2011 Abstracts   Research, Innovations,Clinical Vignettes Competition                 Hospital Medicine 2011              ...
Contents                                                         135. ICU BEDSIDE ASSESSMENTS OF DELIRIUM:                ...
Since the inception of the Society of Hospital Medicine Annual Meeting, the Research, Innovations, and Clinical Vignettes ...
regarding HIV testing have shifted. Further evaluation ofRESEARCH                                                         ...
3                                                                       4INCIDENCE OF VENOUS THROMBOEMBOLISM IN           ...
implementing a standardized protocol will likely improve             needed to determine if these data have clinical signi...
sistently below 1.0 (organizational target is LOS index <                               was a disagreement, a third review...
25(OH) D. The effect of 25(OH) D was calculated for every                                         between all-cause mortal...
lactic method (26.8%), 12.2% of patients received mechan-ical prophylaxis, and 8.8% of patients received anticoagu-lation ...
with the overproduction of acid. Accepted indications            12include upper gastrointestinal bleeding, erosive esopha...
for workload reduction. Conclusions: Although participation                  (starting shift) were significantly less like...
TABLE 1 Postprocedure Complications in Relation to Coagulopathies or                                     after 24 hours fo...
Short-Term Effect of Exenatide (GLP-1 Mimetic) on LVEF                                                     16             ...
TABLE 2 Rapid Response Criteria Operating Characteristics                                            TABLE Demographics an...
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Hospital medicine shm 2011 abstracts

  1. 1. 2011 Abstracts Research, Innovations,Clinical Vignettes Competition Hospital Medicine 2011 May10–13, 2011Gaylord Texan Resort and Convention Center Á Grapevine, TX
  2. 2. Contents 135. ICU BEDSIDE ASSESSMENTS OF DELIRIUM: SUSTAINABILITY AND RELIABILITY. Eduard.............................. . . .Page Vasilevskis, MD, Tennessee Valley VA.Research Abstracts . . . . . . . . . . . . . . . ..... 1 139. A SIMPLIFIED FRAILTY INDEX TO PREDICTResearch Abstracts: Plenary and Oral PERIOPERATIVE RISK IN THE ORTHOPEDIC Presentations, only . . . . . . . . . . . . . . . . . . 93 POPULATION. Peter Watson, MD, Henry Ford Hospital.Other Research Abstracts. . . . . . . . . . . . . . . 96 Research, Oral Presentations OnlyInnovations Abstracts . . . . . . . . . . . . . . . . . . 97 CLINICAL OUTCOMES AMONG NON–MECHANICALLYInnovations Abstracts: Plenary and Oral VENTILATED PATIENTS WITH ACUTE LUNG INJURY. Presentations, only . . . . . . . . . . . . . . . . . .142 Kirsten Kangelaris, MD, MAS, University of California.Clinical Vignettes Abstracts. . . . . . . . . . . . . .143 THE DERIVATION OF THE LUNG INJURY SEVERITYOther Clinical Vignettes Abstracts . . . . . . . . .273 SCORE (LISS): A PROGNOSTIC INDEX FOR IN-HOSPITAL MORTALITY IN ACUTE LUNG INJURY. Kirsten Kangelaris, MD, MAS, University of California.Best of Research, Innovations, and Clinical Vignettes EVALUATION OF AN ELECTRONIC DISCHARGEin 2011 Presentations SUMMARY FOR TIMELINESS AND QUALITY COMPARED TO DICTATION. Michelle Mourad, MD,Research University of California.100. COMPLIANCE WITH NEW ACGME DUTY-HOUR UNDERSTANDING UNSUCCESSFUL PROCEDURES ONREQUIREMENTS CAN IMPROVE PATIENT CARE A HOSPITALIST PROCEDURE SERVICE. MichelleMEASURES. Glenn Rosenbluth, MD, University of Mourad, MD, University of California.California. Innovations, Oral and Poster PresentationsFINANCIAL IMPACT OF PRESENTING LAB COST DATATO PROVIDERS AT THE TIME OF ORDER ENTRY: A 158. RESIDENT CASE REVIEW AT THERANDOMIZED CONTROLLED CLINICAL TRIAL. Leonard DEPARTMENTAL LEVEL: A WIN–WIN SCENARIO.Feldman, MD, Johns Hopkins University Medical Center. Alexander Carbo, MD, Beth Israel Deaconess Medical Center.Innovations 164. DESIGN AND IMPLEMENTATION OF AN AUTO-USING TOYOTA PRODUCTION SYSTEM TOOLS TO MATED E-MAIL NOTIFICATION SYSTEM FOR RESULTSREENGINEER AN ACADEMIC MEDICAL SERVICE. OF TESTS PENDING AT DISCHARGE. Anuj Dalal, MD,Diana Mancini, MD, Denver Health Hospital Authority. Brigham and Women’s Hospital. 197. ASSESSING PERCEPTION OF A NEWLY IMPLEMENTED HOSPITALIST FEEDBACK MODEL.Oral Presentations Dahlia Rizk, DO, Beth Israel Medical Center.Research, Oral and Poster Presentations Innovations, Oral Presentations Only84. PHARMACIST GLYCEMIC CONTROL TEAM IMPROVEMENT IN EMERGENCY DEPARTMENTIMPROVES GLYCEMIC CONTROL AND REDUCES TREATMENT CAPACITY:HOSPITAL READMISSIONS IN NON–CRITICALLY ILL A HEALTH SYSTEM INTEGRATION APPROACH. DiegoSURGICAL PATIENTS. Karen Mularski, MD, Northwest Martinez-Vasquez, MD, MPH, Maryland General Hospital,Permanente. Baltimore, MD, Michael Winters, MD, University Of85. USE OF ELECTROCARDIOGRAPHIC TELEMETRY Maryland Medical Center.MONITORING ON A MEDICINE SERVICE. A NOVEL APPROACH TO THE ADULT PEDIATRICNader Najafi, MD, University of California. PATIENT. Nathan O’Dorisio, MD, Ohio State University.
