What is the efficacy and safety of liberal

• vs. conservative O2 therapy in acutely-ill

adults? Design: Systematic review & meta-analysis of randomized, controlled trials; liberal vs. conservative oxygen

Chu DK, et al. Lancet 2018;391:1693.

• Liberal = higher oxygen goal; different levels
• Conservative = lower oxygen goal; usually room air
• Evidence quality = high

Year in Review Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

Results

Chu DK, et al. Lancet 2018;391:1693.

• Total of 25 RCTs, 16,037 patients
• Sepsis, critical illness, CVA, trauma, AMI,

cardiac arrest, emergency surgery

Mortality

Liberal Conservative NNH In-hospital (n=19) 30-day (n=14) ~90-day (n=23)

Update in Hospital Medicine

Results

Chu DK, et al. Lancet 2018;391:1693.

Mortality

Liberal Conservative NNH In-hospital (n=19)

6.2% 5.1% 90*

30-day (n=14) ~90-day (n=23)

• Total of 25 RCTs, 16,037 patients
• Sepsis, critical illness, CVA, trauma, AMI,

cardiac arrest, emergency surgery

* p<0.01

6/19/2019 10

Update in Hospital Medicine

Results

Chu DK, et al. Lancet 2018;391:1693.

Mortality

Liberal Conservative NNH In-hospital (n=19)

6.2% 5.1% 90*

30-day (n=14)

11.1% 9.1% 71*

~90-day (n=23)

• Total of 25 RCTs, 16,037 patients
• Sepsis, critical illness, CVA, trauma, AMI,

cardiac arrest, emergency surgery

* p<0.01

Update in Hospital Medicine

Results

Chu DK, et al. Lancet 2018;391:1693.

Mortality

Liberal Conservative NNH In-hospital (n=19)

6.2% 5.1% 90*

30-day (n=14)

11.1% 9.1% 71*

~90-day (n=23)

13.0% 11.8% 83*

• Total of 25 RCTs, 16,037 patients
• Sepsis, critical illness, CVA, trauma, AMI,

cardiac arrest, emergency surgery

* p<0.01

• Dose-response association
• Target may be < 94%

Liberal vs. Conservative O2

Question: What is the efficacy and safety of liberal vs. conservative O2 therapy in acutely ill adults? Design:

• Syst. review & meta-analysis of randomized,

controlled trials; liberal v conservative Conclusion: In acutely-ill adults, liberal O2 therapy increases mortality; more oxygen was worse; optimal may be <94% Comments: Heterogeneous settings; different O2 given Robust, high-quality data; Excess oxygen is harmful, plausible Reasonable target: SpO2 ~90–94%

Chu DK, et al. Lancet 2018;391:1693.

Year in Review

• A. Patients (without hypoxia) report increased

comfort with 2-6 liters of supplemental O2.

• B. There is no benefit or harm to giving patients

supplemental O2 for comfort.

• C. Supplemental O2 may increase mortality in

hospitalized patients.

• D. Supplemental oxygen improves wound healing in

skin and soft tissue infections.

• E. Who cares what I think. The nasal cannula

probably isn’t even in his nose. I hate my job.

What do you think about the nurse’s comment about oxygen for comfort?

Year in Review

6/19/2019 11

• A. Patients (without hypoxia) report increased

comfort with 2-6 liters of supplemental O2.

• B. There is no benefit or harm to giving patients

supplemental O2 for comfort.

• C. Supplemental O2 may increase mortality in

hospitalized patients.

• D. Supplemental oxygen improves wound healing in

skin and soft tissue infections.

• E. Who cares what I think. The nasal cannula

probably isn’t even in his nose. I hate my job.

What do you think about the nurse’s comment about oxygen for comfort?

Year in Review Update in Hospital Medicine

Case Presentation

You discuss the data and agree to remove the supplemental oxygen. In the room, the intern asks about any

• ther medical problems and the patient

replies that he has a history of COPD (in addition to hypertension and injection drug use).

Update in Hospital Medicine

Case Presentation

After you leave the room the intern says, “It’s weird because he only has like a 10 pack-year history. I wonder if he really has COPD. Do you know, how often is COPD overdiagnosed?”

Short take: Overdiagnosis of COPD

• Large global database of adults (16,177 pts.)
• A total of 919 self-reported a diagnosis of COPD
• All patients got spirometry
• Overdiagnosis rate = 61.9%
• No obstruction on post-bronchodilator spirometry
• Predictors of overdiagnosis: women, higher

education, respiratory symptoms

• Nearly 50% of overdiagnosed patients were on

medications

Update in Hospital Medicine

Sator L, et al.CHEST. 2019 Jan 31.

