U.S. Trends in Hospitalization and Generalist Physician Workforce and the Emergence of Hospitalists.

J Gen Intern Med. 2010 Mar 30;

Authors: Meltzer DO, Chung JW

BACKGROUND: General internists and other generalist physicians have traditionally cared for their patients during both ambulatory visits and hospitalizations. It has been suggested that the expansion of hospitalists since the mid-1990s has “crowded out” generalists from inpatient care. However, it is also possible that declining hospital utilization relative to the size of the generalist workforce reduced the incentives for generalists to continue providing hospital care. OBJECTIVE: To examine trends in hospital utilization and the generalist workforce before and after the emergence of hospitalists in the U.S. and to investigate factors contributing to these trends. DESIGN: Using data from 1980-2005 on inpatient visits from the National Hospital Discharge Survey, and physician manpower data from the American Medical Association, we identified national trends before and after the emergence of hospitalists in the annual number of inpatient encounters relative to the number of generalists. RESULTS: Inpatient encounters relative to the number of generalists declined steadily before the emergence of hospitalists. Declines in inpatient encounters relative to the number of generalists were driven primarily by reduced hospital length of stay and increased numbers of generalists. CONCLUSIONS: Hospital utilization relative to generalist workforce declined before the emergence of hospitalists, largely due to declining length of stay and rising generalist workforce. This likely weakened generalist incentives to provide hospital care. Models of care that seek to preserve dual-setting generalist care spanning ambulatory and inpatient settings are most likely to be viable if they focus on patients at high risk of hospitalization.

PMID: 20352367 [PubMed - as supplied by publisher]

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Is there still a role for peripheral parenteral nutrition?

Nutr Clin Pract. 2009 Dec;24(6):709-17

Authors: Gura KM

Peripheral parenteral nutrition (PPN) is often viewed as the stepchild of parenteral nutrition (PN) infused via a central venous catheter. Anecdotal reports suggest that there has been increased interest in PPN in the United States and even more so in Europe because of improvements in catheter design and infusion technology, both of which have the potential to decrease complications such as infusion phlebitis. PPN, like PN via a central venous catheter, contains dextrose, amino acids, electrolytes, vitamins, and minerals, but in more limited capacity. One of the perceived benefits of PPN is the relative ease in establishing peripheral access, which may prevent delays in establishing nutrition support. PPN is intended for short-term use or supplementation. In most instances, it is used to maintain a previously well-nourished, nonhypermetabolic patient or to serve as a bridge to centrally administered infusions or enteral feedings until more suitable nutrition can be provided. In some cases, inappropriate use may result in infusion phlebitis or inadequate nutrient intake. Conflicting recommendations from various organizations further complicate and confuse prescribers. The intent of this review is to discuss PPN and the challenges its use presents to the practitioner.

PMID: 19955548 [PubMed - indexed for MEDLINE]

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The STRATIFY tool and clinical judgment were poor predictors of falling in an acute hospital setting.

J Clin Epidemiol. 2010 Jan;63(1):109-13

Authors: Webster J, Courtney M, Marsh N, Gale C, Abbott B, Mackenzie-Ross A, McRae P

OBJECTIVE: To compare the effectiveness of the STRATIFY falls tool with nurses’ clinical judgments in predicting patient falls. STUDY DESIGN AND SETTING: A prospective cohort study was conducted among the inpatients of an acute tertiary hospital. Participants were patients over 65 years of age admitted to any hospital unit. Sensitivity, specificity, and positive predictive value (PPV) and negative predictive values (NPV) of the instrument and nurses’ clinical judgments in predicting falls were calculated. RESULTS: Seven hundred and eighty-eight patients were screened and followed up during the study period. The fall prevalence was 9.2%. Of the 335 patients classified as being “at risk” for falling using the STRATIFY tool, 59 (17.6%) did sustain a fall (sensitivity=0.82, specificity=0.61, PPV=0.18, NPV=0.97). Nurses judged that 501 patients were at risk of falling and, of these, 60 (12.0%) fell (sensitivity=0.84, specificity=0.38, PPV=0.12, NPV=0.96). The STRATIFY tool correctly identified significantly more patients as either fallers or nonfallers than the nurses (P=0.027). CONCLUSION: Considering the poor specificity and high rates of false-positive results for both the STRATIFY tool and nurses’ clinical judgments, we conclude that neither of these approaches are useful for screening of falls in acute hospital settings.

