Approach to anemia.

Dis Mon. 2010 Aug;56(8):449-55

Authors: Hussein M, Haddad RY

PMID: 20800754 [PubMed - in process]

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Anemia in the elderly.

Dis Mon. 2010 Aug;56(8):456-67

Authors: Kheir F, Haddad R

PMID: 20800755 [PubMed - in process]

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Where did the day go?-A time-motion study of hospitalists.

J Hosp Med. 2010 Jul;5(6):323-8

Authors: Tipping MD, Forth VE, O’Leary KJ, Malkenson DM, Magill DB, Englert K, Williams MV

BACKGROUND:: Within the last decade hospitalists have become an integral part of inpatient care in the United States and now care for about half of all Medicare patients requiring hospitalization. However, little data exists describing hospitalist workflow and their activities in daily patient care. OBJECTIVE:: To clarify how hospitalists spend their time and how patient volumes affect their workflow. DESIGN:: Observers continuously shadowed each of 24 hospitalists for two complete shifts. Observations were recorded using a handheld computer device with customized data collection software. SETTING:: Urban, tertiary care, academic medical center. RESULTS:: Hospitalists spent 17% of their time on direct patient contact, and 64% on indirect patient care. For 16% of all time recorded, more than one activity was occurring simultaneously (i.e., multitasking). Professional development, personal time, and travel each accounted for about 6% of their time. Communication and electronic medical record (EMR) use, two components of indirect care, occupied 25% and 34% of recorded time respectively. Hospitalists with above average patient loads spent less time per patient communicating with others and working with the EMR than those hospitalists with below average patient loads, but reported delaying documentation until later in the evening or next day. Patient load did not change the amount of time hospitalists spent with each patient. CONCLUSIONS:: Hospitalists spend more time reviewing the EMR and documenting in it, than directly with the patient. Multi-tasking occurred frequently and occupied a significant portion of each shift. Journal of Hospital Medicine 2010;5:323-328. (c) 2010 Society of Hospital Medicine.

PMID: 20803669 [PubMed - in process]

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Hospitalist time usage and cyclicality: Opportunities to improve efficiency.

J Hosp Med. 2010 Jul;5(6):329-34

Authors: Kim CS, Lovejoy W, Paulsen M, Chang R, Flanders SA

BACKGROUND:: Academic medical centers (AMCs) have a constrained resident work force. Many AMCs have increased the use of nonresident service hospitalists to manage continued growth in clinical volume. To optimize their time in the hospital, it is important to understand hospitalists’ work flow. DESIGN:: We performed a time-motion study of hospitalists carrying the admission pager throughout the 3 types of shifts we have at our hospital (day shift, swing shift, and night shift). SETTING:: Tertiary academic medical center in the Midwest. RESULTS:: Hospitalists spend about 15% of their time on direct patient care, and two-thirds of their time on indirect patient care. Of the indirect activities, communication and documentation dominate. Travel demands make up over 7% of a hospitalists’ time. There are spikes in indirect patient care, followed closely by spikes in direct patient care, at shift changes. CONCLUSIONS:: At our AMC, indirect patient care activities accounted for the majority of the admitting hospitalists’ time spent in the hospital, with documentation and communication dominating this time. Travel takes a significant fraction of hospitalists’ time. There is also a cyclical nature to activities performed throughout the day, which can cause patient delays and impose variability on support services. There is a need for both service-specific and systemic improvements for AMCs to efficiently manage further growth in their inpatient volume. Journal of Hospital Medicine 2010;5:329-334. (c) 2010 Society of Hospital Medicine.

PMID: 20803670 [PubMed - in process]

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The impact of fragmentation of hospitalist care on length of stay.