6/19/2019 12

Year in Review

Case Presentation

You and the intern agree this can go in the discharge summary and you’ll discuss with the patient that he should get spirometry in the future At the end of the day you send a summary email with the key teaching points for the day and the articles attached.

Case Summary

Consider

• 1. Exam features and the LRINEC score are

not sensitive enough to rule out necrotizing fasciitis.

• 2. Stigmatizing language in notes can lead

to negative attitudes toward patients.

• 3. Excess oxygen might increase mortality

in hospitalized patients.

• 4. COPD may be overdiagnosed (~ 60%).

Update in Hospital Medicine

Case Presentation

You are working with a senior resident who is telling you about a patient in the ED. The patient is an 86 year-old woman with a history of dementia, hypertension, and diabetes, who presented with one day of chest pain and nausea. The chest pain is intermittent and dull across the front of her chest. There is no radiation and no change with exertion.

Case Presentation

Her initial vitals are all normal. Her cardiac and lung examinations are unremarkable. Her EKG shows normal sinus rhythm with no ST or T-wave changes. The initial troponin is negative. The resident who is admitting the patient is wondering what to do.

Year in Review

6/19/2019 13

Year in Review

Case Presentation

You ask him, “Do you think it is safe to discharge her with PCP follow-up?”

How does the resident respond to your question?

How does the resident respond to your question?

A. Hmm… she seems low-risk to me… I say we discharge her. B. An 86 year-old with diabetes with chest pain? That’s an admit…. C. I am going into cards and the TIMI Score is 1 so BAM! Discharge!

• D. I wish there were some app on my

phone that could figure this out…. E. Do you think it is safe to discharge him?

Year in Review

H m m … s h e s e e m s l

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Chest Pain & the HEART Score

Question: In patients presenting with chest pain, what is the test accuracy of the HEART Score? Design: Meta-analysis, included observational and RCTs; outcome 30-day or 6 week MACE

Fernando et al, Acad Emerg Med .2019;26:140-151

Year in Review

• Enrolled if > 16 years with chest pain (suspected ACS)
• All in the Emergency Department
• Applied HEART score for prediction short term MACE

Chest Pain & the HEART Score

Fernando et al, Acad Emerg Med .2019;26:140-151

Year in Review

6/19/2019 14

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

Results

Fernando et al, Acad Emerg Med .2019;26:140-151

• Total of 30 studies included; 44,202 patients
• 17 studies with high risk of bias
• All studies evaluated HEART score 0-3

MACE

Sensitivity Specificity Positive LR Negative LR HEART ≤ 4 HEART ≤ 7 TIMI ≥ 2 TIMI ≥ 6

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

Results

Fernando et al, Acad Emerg Med .2019;26:140-151

• Total of 30 studies included; 44,202 patients
• 17 studies with high risk of bias
• All studies evaluated HEART score 0-3

MACE

Sensitivity Specificity Positive LR Negative LR HEART ≤ 4

95.9% 44.6% 1.73 0.09

HEART ≤ 7 TIMI ≥ 2 TIMI ≥ 6

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

Results

Fernando et al, Acad Emerg Med .2019;26:140-151

• Total of 30 studies included; 44,202 patients
• 17 studies with high risk of bias
• All studies evaluated HEART score 0-3

MACE

Sensitivity Specificity Positive LR Negative LR HEART ≤ 4

95.9% 44.6% 1.73 0.09

HEART ≤ 7

39.5% 95.0% 7.89 0.64

TIMI ≥ 2 TIMI ≥ 6

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

Results

Fernando et al, Acad Emerg Med .2019;26:140-151

• Total of 30 studies included; 44,202 patients
• 17 studies with high risk of bias
• All studies evaluated HEART score 0-3

MACE

Sensitivity Specificity Positive LR Negative LR HEART ≤ 4

95.9% 44.6% 1.73 0.09

HEART ≤ 7

39.5% 95.0% 7.89 0.64

TIMI ≥ 2

87.8% 48.1% 1.69 0.25

TIMI ≥ 6

6/19/2019 15

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

Results

Fernando et al, Acad Emerg Med .2019;26:140-151

• Total of 30 studies included; 44,202 patients
• 17 studies with high risk of bias
• All studies evaluated HEART score 0-3