PMID: 19398296 [PubMed - indexed for MEDLINE]

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Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine.

J Gen Intern Med. 2009 Aug;24(8):971-6

Authors: Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, Weiss KB, Williams MV, , , , , ,

The American College of Physicians (ACP), Society of Hospital Medicine (SHM), Society of General Internal Medicine (SGIM), American Geriatric Society (AGS), American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM) developed consensus standards to address the quality gaps in the transitions between inpatient and outpatient settings. The following summarized principles were established: 1.) Accountability; 2) Communication; 3.) Timely interchange of information; 4.) Involvement of the patient and family member; 5.) Respect the hub of coordination of care; 6.) All patients and their family/caregivers should have a medical home or coordinating clinician; 7.) At every point of transitions the patient and/or their family/caregivers need to know who is responsible for their care at that point; 9.) National standards; and 10.) Standardized metrics related to these standards in order to lead to quality improvement and accountability. Based on these principles, standards describing necessary components for implementation were developed: coordinating clinicians, care plans/transition record, communication infrastructure, standard communication formats, transition responsibility, timeliness, community standards, and measurement.

PMID: 19343456 [PubMed - indexed for MEDLINE]

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Narrative Review: Should Teaching of the Respiratory Physical Examination Be Restricted Only to Signs with Proven Reliability and Validity?

J Gen Intern Med. 2010 Mar 27;

Authors: Benbassat J, Baumal R

OBJECTIVE: To review the reported reliability (reproducibility, inter-examiner agreement) and validity (sensitivity, specificity and likelihood ratios) of respiratory physical examination (PE) signs, and suggest an approach to teaching these signs to medical students. METHODS: Review of the literature. We searched Paper Chase between 1966 and June 2009 to identify and evaluate published studies on the diagnostic accuracy of respiratory PE signs. RESULTS: Most studies have reported low to fair reliability and sensitivity values. However, some studies have found high specificites for selected PE signs. None of the studies that we reviewed adhered to all of the STARD criteria for reporting diagnostic accuracy. CONCLUSIONS: Possible flaws in study designs may have led to underestimates of the observed diagnostic accuracy of respiratory PE signs. The reported poor reliabilities may have been due to differences in the PE skills of the participating examiners, while the sensitivities may have been confounded by variations in the severity of the diseases of the participating patients. IMPLICATION FOR PRACTICE AND MEDICAL EDUCATION: Pending the results of properly controlled studies, the reported poor reliability and sensitivity of most respiratory PE signs do not necessarily detract from their clinical utility. Therefore, we believe that a meticulously performed respiratory PE, which aims to explore a diagnostic hypothesis, as opposed to a PE that aims to detect a disease in an asymptomatic person, remains a cornerstone of clinical practice. We propose teaching the respiratory PE signs according to their importance, beginning with signs of life-threatening conditions and those that have been reported to have a high specificity, and ending with signs that are “nice to know,” but are no longer employed because of the availability of more easily performed tests.

PMID: 20349154 [PubMed - as supplied by publisher]

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In vitro evaluation of ceftaroline alone and in combination with tobramycin against hospital-acquired meticillin-resistant Staphylococcus aureus (HA-MRSA) isolates.