J Hosp Med. 2010 Jul;5(6):335-8

Authors: Epstein K, Juarez E, Epstein A, Loya K, Singer A

BACKGROUND:: Different hospitalist staffing models provide different levels of inpatient continuity of care, which may impact length of stay (LOS). OBJECTIVE:: To determine if fragmentation of care (FOC) by hospitalist physicians is associated with LOS. DESIGN:: Concurrent control study. SETTING:: Hospitalist practices managed by IPC The Hospitalist Company. PATIENTS:: A total of 10,977 patients admitted for diagnosis-related group (DRG) of 89 pneumonia with complications or comorbidities (PNA) or a DRG of 127 heart failure and shock (HF) between December 2006 and November 2007. MEASUREMENTS:: FOC was defined as the percentage of care given by hospitalists other than the hospitalist who saw the patient the majority of the stay. Negative binomial regression was performed on DRG 89 and DRG 127 patients with LOS as the dependent variable. We adjusted for gender, age, severity of illness (SOI) scores, risk of mortality (ROM) scores, and number of secondary diagnoses, and admission day of the week. RESULTS:: A 10% increase in fragmentation was associated with an increase of 0.39 days (P < 0.0001) in the LOS for pneumonia, and an increase of 0.30 days (P < 0.0001) in LOS for heart failure. CONCLUSIONS:: As FOC increased for pneumonia and heart failure, the LOS increased significantly. Methods to reduce fragmentation should be explored, while more research is needed to identify the source of the relationship between FOC and LOS. Journal of Hospital Medicine 2010;5:335-338. (c) 2010 Society of Hospital Medicine.

PMID: 20803671 [PubMed - in process]

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Effectiveness of a course designed to teach handoffs to medical students.

J Hosp Med. 2010 Jul;5(6):344-8

Authors: Chu ES, Reid M, Burden M, Mancini D, Schulz T, Keniston A, Sarcone E, Albert RK

INTRODUCTION:: Handoffs of patient care are increasingly common and are known to contribute to medical errors. A significant number, if not the large majority, of first-year Internal Medicine residents have not received formal education pertaining to handoffs during medical school. AIM:: To develop a program designed to teach handoffs to medical students entering their fourth year of training. SETTING:: University of Colorado Denver School of Medicine. PROGRAM DESCRIPTION:: Our Handoff Selective was first offered in April 2007 as part of a 2-week Integrated Clinician's Course conducted once yearly between the third and fourth years of medical school. The Selective consisted of a didactic session in which communication theory and elements were discussed and a practicum in which students used faculty-developed case scenarios to practice both giving and receiving handoffs. PROGRAM EVALUATION:: Sixty (the maximum number of spots available) out of 150 students participated in the course, although many more students chose the course than spots available. Prior to taking the Selective, medical students' confidence in performing handoffs was poor, but it improved after the course (P < 0.001); 92% of students felt the Handoff Selective was "useful" or "extremely useful." While both components of the course were thought to be useful to the large majority of students, the practicum portion was thought to be more useful (P < 0.001). DISCUSSION:: Formal education on handoffs is well received by medical students and improves their self-perceived understanding and performance of handoffs. Journal of Hospital Medicine 2010;5:344-348. (c) 2010 Society of Hospital Medicine.

PMID: 20803673 [PubMed - in process]

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Comparing academic and community-based hospitalists.

J Hosp Med. 2010 Jul;5(6):349-52

Authors: Malkenson D, Siegal EM, Leff JA, Weber R, Struck R

In 2006, hospitalist programs were formally introduced at both an academic and community hospital in the same city providing an opportunity to study the similarities and differences in workflows in these two settings. The data were collected using a time-flow methodology allowing the two workflows to be compared quantitatively. The results showed that the hospitalists in the two settings devoted similar proportions of their workday to the task categories studied. Most of the time was spent providing indirect patient care followed by direct patient care, travel, personal, and other. However, after adjusting for patient volumes, the data revealed that academic hospitalists spent significantly more time per patient providing indirect patient care (Academic: 54.7 +/- 11.1 min/patient, Community: 41.9 +/- 9.8 min/patient, p < 0.001). Additionally, we found that nearly half of the hospitalists' time at both settings was spent multitasking. Although we found subtle workflow differences between the academic and community programs, their similarities were more striking as well as greater than their differences. We attribute these small differences to the higher case mix index at the academic program as well greater complexity and additional communication hand-offs inherent to a tertiary academic medical center. It appears that hospitalists, irrespective of their work environment, spend far more time documenting, communicating and coordinating care than they do at the bedside raising the question, is this is a necessary feature of the hospitalist care model or should hospitalists restructure their workflow to improve outcomes? Journal of Hospital Medicine 2010;5:349-352. (c) 2010 Society of Hospital Medicine.

PMID: 20803674 [PubMed - in process]

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Systematic review of time studies evaluating physicians in the hospital setting.