MACE

Sensitivity Specificity Positive LR Negative LR HEART ≤ 4

95.9% 44.6% 1.73 0.09

HEART ≤ 7

39.5% 95.0% 7.89 0.64

TIMI ≥ 2

87.8% 48.1% 1.69 0.25

TIMI ≥ 6

2.8% 99.6% 6.53 0.98

Chest Pain & the HEART Score

Question: In patients presenting with chest pain, what is the test accuracy of the HEART Score? Design: Meta-analysis, included observational and RCTs; outcome 30-day MACE Conclusion: HEART Score has high sensitivity/negative likelihood ratio for MACE; better than TIMI Comments: Some risk of bias but robust meta-analysis; HEART Score ≤ 4 can be the cutoff to judge as low-risk; Probably preferred decision-tool for patients with chest pain

Fernando et al, Acad Emerg Med .2019;26:140-151

Year in Review

• A. Hmm… she seems low-risk to me… I say we

discharge her.

• B. An 86 year-old with diabetes with chest pain?

That’s an admit….

• C. I am going into cards and the TIMI Score is 1

so BAM! Discharge!

• D. I wish there were some app on my phone

that could figure this out….

• E. Do you think it is safe to discharge her?

How does the resident respond to your question?

Year in Review

• A. Hmm… she seems low-risk to me… I say we

discharge her.

• B. An 86 year-old with diabetes with chest pain?

That’s an admit….

• C. I am going into cards and the TIMI Score is 1

so BAM! Discharge!

• D. I wish there were some app on my

phone that could figure this out….

• E. Do you think it is safe to discharge her?

How does the resident respond to your question?

Year in Review

6/19/2019 16

Case Presentation

Her HEART score is 3 so she is at very low risk for cardiac events. You are planning on discharge but she has persistent nausea. The nurse informs you she also just lost IV access. You are wondering how to treat her nausea.

Year in Review

Case Presentation

She turns to you with a grin, and says, “Honey, how about a shot of whiskey?” You respond, “Well, I just might have something for you,” and reach deep into your pocket…

Year in Review Year in Review

Short Take: Aromatherapy vs Oral Ondansetron

• Randomized, blinded, placebo-controlled trial

using an ED convenience sample

• Three Arms (122 patients):
• 1. Saline solution INH + 4 mg PO ondansetron
• 2. Isopropyl alcohol INH + Placebo PO
• 3. Isopropyl alcohol INH + 4 mg PO ondansetron
• Primary outcome: mean nausea reduction

(0-100mm visual analogue scale)

April MD, et al. Ann Emerg Med. 2018 Aug;72(2):184-93.

Year in Review

6/19/2019 17 Short Take: Aromatherapy vs Oral Ondansetron

April MD, et al. Ann Emerg Med. 2018 Aug;72(2):184-93.

“…provided the route of administration is nasal inhalation alone.”

• Smelling alcohol wipes was more effective than

taking oral ondansetron

• Combining the two modalities worked best
• Minimal risk of adverse events…

Update in Hospital Medicine Update in Hospital Medicine

Case Presentation

She feels better after sniffing the alcohol swab. She then also tells you the chest pain has been going on “since Reagan was the President” and she is actually having dysuria. She then develops fever and tachycardia in the ED. You end up diagnosing acute pyelonephritis and sepsis. She is admitted and given intravenous fluids and antibiotics.

Update in Hospital Medicine

Case Presentation

On hospital day 4 you see her in the morning, expecting that she would be improving. Unfortunately, she has a new fever, productive cough, and worsening oxygen requirement. Her WBC has risen and a CXR shows a new left sided infiltrate. You diagnose her with hospital-acquired pneumonia and order blood and sputum

• cultures. You start vancomycin and

cefepime.

Update in Hospital Medicine

Case Presentation

Two days later, she is clinically improving

• verall but has a low-grade fever, and an
• ngoing oxygen requirement. The blood

cultures and sputum culture are negative. What do you do with her antibiotic regimen?

6/19/2019 18 What do you do with her antibiotic regimen?

A. Discontinue the vancomycin, continue the cefepime B. Discontinue vancomycin and cefepime, start PO levofloxacin C. Continue cefepime and vancomycin

• D. Start PO vancomycin – here comes the C

diff! E. Stop the antibiotics and have her follow- up in Sepsis Clinic.

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

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y c i n – h . . . S t

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t h e a n t i b i

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Update in Hospital Medicine

De-Escalation in Pneumonia

Question: In nosocomial pneumonia, is it safe to “de-escalate” MRSA coverage if cultures are negative? Design: Single-center retrospective study; Patients with nosocomial pneumonia & negative cultures

Update in Hospital Medicine

Cowley MC, et al. CHEST.2019;155(1):53-59.