Int J Antimicrob Agents. 2010 Mar 24;

Authors: Vidaillac C, Leonard SN, Rybak MJ

The aim of this study was to evaluate the in vitro activity of ceftaroline and its potential for synergy with tobramycin in comparison with vancomycin against a collection of hospital-acquired meticillin-resistant Staphylococcus aureus (HA-MRSA), including isolates with reduced susceptibility to glycopeptides. Ceftaroline, vancomycin, daptomycin and linezolid susceptibilities were determined for 200 HA-MRSA isolates. Four randomly selected strains [including one vancomycin-intermediate S. aureus (VISA) and one heteroresistant VISA (hVISA)] were evaluated in time-kill experiments with ceftaroline and vancomycin alone or combined with tobramycin at 0.25 and 0.5 times the minimum inhibitory concentration (MIC). MICs for 50% and 90% of the organisms (MIC(50) and MIC(90), respectively) were both 1mg/L for ceftaroline and were 1mg/L and 2mg/L, respectively, for vancomycin. The same ceftaroline MIC ranges (0.25-2mg/L) were observed for isolates recovered from respiratory tract samples, blood or skin. In time-kill experiments, no synergy was observed at 0.25x MIC against any tested isolates with either ceftaroline or vancomycin. In contrast, the combination of ceftaroline plus tobramycin at 0.5x MIC was synergistic against the two MRSA strains and the hVISA but was indifferent against the VISA isolate. In conclusion, ceftaroline demonstrated antimicrobial activity independently of the specimen source and exhibited lower MICs than vancomycin. Finally, at sub-MIC levels, ceftaroline plus tobramycin displayed significantly greater activity than vancomycin plus tobramycin against MRSA (P<0.01).

PMID: 20346632 [PubMed - as supplied by publisher]

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Management of Multi-Drug Resistant Enterococcal Infections.

Clin Microbiol Infect. 2010 Mar 23;

Authors: Arias CA, Contreras GA, Murray BE

Abstract Enterococci are organisms with a remarkable ability to adapt to the environment and acquire antibiotic resistance determinants. The evolution of antimicrobial resistance in these organisms poses enormous challenges for clinicians when faced with patients affected with severe infections. The increased prevalence and dissemination of multi-drug resistant Enterococcus faecium worldwide has resulted in a major decrease in therapeutic options, since the majority of E. faecium isolates are now resistant to ampicillin, vancomycin and exhibit high-level resistance to aminoglycosides, three of the traditionally most useful anti-enterococcal antibiotics. Newer antibiotics such as linezolid, daptomycin and tigecycline have good in vitro activity against enterococcal isolates but their clinical use may be limited in certain clinical scenarios due to reduced rates of success, possible underdosing for enterococci and low serum levels, respectively, and also by the emergence of resistance. The experimental agent oritavancin may offer some hope for the treatment of vancomycin-resistant enterococci but clinical data are still lacking. Thus, optimal therapies for the treatment of multi-drug resistant enterococcal infections continue to be based on empirical observations and extrapolations from in vitro and animal data. Clinical studies evaluating new strategies, including combination therapies to treat severe vancomycin-resistant E. faecium infections are urgently needed.

PMID: 20345469 [PubMed - as supplied by publisher]

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Randomized Controlled Trial of Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Abscesses in Patients at Risk for Community-Associated Methicillin-Resistant Staphylococcus aureus Infection.

Ann Emerg Med. 2010 Mar 24;

Authors: Schmitz GR, Bruner D, Pitotti R, Olderog C, Livengood T, Williams J, Huebner K, Lightfoot J, Ritz B, Bates C, Schmitz M, Mete M, Deye G

STUDY OBJECTIVE: Community-associated methicillin-resistant Staphylococcus aureus is now the leading cause of uncomplicated skin abscesses in the United States, and the role of antibiotics is controversial. We evaluate whether trimethoprim-sulfamethoxazole reduces the rate of treatment failures during the 7 days after incision and drainage and whether it reduces new lesion formation within 30 days. METHODS: In this multicenter, double-blind, randomized, placebo-controlled trial, we randomized adults to oral trimethoprim-sulfamethoxazole or placebo after uncomplicated abscess incision and drainage. Using emergency department rechecks at 2 and 7 days and telephone follow-up, we assessed treatment failure within 7 days, and using clinical follow-up, telephone follow-up, and medical record review, we recorded the development of new lesions within 30 days. RESULTS: We randomized 212 patients, and 190 (90%) were available for 7-day follow-up. We observed a statistically similar incidence of treatment failure in patients receiving trimethoprim-sulfamethoxazole (15/88; 17%) versus placebo (27/102; 26%), difference 9%, 95% confidence interval -2% to 21%; P=.12. On 30-day follow-up (successful in 69% of patients), we observed fewer new lesions in the antibiotic (4/46; 9%) versus placebo (14/50; 28%) groups, difference 19%, 95% confidence interval 4% to 34%, P=.02. CONCLUSION: After the incision and drainage of uncomplicated abscesses in adults, treatment with trimethoprim-sulfamethoxazole does not reduce treatment failure but may decrease the formation of subsequent lesions.