J Hosp Med. 2010 Jul;5(6):353-9

Authors: Tipping MD, Forth VE, Magill DB, Englert K, Williams MV

BACKGROUND:: Time studies, first developed in the late 19th century, are now being used to evaluate and improve worker efficiency in the hospital setting. This is the first review of hospital time study literature of which we are aware. PURPOSE:: We performed a systematic review of the literature to better understand the available time study literature describing the activities of hospital physicians. DATA SOURCES:: We searched MEDLINE, EMBASE, EMBASE Classic, PsycINFO, Cochrane Library, CINAHL, and Web of Science. We also manually reviewed the reference lists of retrieved articles and consulted experts in the field to identify additional articles for review. STUDY SELECTION:: We selected studies that used time-motion or work-sampling performed via direct observation, included physicians, medical residents, or interns in their study population, and were performed on an inpatient hospital ward. DATA EXTRACTION:: We abstracted data on subject population, study site, collection tools, and percentage of time spent on key categories of activity. DATA SYNTHESIS:: Our search produced 11 time-motion and 2 work-sampling studies that met our criteria. These studies focused primarily on academic hospitals (92%) and the activities of physicians in training (69%). Other results varied widely. A lack of methodological standardization and dissimilar activity categorizations inhibited our efforts to summarize detailed findings across studies. However, we consistently found that activities indirectly related to a patient’s care took more of hospital physicians’ time than direct interaction with hospitalized patients. CONCLUSIONS:: Time studies, when properly performed, have a great deal to offer in helping us understand and reengineer hospital care. Journal of Hospital Medicine 2010;5:353-359. (c) 2010 Society of Hospital Medicine.

PMID: 20803675 [PubMed - in process]

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A model of a hospitalist role in the care of admitted patients in the emergency department.

J Hosp Med. 2010 Jul;5(6):360-4

Authors: Briones A, Markoff B, Kathuria N, Jagoda A, Baumlin K, Hill S, Mumm L, Jervis R, Dunn A

PMID: 20803676 [PubMed - in process]

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The Clinical and Prognostic Importance of Positive Blood Cultures in Adults.

Am J Med. 2010 Sep;123(9):819-828

Authors: Pien BC, Sundaram P, Raoof N, Costa SF, Mirrett S, Woods CW, Reller LB, Weinstein MP

BACKGROUND: Bloodstream infections are a major cause of morbidity and mortality in adults. Bloodstream infections should be reassessed periodically because of increased antibiotic resistance, more patients receiving immunomodulatory therapy, improved antiretroviral therapy, and acquisition of infection in health care settings other than hospitals. METHODS: We conducted retrospective assessment by infectious disease physicians of hospitalized adults with positive blood cultures at 3 academic medical centers. RESULTS: Two thousand two hundred seventy positive blood culture episodes occurred in 1706 patients. Of 2669 isolates, 51% represented true infection, 41% contamination, and 8% unknown clinical significance. Although coagulase-negative staphylococci were most common, only 10% were clinically significant. Among 1225 true bloodstream infections, the most frequent isolates were Staphylococcus aureus, Escherichia coli, Enterococcus spp., Klebsiella pneumoniae, coagulase-negative staphylococci, Pseudomonas aeruginosa, Candida albicans, Enterobacter cloacae, and Serratia marcescens. Intravenous catheters were the most common primary source of bloodstream infection (23% of episodes). Most (81%) bloodstream infections were acquired in the hospital or other health care settings. Crude and attributable in-hospital case-fatality ratios were 20% and 12%, respectively, lower than in previous studies. Increasing age, hypotension, absence of fever, hospital acquisition, extreme white blood cell count values, and the presence of the acquired immunodeficiency syndrome, malignancy, or renal disease were significantly associated with an increased risk of in-hospital attributable death in multivariable analysis. CONCLUSIONS: The proportion of bloodstream infections due to intravenous catheters is continuing to increase. Most episodes were acquired in the hospital or other health care setting. In-hospital case-fatality ratios have decreased compared with previous studies. Several previously identified factors associated with an increased mortality remain statistically significant.

PMID: 20800151 [PubMed - as supplied by publisher]

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Management and Outcomes of Renal Disease and Acute Myocardial Infarction.

Am J Med. 2010 Sep;123(9):847-855

Authors: Santolucito PA, Tighe DA, McManus DD, Yarzebski J, Lessard D, Gore JM, Goldberg RJ