  3. 3. Since the inception of the Society of Hospital Medicine Annual Meeting, the Research, Innovations, and Clinical Vignettes (RIV)Competition has been an integral part of the program. The number of abstract entries has grown to 675 for Hospital Medicine2011, and quality and creativity have grown with quantity. Topics spanned many clinical areas and ranged from scientificresearch to innovations in hospital medicine practice to diagnostic dilemmas in clinical medicine.For the sixth year, SHM is proud to devote a Supplement of the Journal of Hospital Medicine to the publication of the acceptedabstracts.SHM gratefully acknowledges the contributions of the cochairs and abstract reviewers of the RIV Competition.Annual Meeting Course Director Reviewers Francis Mc Bee Orzulak, MD Daniel Dressler, MD, MSc, SFHM, Chadi Alraies, MD David Meltzer, MD, PhD, FHM Emory University School of Vineet Arora, MD, FHM Geraldine Menard, MD Medicine Moises Auron, MD, FAAP, FACP Joshua Metlay, MD, PhDRIV Chair Rubin Bahuva, MD Susanne Mierendorf, MD, MS, FHM Bradley Sharpe, MD, SFHM, FACP, Jeff Barsuk, MD, FHM Satyen Nichani, MD University of California, Adrienne Bennett, MD Heather Nye, MD, PhD San Francisco Aaron Berg, MD Kevin O’Leary, MD, MSResearch Cochairs Pouya Bina, MD Rita Pappas, MD Daniel Brotman, MD, FHM, Shane Borkowsky, MD Mital Patel, MD, MBBS Johns Hopkins University School of Alex Carbo, MD, SFHM Rehan Qayyum, MD, MBBS Medicine Dominique Cosco, MD Anitha Rajamanickam, MD Dana Edelson, MD, MS, Erik DeLue, MD, MBA, SFHM Daniel Ries, MD University of Chicago Margaret Fang, MD, FHM Greg Ruhnke, MD Medical Center Leonard Feldman, MD, FAAP, FACP Adam Schaffer, MDInnovations Cochairs Rachel George, MD, MBA, CPE, Danielle Scheurer, MD, SFHM Luci Leykum, MD, MBA, MSc, FHM, FHM Jeffrey Schnipper, MD, MPH, FHM University of Texas Health Science Sarah Hartley, MD Zishan Siddiqui, MD Center Carrie Herzke, MD William Southern, MD Andrew Modest, MD, Susan Hunt, MD Audrey Tio, MD Harvard Vanguard Medical Saurabh Kandpal, MD Associates Haruka Torok MD, MS Sunil Kripalani, MD, MSc, SFHM Robert Trowbridge, MDClinical Vignettes Cochairs David Lovinger, MD, FHM Ed Vasilevskis, MD Paul Grant, MD, Sudhir Manda, MD Sridhar Venkatachalam, MD University of Michigan Michelle Marks, DO, FAAP Christopher Whinney, MD Tarek Hamieh, MD, Scott Marsal, MD Health Partners Medical Group
  4. 4. regarding HIV testing have shifted. Further evaluation ofRESEARCH physician attitudes and increased education regarding the1 CDC recommendations and changes in state law are neces-EVALUATION OF HIV SCREENING UTILITY AND sary to increase HIV screening rates.PRACTICABILITY IN AN INPATIENT MEDICINE Disclosures:WARD SETTING A. K. Abramson - none; E. Machtinger - noneAnna Abramson, MD, Edward Machtinger, MD; University ofCalifornia, San Francisco, San Francisco, CABackground: The Centers for Disease Control and Preven- 2tion recommended in 2006 to test all patients for HIV with- SAFETY OF ARTHROCENTESIS IN PATIENTS ONout requiring counseling or written consent. The CDC CHRONIC WARFARIN THERAPY WITHsuggested ‘‘opt-out’’ testing to increase adoption. In 2007, THERAPEUTIC INRCalifornia removed the legal requirement for written con- Imdad Ahmed, MD, Elie Gertner, MD, FRCP(C), FACP; Regionssent. However, the volume of HIV tests in the University of Hospital, St. Paul, MNCalifornia, San Francisco infectious disease laboratory didnot increase after either the CDC statement or the change Background: Patients often need arthrocentesis for diagnos-in law. The objective of this study was to determine the tic and therapeutic reasons while on chronic warfarin ther-prevalence of undiagnosed HIV and the practicality of apy. Often the procedure is delayed or avoided because ofimplementing universal opt-out HIV screening for all medi- concern about bleeding. The aim of this retrospective studycine service inpatients ages 18–65. Methods: This was a was to determine the safety of arthrocentesis in patients onsingle-center prospective pilot program run for 1 year on a chronic oral warfarin therapy with INR ! 2.0. Methods:nonteaching academic medicine service to evaluate 3 out- We reviewed the records at Regions Hospital and Health-come measures: (1) number of patients with newly identi- Partners Medical Group of 514 consecutive patients onfied HIV infections; (2) identify barriers to physician- chronic warfarin therapy who underwent 640 joint aspira-administered HIV screening; (3) translatability of the pilot to tion procedures from January 2001 to November 2008. Aa larger academic medical center setting. All providers total of 456 procedures were performed with INR ! 2.0admitting patients to the medicine service were informed of (group A), and 184 procedures were performed with INRthe opt-out HIV screening program by an educational meet- < 2.0 (group B). The end points were: (1) clinically signifi-ing or e-mail memo. A prompt for HIV screening informa- cant bleeding; (2) infection of the joint; and (3) pain in thetion was added to the electronic admission note. When joint needing emergency room, urgent care, or physicianeligible patients were not screened on admission, practi- visits. The end points were both early (within 24 hours post-tioners were contacted via e-mail to encourage next-day procedure) and late (within 30 days). Indications for arthro-screening. Data were collected by a single analyst and centesis were usually pain/effusion in patients withdocumented in a secure hospital intranet repository. All diseases such as rheumatoid arthritis, osteoarthritis, andidentifiers were stripped prior to data analysis. Results: Dur- gout. Results: There were no significant differences in age,ing the initial 6 months of the study, 203 patients between sex, body mass index, and concurrent use of antiplateletages 18 and 65 were admitted to the medicine ward agents between the 2 groups. Groups were also compara-involved in this pilot. Of these, 12 (5.9%) were known HIV- ble among all medical comorbidities examined (diabetespositive persons, and 69 (34%) were not tested. Of the mellitus, hypercoagulability, hypertension, liver failure, re-newly tested patients, 1 (0.82%) tested HIV positive, and 1 nal failure, and smoking status). Mean INR at the time of(0.82%) tested inconclusive. Of the 69 untested persons, the procedure for group A was higher than that for group Bthe most common reasons were physician omission (32 (2.7 Æ 0.03 vs. 1.6 Æ 0.02). Table 1 shows the early andpatients, 46%), patient report of recent negative (15 late complications in both groups. There was no statisticallypatients, 22%), patient refusal (14 patients, 20%), practi- significant difference in the overall complication ratetioner preference due to terminal diagnosis (7 patients, between patients with INR ! 2.0 (group A) and patients10%), and patient inability to consent due to cognitive dis- with INR < 2.0 (group B); P 5 0.708. Receiver operatingturbance (5 patients, 7%). Conclusions: This study shows characteristic (Fig. 1) analysis showed that INR offeredthat a universal opt-out HIV screening program in an inpati- modest value as a predictive instrument, with a c-statistic ofent setting yields a similar percentage of newly detected 0.615. Conclusions: Arthrocentesis in patients on chronicHIV infections as previous emergency department studies. warfarin therapy with therapeutic INR appears to be safeThis study used real-time personal interaction betweenresearcher and clinician to explore physicians’ barriers to without an increased risk of bleeding complications. Thisordering an HIV test. These barriers included forgetting, approach simplifies the periprocedural management ofmisunderstanding the state law, screening only perceived anticoagulation and could lead to improved outcomes andat-risk persons, and discomfort raising this topic with an ill reduced health care costs.patient. Considering the relatively low number of patients to Disclosures:refuse screening, this study suggests that patient attitudes I. Ahmed - none; E. Gertner - noneª 2011 Society of Hospital Medicine S1DOI 10.1002/jhm.920View this article online at wileyonlinelibrary.com.