PMID: 20346539 [PubMed - as supplied by publisher]

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Atrial Fibrillation in Congestive Heart Failure.

Heart Fail Clin. 2010 Apr;6(2):187-200

Authors: Lubitz SA, Benjamin EJ, Ellinor PT

Atrial fibrillation and congestive heart failure are morbid conditions that have common risk factors and frequently coexist. Each condition predisposes to the other, and the concomitant presence of the two identifies individuals at increased risk for mortality. Recent data have emerged that help elucidate the complex genetic and nongenetic pathophysiological mechanisms that contribute to the development of atrial fibrillation in individuals with congestive heart failure. Clinical trial results offer insights into the noninvasive prevention and management of these conditions, although newer technologies, such as catheter ablation for atrial fibrillation, have yet to be studied extensively in patients with congestive heart failure.

PMID: 20347787 [PubMed - as supplied by publisher]

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Impact of a hospital-wide programme of heterogeneous antibiotic use on the development of antibiotic-resistant Gram-negative bacteria.

J Hosp Infect. 2010 Mar 24;

Authors: Takesue Y, Nakajima K, Ichiki K, Ishihara M, Wada Y, Takahashi Y, Tsuchida T, Ikeuchi H

Although antibiotic heterogeneity has been proposed as a strategy to limit the emergence of antibiotic resistance, few clinical studies have been conducted to validate the concept. This paper evaluates a hospital-wide strategy of heterogeneous antibiotic use intended to reduce infections caused by resistant Gram-negative rods (GNR). A strategy termed 'periodic antimicrobial monitoring and supervision' (PAMS) was implemented between September 2006 and February 2008. The 18 month intervention period was compared with the preceding 18 months (12 months pre-establishment and 6 months preparation). During PAMS, recommended, restricted and off-supervised classes of antibiotics active against more resistant GNR were changed every 3 months according to the antimicrobial usage density and rates of resistance to those antibiotics in Pseudomonas aeruginosa during the preceding term. Usage of five categories of antibiotics was supervised by four full-time staff. Antibiotic heterogeneity was estimated using the Peterson index (AHI). AHI estimates were 0.66 and 0.74 during the observation period but rose after the introduction of PAMS (period 1: 0.84; period 2: 0.94; period 3: 0.88). The incidence of patients from whom resistant GNR were isolated decreased significantly (P<0.001), whereas isolation of multidrug-resistant (MDR) GNR decreased from 1.7% to 0.5% (P<0.001). There was no significant difference in the incidence of extended spectrum beta-lactamase-producing organisms. Rates of imipenem resistance among Pseudomonas aeruginosa improved during PAMS2. PAMS facilitated hospital-wide heterogeneous antibiotic usage which was associated with reduced rates of resistant GNR.

PMID: 20346536 [PubMed - as supplied by publisher]

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“GURGLING” BREATH SOUNDS MAY PREDICT HOSPITAL-ACQUIRED PNEUMONIA.