BACKGROUND: Contemporary trends in the management and outcomes of chronic kidney disease patients who develop an acute myocardial infarction have not been adequately described, particularly from the more generalizable perspective of a population-based investigation. METHODS: The study population consisted of 6219 residents of the Worcester, Massachusetts, metropolitan area who were hospitalized with acute myocardial infarction in 6 annual periods between 1995 and 2005. Patients were categorized as having preserved kidney function (n=3154), mild to moderate chronic kidney disease (n=2313), or severe chronic kidney disease (n=752) at the time of hospital admission. RESULTS: Patients with chronic kidney disease were more likely to be older, to have a greater prevalence of comorbidities, and to experience significant in-hospital complications or die during hospitalization in comparison with patients with preserved kidney function. Although patients with chronic kidney disease were less likely to receive effective cardiac medications or undergo coronary interventional procedures than patients without kidney disease, we observed a marked increase in the use of effective cardiac medications and coronary interventional procedures in patients with chronic kidney disease during the period under study. In-hospital death rates declined over time among patients with chronic kidney disease, whereas these death rates remained unchanged among persons with normal kidney function. CONCLUSION: The results of this study in residents of a large New England metropolitan area provide insights into changing trends in the treatment and impact of chronic kidney disease in patients hospitalized with acute myocardial infarction.

PMID: 20800154 [PubMed - as supplied by publisher]

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Agreement between Erythrocyte Sedimentation Rate and C-Reactive Protein in Hospital Practice.

Am J Med. 2010 Sep;123(9):863.e7-863.e13

Authors: Colombet I, Pouchot J, Kronz V, Hanras X, Capron L, Durieux P, Wyplosz B

BACKGROUND: Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are frequently prescribed jointly. The usefulness of this practice is uncertain. METHODS: All patients with ESR and CRP measured at the same time in an academic tertiary hospital during a 1-year period were included. Concomitant measures of serum creatinine, hematocrit, and anti-Xa activity were recorded to study noninflammatory cause of increased ESR. Level of agreement between ESR and CRP was assessed with kappa coefficient, and their accuracy was determined in a medical chart review of 99 randomly selected patients with disagreement between both markers. RESULTS: Among 5777 patients, 35% and 58% had an elevated CRP and ESR, respectively. ESR and CRP were in agreement in 67% of patients (both elevated in 30%, both normal in 37%). A disagreement was observed in 33% (elevated ESR/normal CRP in 28%, normal ESR/elevated CRP in 5%). The kappa coefficient showed poor agreement (k=0.38) between both markers. Review of medical chart showed that 25 patients with elevated CRP and normal ESR had an active inflammatory disease (false-negative ESR). Conversely, 74 patients had elevated ESR and normal CRP-32% had resolving inflammatory disorders, 28% disclosed a variable interfering with the ESR measure (false-positive ESR), 32% had unexplained discrepancies, and 8% had an active inflammatory disease (false-negative CRP). CONCLUSION: In hospital practice, joint measurement of ESR and CRP is unwarranted. Because of slow variation and frequent confounding, ESR is frequently misleading in unselected patients. When an inflammatory disorder is suspected, priority should be given to CRP.

PMID: 20800157 [PubMed - as supplied by publisher]

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Volume of emergency department admissions for sepsis is related to inpatient mortality: Results of a nationwide cross-sectional analysis.

Crit Care Med. 2010 Aug 26;

Authors: Powell ES, Khare RK, Courtney DM, Feinglass J

OBJECTIVES:: Emergency department resuscitation plays a significant role in sepsis care, and it is unknown if patient outcomes vary by institution based on the level of sepsis experience of the emergency department. This study examines whether there is an association between the annual volume of patients admitted via the emergency department with sepsis and inpatient mortality. DESIGN:: Cross-sectional analysis of the 2007 Nationwide Inpatient Sample. SETTING AND PATIENTS:: We included 87,166 adult emergency department sepsis admissions from 551 hospitals. MEASUREMENTS:: Hospitals were categorized into quartiles by 2007 emergency department sepsis volume. Univariate associations of patient characteristics, hospital characteristics, and inpatient mortality with sepsis volume level were evaluated by chi-square test. A population-averaged logistic regression model of inpatient mortality was used to estimate the effects of age, gender, comorbid conditions, payer status, median zip code income, hospital bed size, teaching status, and emergency department sepsis volume. MAIN RESULTS:: Overall inpatient sepsis mortality was 18.0% and early mortality (2 days after admission) was 6.9%. The risk-adjusted odds ratios of mortality were 0.73 (95% confidence interval, 0.64-0.83; p < .001) in quartile 4 (highest volume), 0.83 in quartile 3 (95% confidence interval, 0.74-0.93; p = .001), and 0.90 in quartile 2 (95% confidence interval, 0.82-0.99; p < .05) when compared to quartile 1 (lowest volume). Adjusted results were similar for early mortality: 0.69 (95% confidence interval, 0.61-0.76; p < .001) in quartile 4, 0.83 in quartile 3 (95% confidence interval, 0.74-0.93; p < .05), and 0.85 in quartile 2 (95% confidence interval, 0.77-0.94; p < .05) when compared to quartile 1. CONCLUSIONS:: After adjustment for comorbidity and hospital-level factors, there was a significant relationship between emergency department sepsis case volume and overall and early inpatient mortality among patients admitted through the emergency department with sepsis. Patients admitted to hospitals in the highest-volume quartile had 27% lower odds of inpatient mortality in this large heterogeneous sample.