  5. 5. 3 4INCIDENCE OF VENOUS THROMBOEMBOLISM IN ASSESSMENT OF PAIN IN PATIENTSA HOMEBOUND POPULATION: A RETROSPECTIVE UNDERGOING BONE MARROW BIOPSYCOHORT STUDY AT A COMMUNITY TEACHING HOSPITAL: AJamal Ahmed, BA, Katherine Ornstein, MPH, Andrew Dunn, MULTIDISCIPLINARY PRACTICEMD, Peter Gliatto, MD; Mount Sinai School of Medicine, New IMPROVEMENT PROJECTYork, NY Mohammed Ahmed, MD, George Vinales, MD, Emily Leigh,Background: Venous thromboembolism (VTE) is a source of RN, Jenni Steinbrunner, BS, Susan Partusch, MSN, RN,morbidity and mortality for high-risk populations. The risk of Thomas Imhoff, PharmD, Muhammad Afzal, MD, UmasankarVTE in homebound patients is unknown, and therefore it is Kakumanu, MD; Good Samaritan Hospital, Cincinnati, OHunclear whether they should be offered VTE prophylaxis Background: Bone marrow examination is useful in the diag-when feasible. The purpose of this retrospective cohort nosis and staging of hematologic disease, as well as in thestudy was to estimate the incidence of venous thromboem- assessment of overall bone marrow cellularity. The procedurebolism (VTE) in homebound patients. Methods: The study can be a difficult experience for the patient. Pain and anxietysample included all patients active in a home-based pri- may play a role in the experience. The purpose of the studymary care program, the Mount Sinai Visiting Doctors Pro- was to assess practices for pain control in patients under-gram; VDP), over a 4-year period. Outpatient medical going bone marrow biopsy at a private community hospitalrecords and relevant inpatient admissions or clinical testing and to determine if pain medication before bone marrow bi-were retrospectively reviewed. Data were extracted to opsy impacts pain during and after the procedure. Methods:determine whether the patient experienced a VTE and if the Patients undergoing bone marrow biopsy at a 588-bed com-event occurred in a home setting while the patient was en- munity teaching hospital during a 1-year period wererolled in the VDP. Baseline functional assessment scores included in a prospective cohort study. Patients were askedwere abstracted when available. Incident VTE in a home to rate their level of pain and anxiety before the procedure,setting was defined as the diagnosis of a symptomatic deep their highest level of pain during the procedure, and theirvein thrombosis or pulmonary embolism that did not occur level of pain after the procedure. The visual analog scale wasduring a hospitalization, within 4 weeks of a medical hospi- used for pain scores and the distress thermometer was usedtalization, or within 12 weeks of a surgical hospitalization. for anxiety scores. Patients who received some type of painDefinite VTE was defined as events substantiated by clinical medication before the procedure were compared withtesting (Doppler ultrasound, CT angiography, ventila- patients who did not receive any type of medication beforetion–perfusion scan, and/or pulmonary angiography.) Prob- the procedure. Results: Eighty-five patients were included inable VTE was defined as events not substantiated by the study. The majority of patients (72%) received some typeclinical testing but that resulted in a decision to anticoagu- of pain medication before the procedure. Administration oflate. Incident VTE was calculated as the number of patients pain medication throughout the various hospital sites waswith probable and or definite VTE over person time. Statisti- inconsistent. All patients receiving their bone marrow biopsycal analysis was done using the Student t test. Results: A through the radiology department and the majority oftotal of 1913 patients were enrolled in the VDP during the patients (77%) undergoing bone marrow biopsy at inpatientstudy period. The database queries yielded 196 patients bedside received pain medication before the procedure.with possible home-based VTE for full chart review. Fromthese patients, there were 33 VTE events (28 definite and 5 However, only 30% of patients receiving their bone marrowprobable) that occurred in a home setting, yielding an inci- biopsy at the outpatient cancer center received pain medica-dence rate of 0.68 symptomatic VTE events per 100 person tion before the procedure. Furthermore, patients whoyears (95% CI, 0.448–0.912). There was no difference in received pain medication before the procedure experiencedbaseline functional assessment scores for patients with or significantly lower pain during and after the procedure whenwithout incident VTE. Conclusions: The estimated incidence compared with patients who received no pain medication.of VTE in a chronically homebound population is low and The average difference in the pain rating from before the pro-does not correlate with baseline functional status. There is cedure to the most pain experienced during the procedureinsufficient evidence to recommend VTE prophylaxis for this was 2.9 for patients who received pain medication and 6.2patient population. for patients who did not receive pain medication (P <Disclosures: 0.001). In addition, the average difference in the pain ratingJ. Ahmed - none; K. Ornstein, none; A. Dunn - none; P. Gliatto - none from before to after the procedure was 0.6 for patients who received pain medication and 2.2 for patients who did not receive pain medication (P 5 0.01). Conclusions: Currently, there is not a standard way of managing pain for patients undergoing bone marrow biopsies. Pain medication has a significant impact on pain experienced by the patient during and after the bone marrow biopsy. Increasing awareness byS2 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
  6. 6. implementing a standardized protocol will likely improve needed to determine if these data have clinical significancepatient care. and if prophylactic doses should be adjusted for body weightDisclosures: Disclosures:M. Ahmed - none L. Rojas - none; A. Aizman, none; D. Ernst, none; M. Paz Acuna, none; ˜ P. Moya, none; R. Mellado, none; F. Garrido, none; J. Cerda - none5 6ANTIFACTOR Xa ACTIVITY AFTER PROPHYLACTIC STREAMLINING DISCHARGE PROCESS UTILIZINGDOSE OF ENOXAPARIN (40 MILLIGRAMS) IN LEAN METHODOLOGY—EXPERIENCE OF AHOSPITALIZED PATIENTS WITH LESS THAN 55 NURSING UNITKILOGRAMS OF WEIGHT Val Akopov, MD, Willie Smith, MD, Sandra Thomason, RN,Andres Aizman, Instructor1, Luis Rojas, Instructor1, Daniel Ernst, Kimberly Graham, RN, Pam Graham, RN, Sandra Mullings,Resident1, Maria Paz Acuna, Resident1, Pablo Moya, Intern2, Rose- ˜ LCSW, Karen O’Donald, CPA; Emory Healthcare, Atlanta, GAmarie Mellado, Porfessor2, Felipe Garrido, Instructor2, Jaime Background: The cohesiveness of the discharge process isCerda, Professor1; 1Faculty of Medicine, Pontificia Universidad critical for ensuring the safety and quality of transition ofCatolica de Chile, Santiago, Chile, 2Faculty of Pharmacy, Pontifi- ´ patient care from the inpatient setting to the next level of ´lica de Chile, Santiago, Chile,cia Universidad Cato care. The discharge process is often viewed as chaotic by theBackground: Low-molecular-weight heparins are the most health care team as well as patients and families. A few rea-commonly used for thromboembolic disease prophylaxis, sons why the discharge process is being viewed as complexprobably because of their security profile and once-daily and at times disjointed include the declining presence of pri-administration. Contrary to therapeutic doses, prophylactic mary care physicians in hospitals and emergence of hospital-recommended doses are fixed (40 mg once a day for enoxa- ists; lack of consistency in information flow between hospitalparin). Dosing in extreme body weights has little evidence, team and the next level of care team; and patients feelingespecially in patients with low weight. The aim of the study unprepared for discharge. Certain peridischarge interven-was to establish if the recommended dose of enoxaparin (40 tions have demonstrated improved primary care physicianmg once a day) in patients who weighed less than 55 kg pro- satisfaction, patient satisfaction, and readmission rates.duces antifactor Xa activity over desired ranges for throm- Methods: This study was conducted on a 50-bed generalboembolic prophylaxis. Methods: This was a transversal medical telemetry nursing unit that served as the test site forstudy with prospective recruitment. Sample size was esti- inpatient discharge process improvement from January 2008mated in 53 patients. Inclusion criteria were: patients older to December 2008. A multidisciplinary