Chest. 2010 Mar 26;

Authors: Vazquez R, Gheorghe C, Ramos F, Dadu R, Amoateng-Adjepong Y, Manthous CA

ABSTRACTHypothesis: Gurgling sounds heard during speech or quiet breathing, with or without a stethoscope over the glottis, predict hospital- acquired pneumonia (HAP). SETTING: Medical wards of a 350-bed community teaching hospital. METHODS: All patients admitted to a respiratory and general medicine ward were eligible. Patients were examined each day and those who had upper airway gurgling, heard with or without the stethoscope, during breathing or speech at any point during admission, were termed "gurglers." Assuming an overall incidence of HAP of 5-10% and estimated incidence of 30-50% in gurglers, twenty gurglers and 60 non-gurglers, matched on the same day and ward of admission, were included in the study. Demographic, physiologic and outcome variables were compared using univariate and multivariate techniques to ascertain whether gurgling is independently associated with HAP, rate of transfer to intensive care (ICU) and in-hospital mortality. RESULTS: Twenty gurglers were compared with 60 non-gurglers. Gurglers were older (78.5 vs. 65.2 y, p<0.001), more likely to reside in nursing homes (75% vs. 6%; p<0.001) and were more likely to have dementia (70% vs. 13%; p<0.001). In multivariate analysis, dementia (odds ratio=23.4; 95%CI=4.2-131.9) and recent (within 24 hours) treatment with opiates (odds ratio=14.7; 95%CI=2.2-97.5) emerged as the only statistically significant independent predictors of gurgling. HAP occurred in 55% of gurglers compared to 1.7% of non-gurglers (p<0.001) and 50% of the gurglers vs. 3.3% of the non-gurglers required transfer to ICU (p<0.001). After adjustment for age, Charlson score, dementia, opiate administration and stroke, gurgling emerged as the sole independent predictor of HAP (odds ratio=140.1; 95%CI=5.6-3529.4) and ICU transfer (odds ratio=35.1; 95%CI=4.1-303.7). Gurgling did not predict mortality; the Charlson comorbidity index was the only significant predictor of in-hospital death. CONCLUSIONS: Gurgling sounds heard during quiet breathing or speech are independently associated with HAP.

PMID: 20348197 [PubMed - as supplied by publisher]

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Discontinuation of Contact Precautions for Patients No Longer Colonized with Methicillin-Resistant Staphylococcus aureus.

Infect Control Hosp Epidemiol. 2010 Mar 25;

Authors: Vikram HR, Dumigan DG, Kohan C, Havill NL, Tauman A, Boyce JM

To reduce the number of patients with known methicillin-resistant Staphylococcus aureus (MRSA) colonization who are repeatedly placed in isolation on hospital readmission, we screened patients who had no positive results for MRSA culture in the previous 6 months. Twenty-one (21%) of 98 patients were no longer colonized and were removed from contact precautions.

PMID: 20337527 [PubMed - as supplied by publisher]

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The Glasgow Blatchford scoring system enables accurate risk stratification of patients with upper gastrointestinal haemorrhage.

Int J Clin Pract. 2010 Mar 10;

Authors: Srirajaskanthan R, Conn R, Bulwer C, Irving P

Summary Background: Upper gastrointestinal (UGI) haemorrhage is a frequent cause of hospital admission. Scoring systems have been devised to identify those at risk of adverse outcomes. We evaluated the Glasgow Blatchford score's (GBS) ability to identify the need for clinical and endoscopic intervention in patients with UGI haemorrhage. Methods: A retrospective observational study was performed in all patients who attended the A&E department with UGI haemorrhage during a 12-month period. Patients were separated into low and high risk categories. High risk encompassed patients who required blood transfusions, operative or endoscopic interventions, management on high dependency or intensive care units, and those who re-bled, represented with further bleeding, or who died. Results: A total of 174 patients were seen with UGI bleeding. Eight of them self-discharged and were excluded. Of the remaining 166, 94 had a 'low risk' bleed, and 72 'high risk'. The GBS was significantly higher in the high risk (median = 10) than in the low risk group (median 1, p < 0.001). To assess the validity of the GBS at separating low and high risk groups, receiver-operator characteristic (ROC) curves were plotted. The GBS had an area under ROC curve of 0.96 (95% CI 0.95-1.00). When a cut-off value of >/= 3 was used, sensitivity and specificity of GBS for identifying high risk bleeds was 100% and 68%. Thus at a cut-off value of </= 2 the GBS is useful for distinguishing those patients with a low risk UGI bleed. Conclusions: The GBS accurately identifies low risk patients who could be managed safely as outpatients.