• Had to have a sputum culture
• “De-escalation” = MRSA coverage stopped by day 4

De-Escalation in Pneumonia

Cowley MC, et al. CHEST.2019;155(1):53-59.

Outcome

De-escalation No

p Length of Stay (days) Acute Kidney Injury Mortality (28-day)

• A total of 279 patients
• Most in the ICU (87%), 56% VAP
• A total of 92 (33.0%) had de-escalation
• No clinical difference between the two groups

De-Escalation in Pneumonia

Cowley MC, et al. CHEST.2019;155(1):53-59.

Outcome

De-escalation No

p Length of Stay (days) 15 20

<0.05

Acute Kidney Injury Mortality (28-day)

• A total of 279 patients
• Most in the ICU (87%), 56% VAP
• A total of 92 (33.0%) had de-escalation
• No clinical difference between the two groups

6/19/2019 19

De-Escalation in Pneumonia

Cowley MC, et al. CHEST.2019;155(1):53-59.

Outcome

De-escalation No

p Length of Stay (days) 15 20

<0.05

Acute Kidney Injury 36.2% 50.0%

<0.05

Mortality (28-day)

• A total of 279 patients
• Most in the ICU (87%), 56% VAP
• A total of 92 (33.0%) had de-escalation
• No clinical difference between the two groups

De-Escalation in Pneumonia

Cowley MC, et al. CHEST.2019;155(1):53-59.

Outcome

De-escalation No

p Length of Stay (days) 15 20

<0.05

Acute Kidney Injury 36.2% 50.0%

<0.05

Mortality (28-day) 22.8% 28.3% NS

• A total of 279 patients
• Most in the ICU (87%), 56% VAP
• A total of 92 (33.0%) had de-escalation
• No clinical difference between the two groups

Question: In HAP, is it safe to “de-escalate” MRSA coverage if cultures are negative? Design: Single-center, retrospective; nosocomial pneumonia & negative cultures Conclusion: No harm to de-escalating MRSA coverage; Shorter LOS, less AKI, no change in mortality Comments:Retrospective study, confounder? Appears no harm, potential benefit to de- escalation; Not much data otherwise; Seems reasonable to stop in most patients

Update in Hospital Medicine

De-Escalation in Pneumonia

Cowley MC, et al. CHEST.2019;155(1):53-59.

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

• A. Discontinue the vancomycin, continue the

cefepime

• B. Discontinue vancomycin and cefepime,

start PO levofloxacin

• C. Continue cefepime and vancomycin
• D. Start PO vancomycin – here comes the C

diff!

• E. Stop the antibiotics and have her follow-up

in Sepsis Clinic.

What do you do with her antibiotic regimen?

6/19/2019 20

Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine Update in Hospital Medicine

• A. Discontinue the vancomycin,

continue the cefepime

• B. Discontinue vancomycin and

cefepime, start PO levofloxacin

• C. Continue cefepime and vancomycin
• D. Start PO vancomycin – here comes the C

diff!

• E. Stop the antibiotics and have her follow-up

in Sepsis Clinic.

What do you do with her antibiotic regimen?

Year in Review

Case Presentation

You make the antibiotic change and transfer her out of the ICU that afternoon. You get on the elevator and see your friend,

• ne of the hospitalists in the group. “Hey,”

she says, looking down at your shirt, “Wash the scrubs much?” You are wearing just scrubs (no white coat) and there is a coffee stain and some crumbs (muffin) on your scrubs. You brush them

• ff. “It’s been busy…,” you mumble.

Year in Review

Case Presentation

“You know, patients care about that sort of thing,” she says as she gets off on the next floor. You wonder how much your clothes matter….

Short Take: Physician Dress

• Survey of 4062 patients at 10 academic hospitals
• Shown photographs of a male and female

physician in different forms of attire

• Asked about trust, confidence, and attire

preference in different care settings

Petrilli CM, et al. BMJ Open 2018;8(5):e021239

6/19/2019 21

Short Take: Physician Dress

• Survey of 4062 patients at 10 academic hospitals
• Shown photographs of a male and female

physician in different forms of attire

• Asked about trust, confidence, and attire

preference in different care settings

Petrilli CM, et al. BMJ Open 2018;8(5):e021239

Short Take: Physician Dress

• A total of 53% said physician attire was

important to them in their care

• The most preferred overall: Formal attire with

a white coat

• Second most preferred: Scrubs with white

coat

• Scrubs were most highly rated for the ED and

for surgeons

Petrilli CM, et al. BMJ Open 2018;8(5):e021239

Update in Hospital Medicine

Case Presentation

You go back to the office and grab your white coat and plan on hitting the dry cleaner at the end of the week. Then, out of the blue, you have the acute

• nset of severe right flank pain. You go to

the bathroom and have gross hematuria… You head right down to the ED and you are quickly diagnosed with a kidney stone.