team of physicians,than 18 years, body weight 55 kg, hospitalized in medical frontline nursing staff, social workers, hospital administration, ´or surgical services in the Hospital Clınico Pontificia Universi- unit leadership, and personnel from the office of quality who ´dad Catolica de Chile, and with indication of thromboem- were trained in the Lean methodology were assembled forbolic prophylaxis with enoxaparin 40 mg once a day by the this initiative. First, the team created a detailed process map,treating physician. Exclusion criteria were: renal failure (cre- called a Value Stream. This map allowed for the visualizationatinine clearance < 30 mL/min estimated with Cockroft- of the entire process flow from admission to treatment to dis-Gault formula), amyloidosis, and concomitant use of oral charge. Second, the team identified 5 areas of delay withinanticoagulants. Antifactor Xa activity was measured 3–4 the discharge flow. These identified areas became targets forhours after the second or third dose of enoxaparin. We esti- intervention or rapid improvement events (RIEs). RIEs aremated the proportion of patients with antifactor Xa activity weeklong activities that are a part of the Lean tool kit and pro-over 0.5 unit/mL and the average of antifactor Xa activity. vide a mechanism for making radical changes to current pro-Results: The average age of patients was 65.4 Æ 20.3 years, cesses and activities within very short timescales. Over thethe average weight was 47.7 kg (26–54.8 kg), and 86.7% course of 1 year the team participated in 7 RIE initiatives: (1)of patients were female. The average antifactor Xa activity visual notification of discharge readiness, (2) patient dis-was 0.54 Æ 0.18 units/mL, and the proportion of patients charge education, (3) standardization of the MD dischargewith values over 0.5 units/mL was 60%. Weight and antifac- process, (4) demographic and insurance quality, (5) stand-tor Xa activity had an inverse correlation, with a Pearson ardization of the RN discharge process, (6) standardizationcoefficient of 20.497. In subgroup analysis, patients < 50 of SW discharge—disposition home, and (7) standardizationkg of weight had antifactor Xa activity of 0.61 Æ 0.18 units/ of SW discharge—disposition skilled nursing facility. The fol-mL, whereas those who weighed > 50 kg had an antifactor lowing outcomes were measured: (1) length of stay indexXa activity of 0.47 Æ 0.16 unit/mL (P 5 0.019). Conclusions: (LOS index), defined as a ratio of observed to expectedAntifactor Xa activity rises significantly when body weight length of stay, (2) physician and RN satisfaction with dis-decreases. Patients with low weight had antifactor Xa activity charge process before and after the study, and (3) proportionover the desired range for thromboembolic prophylaxis, of discharges before 2 PM. Results: As a result of the interven-especially in those under 50 kg. Further investigation is tion, the LOS index had steadily declined from 1.16 to con- Hospital Medicine 2011 Abstracts S3
  7. 7. sistently below 1.0 (organizational target is LOS index < was a disagreement, a third reviewer determined appropriate-1.0); physician and nursing satisfaction with discharge pro- ness. Bayesian statistics were used to determine the diagnosticcess significantly improved from the pre- to the postinterven- accuracy of emergency medicine providers, and chi-squaredtion state; the proportion of patients discharged before 2 PM testing was used to compare accuracy pre- and postinterven-increased from 24% to 36% Conclusions: Lean methodology tion. Results: Neither the overall admission rate nor the inap-is an excellent tool for improving the quality and efficiency of propriate admission rate changed from pre- to postinterventionthe discharge process and should be widely utilized in the (Table). The positive predictive values and negative predictivehealth care setting values of the ED decision to admit were >98% and 99%,Disclosures: respectively, and did not change postintervention. In the postin-V. Akopov - none; W. Smith, Jr. - none; S. Thomason - none; K. Graham - none; tervention period, 82.5% of triage changes (n 5 141) wereP. Graham - none; C. Mims - none; S. Mullings - none; K. O’Donald - none classified as escalations in care setting. The most common diagnoses were chest pain (n 5 78, 46%), pneumonia (n 5 11, 6.4%), alcohol withdrawal (n 5 8, 4.7%), and sepsis (n 57 8, 4.7%). Of triage changes, 17.5% (n 5 30) were classifiedHOSPITALIST SCREENING OF EMERGENCY as de-escalations of care setting. The most common diagnosesMEDICINE TRIAGE DECISIONS DOES NOT for these patients were chest pain (n 5 18, 60%) and deepIMPROVE TRIAGE ACCURACY vein thrombosis (n 5 3, 10%). Conclusions: Our study suggestsRebecca Allyn, MD, Jeremy Long, MD, Lee Shockley, MD, that the screening of admissions from the ED by hospital medi-Angela Keniston, MSPH, Barbara Cleary, MD, Eugene Chu, cine attending physicians is not an efficient allocation ofMD; Denver Health Medical Center, Denver, CO resources. At our institution, inappropriate admissions are rela-Background: Hospital care accounts for more than 30% of tively rare events. Attempts to further reduce inappropriatehealth care expenditures in the United States. In an effort to admissions may increase inappropriate discharges.reduce inappropriate admissions, we implemented hospital Disclosures:medicine attending screening of non–intensive care unit (ICU) R. Allyn - none; J. Long - none; L. Shockley - none; B. Cleary - none; A. Keniston - none; E. S. Chu - nonemedicine admissions. Methods: We conducted a before andafter study at our urban, academic safety-net hospital. FromJanuary to June 2008, all patients admitted to the medicine 8wards or to the chest pain observation unit were screened by a RELATIONSHIP BETWEEN 25-HYDROXYVITAMIN Dhospital medicine attending physician, who, in collaborationwith referring providers, could change the initially recom- AND ALL-CAUSE AND CARDIOVASCULARmended disposition. Patients who were admitted to inpatient MORTALITY: RESULTS FROM THE NATIONALmedicine and discharged or transferred to the ICU within 24 HEALTH AND NUTRITIONAL EXAMINATIONhours or admitted to medicine after having been discharged SURVEY LINKED MORTALITY FILES, 2001–2004within 7 days from the Emergency Department (ED) from Janu- Muhammad Amer, MD1, Muhammad Bakht, MBBS2, Rehanary to June 2008 were identified and compared with a histori- Qayyum, MD, MHS1; 1Johns Hopkins School of Medicine, Bal-cal control from the same months 1 year prior. Two physicians timore, MD, 2 University of Medicine and Dentistry of New Jer-reviewed each chart for appropriateness of disposition. If there sey School of Public Health, Piscataway, NJ Background: Observational studies have reported significant protective associations between 25-hydroxyvitamin DAccuracy of Triage Decisions [25(OH) D] and all-cause and cardiovascular (CV) mortality. Prehospitalist Screening Posthospitalist Screening We believe that these associations have nonlinear relation- ships and 25(OH) D probably offers greater protection at Appropriate Appropriate Appropriate Appropriate lower serum levels. To study this hypothesis, we examined the Admission: Admission: Admission: Admission: relationship between 25(OH) D and all-cause and CV mortal- Yes No Total Yes No Total ity in a healthy adult U.S. population. Methods: We usedAdmitted: yes 2812 38 2850 3865 76 3941 data from the continuous National Health and Nutrition Ex-Admitted: no 6 5712 5718 4 6623 6627 amination Survey (NHANES), a probability sample of nonin-Total 2818 5750 8568 3869 6699 10,568 stitutionalized civilians for the years 2001–2004 (baseline).Prevalence of 1.3%y 1.9%y Data on mortality status were obtained from NHANES linked inappropriate admissions (National Death Index) mortality files, with follow-up informa-Sensitivity 99.8 (99.5–99.9)y 99.9 (99.7–100.0)y tion from date of survey participation to December 2006. percent (95% CI) Analysis was limited to individuals older than 18 years. IfSpecificity 99.3 (99.1–99.5)y 98.9 (98.6–99.1)y needed, variables were log-transformed to meet assumptions percent (95% CI) of residual normality. To examine the nonlinear relationshipy of 25(OH) D with all-cause and CV mortality, we used a P 5 NS. spline, with single knot at median serum levels (21 ng/mL) ofS4 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