PMID: 20337750 [PubMed - as supplied by publisher]

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Management of COPD exacerbations.

Am Fam Physician. 2010 Mar 1;81(5):607-13

Authors: Evensen AE

Exacerbations of chronic obstructive pulmonary disease contribute to the high mortality rate associated with the disease. Randomized controlled trials have demonstrated the effectiveness of multiple interventions. The first step in outpatient management should be to increase the dosage of inhaled short-acting bronchodilators. Combining ipratropium and albuterol is beneficial in relieving dyspnea. Oral corticosteroids are likely beneficial, especially for patients with purulent sputum. The use of antibiotics reduces the risk of treatment failure and mortality in moderately or severely ill patients. Physicians should consider antibiotics for patients with purulent sputum and for patients who have inadequate symptom relief with bronchodilators and corticosteroids. The choice of antibiotic should be guided by local resistance patterns and the patient’s recent history of antibiotic use. Hospitalized patients with exacerbations should receive regular doses of short-acting bronchodilators, continuous supplemental oxygen, antibiotics, and systemic corticosteroids. Noninvasive positive pressure ventilation or invasive mechanical ventilation is indicated in patients with worsening acidosis or hypoxemia.

PMID: 20187597 [PubMed - indexed for MEDLINE]

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Swiss results from a global observational study of venous thromboembolism risk and prophylaxis use in the acute care hospital setting: analysis from the ENDORSE study.

Swiss Med Wkly. 2009 Oct 31;139(43-44):630-5

Authors: Chopard P, Spirk D, Beer HJ, Peter J, Brunner B, Bounameaux H, Dörfller-Melly J

BACKGROUND: The aim of the present analysis from the epidemiologic international day for the evaluation of patients at risk for venous thromboembolism (VTE) in the acute hospital care setting (ENDORSE) study was to evaluate the prevalence of VTE risk in acute care hospitals and the proportion of at-risk medical and surgical patients who receive recommended prophylaxis in Switzerland. METHODS: All patients (age >or=40 years) admitted to a medical ward or those (age >or=18 years) admitted to a surgical ward in ten randomly selected Swiss hospitals were assessed for risk of VTE. The 2004 American College of Chest Physicians (ACCP) evidence-based consensus guidelines were used to assess VTE risk and to determine whether patients were receiving recommended thromboprophylaxis. RESULTS: 2000 patients were eligible; of these 1153 (58%) were in surgical wards, and 847 (42%) in medical wards. According to the ACCP criteria, the proportion of surgical patients at VTE risk was similar in Switzerland (68%, between hospital range 48-86%) in comparison to the global ENDORSE study (64%) (p = 0.296). The rate of at-risk medical patients was lower in Switzerland (21%, range 3-44%) than in the global study (42%) (p <0.001). The proportion of at-risk surgical patients with ACCP-recommended VTE prophylaxis was higher in Switzerland (81%, between-hospital range 76-93%) than in the global study (59%) (p <0.001). Among medical patients at risk, the use of recommended thromboprophylaxis was higher in Switzerland (61%, between-hospital range 0-84%) than in the global ENDORSE (40%) (p <0.001). However 56% of the patients with cancer, 41% with major trauma, and 29% undergoing vascular surgery did not receive any recommended prophylaxis. Among surgical patients at risk, the use of ACCP-recommended prophylaxis was lower in academic (77%) vs. non-academic (86%) institutions (p = 0.0025). CONCLUSIONS: In Switzerland, although the rate of recommended thromboprophylaxis is higher than in many countries, it is still improvable in medical patients at risk according to the ACCP guidelines. Consequently, hospital wide strategies for systematic risk factor assessment and implementation of practical tools to ensure appropriate use of prophylaxis in patients at VTE risk are required.

PMID: 19950025 [PubMed - indexed for MEDLINE]

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