Update in Hospital Medicine

Case Presentation

As you writhe in pain, your friend comes to visit you in the ED. She says, “You know what you need right now? Two words for you. Roller. Coaster.” “What? Are you kidding? A roller coaster?” you reply. She hands you the following paper…

6/19/2019 22

Year in Review

Mitchell MA and Wartinger DD. J Am Osteopath Assoc. 2016;116(10):647-52.

• Study investigators used a modified and remolded

ureteroscopy and renoscopy simulator

• Inserted three calculi of different sizes (4.5, 13.5,

46.6 mm3) in different anatomic locations

• Donated by patient whose kidney was used to

develop the above simulator

• Then, took the surrogate kidneys for 20 rides on a

roller coaster at a large, suburban, quaternary care amusement park…

Short take: Roller Coasters & Kidney Stones

Update in Hospital Medicine

Short take: Roller Coasters & Kidney Stones

Year in Review

Mitchell MA and Wartinger DD. J Am Osteopath Assoc. 2016;116(10):647-52. Big Thunder Mountain Railroad Simulator Varying placement of simulator

Short take: Roller Coasters & Kidney Stones

Year in Review

Mitchell MA and Wartinger DD. J Am Osteopath Assoc. 2016;116(10):647-52. Big Thunder Mountain Railroad Simulator Varying placement of simulator

Front n=24

Stone Passage

6/19/2019 23

Short take: Roller Coasters & Kidney Stones

Year in Review

Mitchell MA and Wartinger DD. J Am Osteopath Assoc. 2016;116(10):647-52. Big Thunder Mountain Railroad Simulator Varying placement of simulator

Front n=24

Stone Passage

16.7 %

Short take: Roller Coasters & Kidney Stones

Year in Review

Front n=24 Rear n=36

Stone Passage

16.7 % 63.9%

Mitchell MA and Wartinger DD. J Am Osteopath Assoc. 2016;116(10):647-52. Big Thunder Mountain Railroad Simulator Varying placement of simulator

If you’ve got stones, sit in the back of the roller coaster!

Short take: Roller Coasters & Kidney Stones

Year in Review

Front n=24 Rear n=36

Stone Passage

16.7 % 63.9%

Mitchell MA and Wartinger DD. J Am Osteopath Assoc. 2016;116(10):647-52. Big Thunder Mountain Railroad Simulator Varying placement of simulator

If you’ve got stones, sit in the back of the roller coaster!

Update in Hospital Medicine

Case Presentation

As the pain has only subsided a bit, you consider it as an option… In that moment, she receives a text message and has an embarrassed look on her face. “What is it? you ask. “Well, my three year-old son just swallowed a Lego head. Do I need to worry about that thing getting stuck?” she asks.

6/19/2019 24

Update in Hospital Medicine

Case Presentation

“You know, I don’t think so…” you reply as you had her the following paper…

Year in Review

Tagg A, et al. J Ped Child Health.2018;XXX.

• Six pediatric healthcare providers ingested a

Lego head

• Stool were self-monitored for excretion
• The primary outcome was the Found and

Recovery Time

• FART Score

Short take: Lego Head Ingestion

Year in Review

Tagg A, et al. J Ped Child Health.2018;XXX.

• A total of 5/6 were able to retrieve the head
• The average FART score was 1.71 days (1.14 –

3.04 days)

• Some evidence women may be better than med

at searching through stool (not statistically significant)

• Parents should be reassured & not routinely

search through stool for swallowed objects

Short take: Lego Head Ingestion Case Summary

Consider

• 1. Using the HEART Score when evaluating

patients with chest pain.

• 2. Using alcohol swabs to assist with nausea.
• 3. De-escalating MRSA covering in patients with

HAP and negative cultures at 48 hours.

• 4. Patients may prefer formal attire with a white

coat.

• 5. Sitting on the back of the roller coaster if you

have kidney stones.

• 6. The Lego head shall pass.

6/19/2019 25

Case Summary

Consider

• 1. Exam features and the LRINEC score are

not sensitive enough to rule out necrotizing fasciitis.

• 2. Stigmatizing language in notes can lead to

negative attitudes toward patients.

• 3. Excess oxygen might increase mortality in

hospitalized patients.

• 4. COPD may be overdiagnosed (~ 60%).