  8. 8. 25(OH) D. The effect of 25(OH) D was calculated for every between all-cause mortality and 25(OH) D below (HR, 0.59;10-unit increase below and above spline. Cox proportional 95% CI, 0.45–0.77) but not above its median serum levelsregression models were used to estimate the hazard ratio (HR, 0.83; 95% CI, 0.65–1.06). In the multivariable model,(HR) and 95% confidence interval (CI) for all-cause and CV the association between all-cause mortality and 25(OH) Dmortality. Results: There were 509 all-cause and 184 CV- below its median remained significant (HR, 0.55; 95% CI,related deaths during the median (range) follow-up of 4 years 0.4–0.82). Similarly, in univariate regression, we observed a(3–5 years). Of the 10,170 participants, 52% were female, significant association between CV mortality and 25(OH) D51% were white, 16.4% were current smokers, and 37% below (HR 0.56, 95% CI 0.4-0.8) but not above its medianhad hypertension. Mean (SD) age and 25(OH) D levels were (HR, 0.91; 95% CI, 0.56–1.5). In the multivariable-adjusted46.6 (20.5) and 22 (9.2), respectively. In the univariate model, 25(OH) D retained its significant association with CVregression, we found a statistically significant association mortality below its median (HR, 0.53; 95% CI, 0.3–.93), whereas it conferred no protection for CV mortality above its median serum levels (HR, 0.89; 95% CI, 0.52–1.53). Con-TABLE Population Characteristics of Participants Aged 18 and Above; clusions: The protective relationships between 25(OH) D andNHANES 2001–2004 all-cause and CV mortality are nonlinear. In addition, we found that serum 25(OH) D levels above 21 ng/mL appear Vitamin D(ng/mL) to offer no protection against all-cause and CV mortality in both simple and multivariable-adjusted models in a healthyCovariates £ 21 (N 5 5237) > 21 (N 5 4933) p-values adult U.S. population.Age (years), Mean (SD) 45.75 (20.6) 47,56 (20,4) <0.0001 Disclosures:Females n (%) 2795 (53) 2470 (50) 0.001 M. Amer - none; M. Bakht - none; R. Qayyum - noneRare, n (%) Mexican American 1358 (26) 852 (17) 0,001 Non Hispanic Black 1686 (32.2) 334 (7) 0.001 9 Other Hispanic 133 (4) 175 (3.5) 0.7 DURATION OF RISK OF VENOUS Other Rare 258 (5) 127 (2.6) 0.001 THROMBOEMBOLISM IN REAL-WORLD U.S. Caucasians (Ref) 1742 (33.3) 3 445 (70) 0.001HTN, n(%) 2054 (39) 1740 (35.3) 0.001 PATIENTS HOSPITALIZED FOR MEDICAL ILLNESSCurrent Smoker, n (%) 896 (20) 771 (17) 0.01 Alpesh Amin, MD, MBA, FACP1, Helen Varker, BS2, Jay Lin,GFRml/mtn/m2, Mean(SD) 103.8 (32.34) 95.52 (32.33) 0.0001 PhD3, Stephen Thompson, MS4, Stephen Johnston, MA2; 1SchoolCholesterol (mg/dL), Mean (SD) 137 (45.05) 202.4 (43.51) 0.0001 of Medicine, University of California, Irvine, Irvine, CA;All cause mortality, n (%) 297 (6) 216 (4.4) 0.003 2 Thomson Reuters, Washington, DC; 3 Bruce Wong AssociatesCardiovascular mortality, n (%) 109 (2.1) 77(1.6) 0.05 Inc., Radnor, PA; 4 Sanofi-aventis, Bridgewater, NJHTN; hypertension; defined as average systolic BP 140 or average diastolic BP 90 mm Hg or Background: Patients hospitalized for medical illness are atindividuals ever told to have HTN, or if participants we re taking an antihypertensive. Current an increased risk of developing venous thromboembolismsmoker, individuals smoke daily. GFR, Glomerular Filtration Rate measured using Modification of (VTE). The present study retrospectively assessed the inci-Diet in Renal Disease (MDRD) equation. dence and time course of symptomatic VTE events following hospitalization in a large, real-world patient population. Methods: Administrative claims data derived from the Thom- son Reuters MarketScan1 Inpatient Drug Link File were used to identify patients hospitalized for severe infectious disease, congestive heart failure, cancer, or chronic ob- structive pulmonary disease. Included patients had been admitted to the hospital between January 1, 2005, and De- cember 31, 2008, and had been continuously enrolled ! 12 months prior to admission (patient history) and ! 180 days after admission. The cumulative risk and hazard of VTE—measured as the number of VTE events per 1000 per- son-days—were established across an evaluation period of 180 days. Results: The study cohort consisted of 11,139 medical patients, with a mean (standard deviation [SD]) age of 67.6 (13.9) years, and 51.6% were female. The mean (SD) length of stay in the hospital was 5.3 (5.3) days, during which 46.7% of patients (ranging from 30.7% of cancer patients to 64.1% of heart failure patients) received any VTE prophylaxis for a mean (SD) duration of FIGURE . Kaplan–Meier survival curves for cardiovascular mortality. 5.0 (4.7) days. Enoxaparin was the most common prophy- Hospital Medicine 2011 Abstracts S5
  9. 9. lactic method (26.8%), 12.2% of patients received mechan-ical prophylaxis, and 8.8% of patients received anticoagu-lation therapy within the period extending from discharge Outcome HN Cohort Non-HN Cohort Difference P Valueto 35 days after discharge, most commonly with warfarin Mortality (%) 1.57 1.45 0.12 0.001(7.7%). Appropriateness of prophylaxis was not deter- ICU admission (%) 23.13 22.10 1.03 0.001mined. During the 180-day evaluation period, 366 sympto- LOS (days) 8.78 7.65 1.13 0.001matic VTE events occurred (3.3%), comprising 241 deep ICU LOS (days) 5.51 4.85 0.66 0.001vein thrombosis (DVT)–only events, 98 PE-only events, and ICU cost ($) 8525 7597 928 0.00127 events with evidence of both DVT and PE. Of the events, Total hospital cost ($) $15,281 $13,439 $1842 0.00143% (97 DVT only, 44 PE only, and 18 both DVT and PE)occurred during the index hospitalization. The highest num- spective analysis used the Premier’s Perspective1 databaseber of VTE events occurred during the first 9 days (97 to select hospitalizations with HN (serum sodium 135events, 88% in-hospital; proportion of 180-day cumulativerisk, $20%) and during days 10-–9 (82 events, 71% in-hos- mmol/L as defined by primary or secondary ICD-9 276.1)pital; proportion of 180-day cumulative risk, $45%) follow- for the January 2007 to June 2009 time frame. Patientsing index admission. VTE hazard peaked at approximately transferred to/from another acute care facility and who left1.05 per 1000 person-days on the eighth day following against medical advice, and labor/delivery patients wereadmission, and 50% had been incurred by the 23rd day. excluded from this analysis. HN patients (n 5 564,723)VTE frequency gradually declined thereafter, fluctuating at were matched to a non-HN control by age, sex, providera background level of 4–7 events during each 10-day inter- region, and 3MTM APR-DRG assignment. Matching wasval from 130 to 139 days up to 170–180 days. Conclu- refined using propensity scores on other patient and hospi-sions: Among the cohort of 11,139 medical patients at risk tal characteristics and patient comorbidities. Matchedof VTE, 3.3% experienced a symptomatic VTE event during patients were assigned to HN and non-HN groups for com-the 180-day evaluation period following index hospitaliza- parisons of total hospital cost, intensive care unit (ICU) cost,tion, and more than half of these events (57%) occurred length of stay, ICU length of stay, rate of ICU admission,postdischarge. Although the risk of VTE was highest within and inpatient mortality rate. Results: Hospital demographicsthe first 19 days after the index admission, results from this were similarly distributed across both cohorts. Approxi-study indicate that a considerable risk of VTE extends into mately 57% of the patients came from hospitals located inthe period after discharge. the South Atlantic, Middle Atlantic, and Pacific regions. Sixty percent of hospitals were nonteaching. Patient demo-Disclosures: graphics included: 57% female, mean age of approxi-A. Amin - sanofi-aventis U.S., Inc., research honorarium, speakers bureau; H.Varker - sanofi-aventis U.S., Inc., employee at Thomson Reuters, which mately 68 years, and 41% hypervolemic with comorbiditiesreceived funding to carry out this work from sanofi-aventis U.S., Inc.; J. Lin - of heart failure and/or cirrhosis in approximately 48% ofsanofi-aventis U.S., Inc., employee at Bruce Wong Associates Inc., which both cohorts. A hospitalist attended to 43% of all patients.received funding to carry out this work from sanofi-aventis U.S., Inc.;S. Thompson - sanofi-aventis U.S., Inc., employment; S. Johnston - sanofi- HN contributed to an increased LOS, increased total andaventis U.S., Inc., employee at Thomson Reuters, which received funding to ICU hospitalization costs, increased percentage of patientscarry out this work from sanofi-aventis U.S., Inc requiring an ICU admission, increased