PMID: 20802323 [PubMed - as supplied by publisher]

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Cirrhotic patients in the medical intensive care unit: Early prognosis and long-term survival.

Crit Care Med. 2010 Aug 26;

Authors: Das V, Boelle PY, Galbois A, Guidet B, Maury E, Carbonell N, Moreau R, Offenstadt G

OBJECTIVES:: To reassess the prognosis of patients with cirrhosis admitted to the intensive care unit. DESIGN:: A retrospective study in a medical intensive care unit in a teaching hospital in France. PATIENTS:: All patients with cirrhosis without previous liver transplantation admitted in the period from 2005 to 2008. INTERVENTIONS:: None. MAIN RESULTS:: One hundred thirty-eight patients were studied. Survival rates in the intensive care unit, in hospital, and at 6 months were 59% (95% confidence interval, 50%-67%), 46% (95% confidence interval, 38%-54%), and 38% (95% confidence interval, 30%-47%), respectively. In-hospital survival rates for patients requiring vasopressors, mechanical ventilation, or renal replacement therapy were 20%, 33%, and 31%, respectively. On day 1, independent risk factors for in-hospital mortality were age, albuminemia, international normalized ratio, and the Sequential Organ Failure Assessment score computed after discarding points for hematologic failure (modified Sequential Organ Failure Assessment score). Liver disease severity, assessed using a clinical classification, did not correlate with in-hospital mortality. In patients still alive after 3 days, the only prognostic factor was the modified Sequential Organ Failure Assessment score computed after 3 days. To predict in-hospital mortality, the modified Sequential Organ Failure Assessment score on day 1 had a greater area under the receiver operating characteristic curve (0.84) than the Simplified Acute Physiology Score II (0.78), the Child-Pugh score (0.76), the model for end-stage liver disease score (0.77), or the model for end-stage liver disease-natremia score (0.75). The in-hospital mortality rate with three or four nonhematologic organ failures on day 1 was not >70%, whereas it was 89% with three nonhematologic organ failures after 3 days spent in the intensive care unit. CONCLUSION:: In-hospital survival rate of intensive care unit-admitted cirrhotic patients seemed acceptable, even in patients requiring life-sustaining treatments and/or with multiple organ failure on admission. The most important risk factor for in-hospital mortality was the severity of nonhematologic organ failure, as best assessed after 3 days. A trial of unrestricted intensive care for a few days could be proposed for select critically ill cirrhotic patients.

PMID: 20802324 [PubMed - as supplied by publisher]

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Primary care summary of the British Thoracic Society Guidelines for the management of community acquired pneumonia in adults: 2009 update. Endorsed by the Royal College of General Practitioners and the Primary Care Respiratory Society UK.

Prim Care Respir J. 2010 Mar;19(1):21-7

Authors: Levy ML, Le Jeune I, Woodhead MA, Macfarlaned JT, Lim WS,

INTRODUCTION: The identification and management of adults presenting with pneumonia is a major challenge for primary care health professionals. This paper summarises the key recommendations of the British Thoracic Society (BTS) Guidelines for the management of Community Acquired Pneumonia (CAP) in adults. METHOD: Systematic electronic database searches were conducted in order to identify potentially relevant studies that might inform guideline recommendations. Generic study appraisal checklists and an evidence grading from A+ to D were used to indicate the strength of the evidence upon which recommendations were made. CONCLUSIONS: This paper provides definitions, key messages, and recommendations for handling the uncertainty surrounding the clinical diagnosis, assessing severity, management, and follow-up of patients with CAP in the community setting. Diagnosis and decision on hospital referral in primary care is based on clinical judgement and the CRB-65 score. Unlike some other respiratory infections (e.g. acute bronchitis) an antibiotic is always indicated when a clinical diagnosis of pneumonia is made. Timing of initial review will be determined by disease severity. When there is a delay in symptom or radiographic resolution beyond six weeks, the main concern is whether the CAP was a complication of an underlying condition such as lung cancer.

PMID: 20157684 [PubMed - indexed for MEDLINE]

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