ICU LOS, and increased inpatient mortality. Conclusions: In a hospitalized population, HN was associated with a statistically signifi-10 cant negative impact on inpatient mortality, ICU admission,IMPACT OF HYPONATREMIA ON PATIENT and total/ICU LOS. HN was also associated with signifi-OUTCOMES AND HEALTH CARE RESOURCE cantly increased total hospital and ICU costs.UTILIZATION IN HOSPITALIZED PATIENTS Disclosures:Alpesh Amin, MD1, Steven Deitelzweig, MD1, Jay Lin, PhD2, A. Amin - Otsuka, research funding, speakers bureau; S. Deitelzweig - Otsuka,Kathy Belk, BA3, Dorothy Baumer, MS3; 1Ochsner Health Sys- research funding, speakers bureau; J. Lin - Otsuka, consultant; K. Belk - Otsuka,tem, New Orleans, LA; 2Novosys Health, Flemington, NJ; 3Pre- consultant; D. Baumer - Otsuka, consultantmier, Charlotte, NCBackground: Hyponatremia (HN) is the leading electrolyte 11abnormality among hospitalized patients. In the absence of PROTON PUMP INHIBITOR USE IN HOSPITALIZEDsymptoms, HN is often overlooked as a condition that war- MEDICAL PATIENTSrants aggressive intervention. However, a careful history of-ten reveals symptoms associated with HN. Although HN is Mary Anderson, MD1, Amy Go, PharmD2, Dimitriy Levin,common, little is known regarding the influence of HN on MD1; 1University of Colorado Denver, Aurora, CO; 2Universitypatient outcomes and health care resource utilization. The of Colorado Hospital, Aurora, COpresent study was designed to identify the impact of HN on Background: Acid suppressive medications, including hista-length of stay (LOS), inpatient mortality, and cost variables mine2-receptor antagonists (H2RAs) and proton pump inhibi-in a hospitalized patient population. Methods: This retro- tors (PPIs), are widely used to treat conditions associatedS6 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
  10. 10. with the overproduction of acid. Accepted indications 12include upper gastrointestinal bleeding, erosive esophagitis PARTICIPATION IN UNPROFESSIONAL BEHAVIORSor gastritis, gastroesophageal reflux disease, ulcers, Helico- AMONG HOSPITALISTS: A MULTISITE STUDYbacter pylori eradication, Zollinger–Ellison syndrome, stress Vineet Arora, MD, MAPP1, James Iwaz, BS1, Kevin O’Leary,ulcer prophylaxis (SUP) in high-risk patients, dyspepsia MD2, Aashish Didwani, MD2, Andy Anderson, MD3, Hollyassociated with nonsteroidal anti-inflammatory drugs in Humphrey, MD1, Jeanne Farnan, MD, MHPE1, Diane Wayne,high-risk patients, and severe dyspepsia unresponsive to MD2, Shalini Reddy, MD1; 1University of Chicago, Chicago,adequate trials of symptomatic drugs. Although PPIs are IL; 2Northwestern University, Chicago, IL; 3NorthShore Univer-effective and well tolerated, there is growing concern about sity HealthSystem, Chicago, IL,the overuse of PPIs in hospitalized patients. PPIs mayincrease the risk of nosocomial Clostridium difficile infec- Background: Unprofessional behaviors can undermine thetions and hospital-acquired pneumonia. The literature also hospital learning environment and patient care. To date, nosuggests that patients frequently receive PPIs without a clear study has examined unprofessional behaviors in hospital-indication and that PPIs are often inadvertently continued ists. Methods: A 35-item survey of unprofessional behaviorson discharge. The purpose of this quality improvement pro- adapted from prior studies was administered to hospitalistsject was to evaluate current prescribing practices for PPIs in from 3 academic programs at 7 Chicago hospitals. The sur-hospitalized medical patients. Methods: This was a pro- vey included behaviors related to interactions with othersspective observational study of adults admitted to general (i.e., making fun of residents), patient care scenarios (i.e.,medicine (non-ICU) services at a tertiary-care medical cen- blocking an admission), and interactions with trainees (i.e.,ter between February and May 2010. Patients were identi- asking a student to perform a procedure beyond his or herfied based on pharmacy order entry for esomeprazole, the skill). Participants reported whether they participated andPPI on formulary. The frequency of PPI use, indications, rated their perception of this behavior on a Likert-type scaleappropriateness of use, and discharge PPI orders were ranging from 1 (unprofessional) to 5 (professional). Routineexamined. Results: The overall frequency of PPI use was demographics including job type (clinical, teaching,45% in this study. Of 100 patients randomly selected for research, administrative, night work, etc.) were alsoanalysis, 69% were taking a PPI prior to hospitalization, assessed. Data were merged with a deidentified code forwhereas 31% were started on a PPI as an inpatient. Major site. Factor analysis was performed to extract the principalindications for a new PPI during hospitalization included components of unprofessional behavior. A scree plot deter-gastrointestinal bleeding (26%), followed by dyspepsia mined the number of factors to retain. Item loadings were(23%) and SUP (23%). The new PPI was appropriate in used to name factors. Site-adjusted multivariate regression52% and inappropriate in 36% of patients; inappropriate models were used to examine the association between de-indications included SUP in low-risk patients and dyspepsia mographic and job characteristics and factors of unprofes-without a prior trial of calcium carbonate or H2RA. Overall, sional behavior. Results: Seventy-eight percent of83% of patients were continued on a PPI at discharge, hospitalists (79 of 101) responded. Participation in egre-including 52% (17 of 31) of those started on a PPI in the gious behaviors (i.e., falsifying medical records, mistreat-hospital. Of those patients discharged with a new PPI, the ment of students) was very low (5%), and most behaviorsmedication was likely unnecessary in 42% of cases. Con- were recognized as unprofessional (rated 3 on theclusions: PPI use in hospitalized medical patients is com- Likert). The most common unprofessional behaviors reportedmon, with a high rate of inappropriate use both during were having personal conversations in patient corridorshospitalization and at discharge. This increases the likeli- (66%), ordering a routine test as ‘‘urgent’’ to expedite carehood of adverse medication events as well as the cost of (62%), texting or using smartphones during educationalhealth care. Patients started on a new PPI during hospitali- conferences (40%), and disparaging the emergency roomzation represent the first target group for intervention. (ER) or primary care physician for findings later discoveredAdhering to approved indications for PPI use, discontinuing on the floor (40%). Factor analysis revealed 3 major factorsPPIs when no longer indicated, and considering alternative that accounted for half of survey variance: (1) disrespecttherapies such as H2RAs are areas for improvement. Strate- (e.g., making fun of residents, disparaging the ER), (2)gies to improve prescribing practices may include imple- patient safety (e.g., failing to report an error), and (3) work-menting automatic stop orders on PPIs, reevaluating use of load reduction (e.g., blocking admissions). In site-adjustedPPIs on standardized order sets, and integrating decision- multivariate regression models, hospitalists with less clinicalmaking prompts into the electronic medical record. time were more likely to participate in disrespectful beha-Disclosures: viors (b 5 0.75, P 5 0.014), but less likely to disregard safety (b 5 20.69, P 5 0.034). In addition, hospitalistsM. Anderson - none; A. Go - none; D. Levin - none with any night work were more likely to disregard safety (b 5 0.57, P 5 0.044). Younger hospitalists (b 5 0.94, P 5 0.029) and those with administrative time (b 5 0.56, P 5 0.38) were more likely to participate in behaviors to actively reduce workload. Site differences were only noted Hospital Medicine 2011 Abstracts S7
  11. 11. for workload reduction. Conclusions: Although participation (starting shift) were significantly less likely to provide super-in egregious unprofessional behaviors was low, job type ior (top quartile) ratings in 3 areas (overall, organization,(clinical, administrative, and night work), age, and institu- setting) than were receivers (ending shift). Observer ratingstional culture seem to be associated with certain behaviors. did not show this disparity. Evaluator satisfaction with theFuture work to address professionalism among hospitalists tool was high (mean, 6.80; IQR, 6–8) and was also asso-should take these findings into account. ciated with overall hand-off quality (b 5 0.60, P 0.001).Disclosures: Conclusions: Real-time assessment of hand-off quality byV. Arora - ABIM Foundation, NIA, AHRQ, ACGME, research funding; J. Iwaz - clinicians using the Handoff CEX is feasible and reliable.NIA, research funding; K. O’Leary - ABIM Foundation, research funding; A. Arriving late to hand-offs can dramatically affect ratings ofDidwania - ABIM Foundation, research funding; A. Anderson - ABIMFoundation, research funding; H. Humphrey - ABIM Foundation, research hand-off quality. Other characteristics, such as day of weekfunding; J. Farnan - ABIM Foundation, research funding; D. Wayne - ABIM and sender/receiver roles, are also related to hand-off rat-Foundation, research funding; S. Reddy - ABIM Foundation, research funding ings. It may be easier to critically evaluate senders, who bear the burden of communication, than receivers. Alternatively, receivers may be more critical because of the stress of receiv-13 ing work, or senders may overestimate receiver performanceREAL-TIME RATINGS OF HAND-OFF QUALITY BY because of the excitement of ending their shift. Further workHOSPITALIST CLINICIANS to explore the mechanism of these findings is under way. Disclosures:Vineet Arora, MD, MAPP1, Paul Staisiunas, BA1, Stacy Bane-rjee, MD1, Elizabeth Greenstein, BA1, Leora Horwitz, MD, V. Arora - AHRQ, NIA, ABIM, ACGME, research funding; P. Staisiunas - AHRQ, research funding; S. Banerjee - none; E. Greenstein - NIA, researchMHS2, Jeanne Farnan, MD, MHPE1; 1University of Chicago, funding; L. Horwitz - NIA, AHRQ, research funding; J. Farnan - AHRQ,Chicago, IL, 2Yale University, New Haven, CT research fundingBackground: Hand-offs are a core competency of hospital-ists. Although the Society of Hospital Medicine and othersrecommend improving hand-offs, monitoring and improving 14hand-off quality are limited by lack of reliable tools to mea- THORACENTESIS BLEEDING RISK FACTORS:sure hand-off quality. This study aimed to assess the feasibil- THEY’RE NOT WHAT YOU THINKity and reliability of using a paper-based tool, ‘‘HandoffCEX (Clinical Evaluation Exercise),’’ to evaluate real patient Mark Ault, MD, FACEP, Bradley Rosen, MD, MBA, FHM;hand-offs between hospitalist clinicians. Methods: The Cedars–Sinai Medical Center, Los Angeles, CAHandoff CEX, developed based on literature review and Background: Postprocedural bleeding is a significant adverseexpert consensus, includes ratings of overall performance outcome. Clinicians routinely assess bleeding risk by orderingand its components (organization, communication skills, coagulation labs (INR, PTT, platelets) and administer blood pro-clinical judgment, setting, patient-focused) on a 0–9 scale. ducts to correct any discovered coagulopathies. CertainFor 3 hand-offs a week (Monday/Tuesday/Friday), clini- ‘‘bleeding risk’’ medications are also held. Although the effi-cian senders and receivers were evaluated by a trained cacy of these steps seems intuitive, coagulation labs were notthird-party nonmedical observer using the Handoff CEX. designed to assess bleeding risk, and the need to ‘‘correct’’Senders and receivers also evaluated each other using the abnormal coagulation lab values or stop certain medicationsinstrument. Interrater reliability between clinician and ob- has never actually been demonstrated. Further, this practiceserver was calculated using Spearman’s rho. Descriptive comes at the expense of valuable time, limited blood bankand comparative statistics were used to examine mean per- resources, and increased cost. The Procedure Center atformance and ‘‘superior’’ performance, defined as the top Cedars–Sinai Medical Center performs approximately 1200quartile. Results: From March to December 2010, all 38 thoracenteses annually, and historically has relied on patients’(100%) hospitalist clinicians (nurse practitioners, hospital- bleeding history to determine preprocedural risk rather thanists) consented to participate. Senders, receivers, and a routine lab screening or the presence of certain medications.trained observer rated 78 hand-offs, resulting in 156 partic- To evaluate the safety of this practice, we undertook an assess-ipant and 153 observer evaluations. Domain means were ment of procedural outcomes for thoracenteses relative tobetween 6 and 7, with full use of the 0–9 scale noted. Inter- patients’ coagulation parameters and/or the presence ofnal consistency was high (Cronbach’s alpha 5 0.90). blood-thinning or antiplatelet medications. Methods: PatientsSpearman’s rho between participating clinicians and for whom a thoracentesis was order were evaluated consecu-trained observer was calculated as 0.52 (P 0.001), indi- tively. A chart review was performed to capture coagulationcating moderate interrater reliability. Although tardiness parameters (INR, PTT, platelets), and the presence of blood-thin-was noted in only 9% of hand-offs, nearly all ratings were ning or antiplatelet medications. The decision to perform thelower if a clinician arrived late (overall, 7.26 not tardy vs. procedure was not affected by the findings of the preprocedure5.85 tardy, P 0.001). Setting was rated significantly chart review, and the proceduralist generally was not aware ofhigher on Monday than on other days (7.50 Monday vs. the findings. All procedures were performed according to6.75 Tuesday/Friday, P 0.001). Clinician senders established Procedure Center protocol. Patients were assessedS8 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
  12. 12. TABLE 1 Postprocedure Complications in Relation to Coagulopathies or after 24 hours for complications (bleeding related or other),‘‘Bleeding Risk’’ Medications and complications were categorized as ‘‘major’’ or ‘‘minor.’’ Results: A thousand consecutive thoracenteses were performed Minor from February 2010 to October 2010. Figure 1 depicts (a) the Major Complications frequency of abnormal preprocedure coagulation labs and (b) Cases Complications from Nonbleeding the prevalence of ‘‘bleeding risk’’ medications. Table 1 sum- (n) from Bleeding Bleeding Complications marizes the incidence of complications for each of those cate-All coag labs unknown 132 0 0 19 (3 major, gories. Patients with abnormal coagulation parameters or who 16 minor) were on certain medications did not suffer higher rates of com-!1 Coag lab known, normal 224 0 4 (3.5%) 0 plications than other patients. Conclusions: The overall compli-!1 Coag known, abnormal 644 0 1 (0.2%) 0 cation rate in this series of thoracenteses was very low (2.4%).No ’’bleeding risk’’ 485 0 3 (0.6%) 19 (3 major, The presence of abnormal coagulation labs and/or blood-thin- medications present 16 minor) ning medications did not increase the incidence of complica-1 ’’Bleeding risk’’ 405 0 2 (0.5%) 0 tions. These findings suggest that routinely checking medication present coagulation labs, transfusing blood products to correct abnor-1 ’’Bleeding risk’’ 110 0 0 0 mal lab values, and/or stopping certain medications prior to medication present performing thoracenteses may be unnecessary.Note: Each complication is listed twice—once in the ‘‘coag labs’’ section (top half of table) and once Disclosures:in the ‘‘bleeding risk meds’’ section (bottom half of table). M. Ault - none; B. Rosen - none 15 EXENATIDE, A GLUCAGON-LIKE PEPTIDE-1 MIMETIC, IMPROVES LEFT VENTRICULAR EJECTION FRACTION IN PATIENTS WITH STABLE ISCHEMIC CARDIOMYOPATHY AND LEFT VENTRICULAR EJECTION FRACTION £ 40% Wamiq Banday, MBBS, MD, Aravind Herle, MD, Banjamin Rueda, MD, Howard Lippes, MD; FACP; University of Buffalo, Sisters of Charity Hospital, Buffalo, NY Background: Glucagon-like peptide-1 (GLP-1) receptors are present in human cardiac myocytes. Myocardial cells demonstrate insulin resistance in the setting of left ventricu- lar dysfunction. Exenatide is a synthetic GLP-1 mimetic mol- ecule with insulinotropic and insulinomimetic properties. It has a favorable pharmacokinetic profile over GLP-1. Insulin and GLP-1 increase glucose utilization by cardiac myocytes and improve cardiac contractility. We hypothesized that a single subcutaneous dose of exenatide would improve the left ventricular ejection fraction (LVEF) of patients with stable CHF and an LVEF 40%. Methods: We investigated the short-term efficacy and safety of a single dose of exenatide in patients with an LVEF 40%. A single 5-lg subcuta- neous dose of exenatide was given to 7 patients who were previously on standard heart failure medication for at least 6 weeks. These patients acted as their own controls. The primary end point was change in LVEF, and secondary end points were end-systolic volume index (ESVI), end-diastolic volume index (EDVI), peripheral blood sugar, and hemody- namic response (systolic blood pressure, diastolic blood pressure, heart rate, and mean arterial pressure). Base line LVEF assessment was done with a MUGA scan with stand- ard radioactive isotope dose and technique, and a repeat MUGA scan was done 1 hour after the administration of 5FIGURE (a) Coagulation laboratory abnormalities preprocedure. (b) lg of subcutaneous exenatide. This study was HIPAA com-Prevalence of ‘‘bleeding risk’’ medications. pliant. The hospital institutional review board approved Hospital Medicine 2011 Abstracts S9
  13. 13. Short-Term Effect of Exenatide (GLP-1 Mimetic) on LVEF 16 EFFECTIVENESS OF RAPID RESPONSE CALL 60 Minutes After CRITERIA: A SYSTEMATIC REVIEW AND Before Exenatide Exenatide (Mean 6 SEM), (Mean 6 SEM), P Value META-ANALYSIS n57 n 5 7. (2-Tailed)* Srinivas Bapoje, MD, MPH1, Philip Mehler, MD1, Richard Albert, MD1, Allison Sabel, MD, MPH, PhD1, Rinaldo Bellomo,LVEF (%) 33.86 Æ 3.1 35.86 Æ 2.9 0.013 MD2, Sumithra Chandrasekaran, MD3, Eugene Chu, MD,EDVI (mL/m2)a 63.2 Æ 4.7 70.4 Æ 3.5 0.212 FHM1; 1Denver Health Medical Center, Denver, CO; 2Univer-ESVI (mL/m2)b 41 Æ 3.9 44.2 Æ 3.85 0.381 sity of Colorado Denver School of Medicine, Denver, CO;Blood sugar (mg/dL) 121.29 Æ 10.6 82.43 Æ 7.5 0.021 3 Portland Medical Center, Portland, ORHeart rate (beats/min) 71.86 Æ 5.4 71.29 Æ 3.4 0.888SBP (mm Hg) 124.86 Æ 4.3 128.57 Æ 2.8 0.528 Background: In-hospital adverse events such as unplannedDBP (mm Hg) 73.43 Æ 4.3 76.71 Æ 2.0 0.276 intensive care unit transfers (UICUTs), cardiopulmonaryMAP (mm Hg) 88.2 Æ 4.2 93.014 Æ 2.7 0.207 arrests (CAs), and unanticipated mortality are frequently preceded by clinical instabilities. Rapid response systemsa EDVI was measured in only 6 of 7 patients; b ESVI was measured in only 6 of 7 patients. (RRSs) have been advocated to detect and intervene on * P values were calculated with the paired t test. LVEF, left ventricular ejection fraction; EDVI, end- these instabilities with the goal of preventing seriousdiastolic volume index; ESVI, end-systolic volume index; SBP, systolic blood pressure; DBP, diastolic adverse events. Although call criteria have been establishedblood pressure; MAP, mean arterial pressure. based on retrospective analyses of patients’ clinical courses preceding in-hospital adverse events, how well these crite- ria operate in practice is not known. Methods: We per-conducting this pilot, nonrandomized single-center study. formed a search of major scientific databases andSeven of 10 patients were able to complete the study. Data conference proceedings including Pubmed (MEDLINE),were analyzed using the paired t test and the independent t EMBASE, CINAHL, Cochrane Database, and Web oftest and are presented as mean Æ SEM. The P value was 2- Knowledge through March 1, 2010, for studies using keytailed, and a value 0.05 was considered statistically sig- words for RRSs. The quality of all studies was judged usingnificant. Statistical analysis was done using SPSS software. prespecified criteria. Two independent reviewers using aResults: Single-dose exenatide in immediate follow-up standardized data extraction form extracted call criteria asincreased the LVEF (from 33.86 Æ 3.051 to 35.86 Æ 2.915, well as event and call rates for each adverse outcome. InP 5 0.013) and decreased peripheral blood sugar (from the initial stages of data analysis, we pooled the individual121.29 Æ 10.58 to 82.43 Æ 7.521, P 5 0.021). There event and call rates from each study and used Bayesian sta-was no significant change in EDVI (from 63.2 Æ 4.7 to 70.4 tistics to determine the overall accuracy of call criteria byÆ 3.5, P 5 0.212), ESVI (from 41 Æ 3.9 to 44.2 Æ 3.85, adverse outcome. Results: We retrieved 2197 citationsP 5 0.381), heart rate (from 71.86 Æ 5.378 to 71.29 Æ based on a key word search. Of these, 13 studies repre-3.414, P 5 0.888), and mean arterial pressure (from 88.2 senting 416,797 patients matched our screening criteriaÆ 4.182 to 93.014 Æ 2.71, P 5 0.207). One patient had and were included. All 13 studies reported data for CAnausea, and 1 patient experienced hypoglycemia. There and unanticipated mortality. Only 7 of 13 studies reportedwere no adverse cardiovascular events. All 7 patients com- data in UICUT. RRS calling criteria demonstrated significantpleted the study. Conclusions: There was significant improve- heterogeneity. For example, respiratory rate criteria rangedment in LVEF 1 hour after administration of subcutaneous from highs of 30–36/minute to lows of 5–8/minute. Prelim-exenatide in patients with an LVEF 40% who were onstandard heart failure medications for at least 6-weeks. Nolarger prospective human clinical trial has been conducted so TABLE 1 Pooled Event and Call Rate by Adverse Outcomefar to elucidate the long-term effects of GLP-1 or exenatide onthe stable heart failure population. Exenatide has provided CAy (1) Event (2) Event Totalpromising results in our study, and it can be studied prospec- (1) Call 782 4496 5278tively in a larger population, which is technically feasible. (2) Call 3302 408,217 411,519 Total 4084 412,713 416,797Disclosures: Mortality (1) Event (2) Event TotalW. Y. Banday - none; B.G. Rueda - none; A. Herle - none; H. Lippes - Amylin (1) Call 294 6195 6489Pharmaeuticals; Eli Lilly Co; Novo Nordisk - speakers bureau (2) Call 422 405,759 406,181 Total 716 411,954 412,670 UICUT{ (1) Event (2) Event Total (1) Call 1027 25,429 26,456 (2) Call 469 197,959 198,428 Total 1496 223,388 224,884 y Cardiopulmonary arrest; {unplanned intensive care unit transfer.S10 Journal of Hospital Medicine Vol 6 / No 4 Supplement 2 / April 2011
  14. 14. TABLE 2 Rapid Response Criteria Operating Characteristics TABLE Demographics and LOS Sensitivity Specificity PPV* NPV** Prevalence Pre (n 5 557) Post (n 5 230)Event (%) (%) (%) (%) (%) Age* 49 (14) 51 (14)**CAy 41 98 4 100 2 Maley 369 (66) 152 (66)**Mortality 19 99 15 99 2 Hispanicy 178 (32) 91 (40)**UICUT{ 67 89 4 100 7 Blacky 92 (17) 37 (16)** Whitey 251 (45) 93 (40)**y Cardiopulmonary arrest; { unplanned intensive care unit transfer; * positive predictive value; Case Mix Index* 2.40 (2.47) 2.44 (1.86)**** negative predictive value. LOS, median (95% CI) 8.5 (7.9, 9.0) 6.9 (6.7, 8.2){ * Mean (SD); y n (%); ** P ! 0.05; { P 0.05.inary results of pooled events and call rates are shown inTable 1. Operating characteristics of call criteria are shownin Table 2. Conclusions: Only 41% of CA and 19% of by HMPs between May 2009 and October 2010. Exclu-unexpected deaths are detected by rapid response screen- sion criteria included patients receiving triple-lumen CVCs,ing criteria. Anywhere from 6.8 (mortality) to 25.6 (UICUT) CVCs placed while in the intensive care unit, and multiplecalls are needed to prevent 1 adverse in-hospital event placements of CVCs. We recorded demographics, thebecause of a low positive predictive value (PPV). The low Diagnostic Related Group–based Case Mix Index, medianPPV of calling criteria may help explain why nurses often length of stay (LOS) and complications, including centraldo not activate RRSs. Although attempts to improve the PPV line–associated bloodstream infection, pneumothorax, andby increasing the specificity of criteria would be limited by major bleeding (need for blood transfusion). Data from thethe concomitant decrease in sensitivity, screening a higher- 2 groups were compared using the Wilcoxon rank sumrisk subset of inpatients would improve the overall perform- test. A P 0.05 was considered significant. All analysesance of the call criteria. The poor real-world operating were performed using SAS Enterprise Guide 4.1. Results:characteristics of RRS calling criteria highlight the uncertain Two hundred and thirty single-lumen LT-CVCs were placedvalue of implementing RRSs to improve hospital outcomes. by HMPs in the 18-month intervention period (13/month)Disclosures:S. R. Bapoje - none; P. S. Mehler - none; R. K. compared with 557 by IR over the 2 years prior (23/Albert - none; A. Sabel - none; R. Bellomo - none; S. Chan- month). Patients in the 2 groups were well matched (seedrasekaran - none; E. S. Chu - none Table 1). Median LOS was reduced by 1.6 days. In the 230 line placements, accounting for 1863 line-days, no17 major complications (central line–associated bloodstreamHOSPITAL MEDICINE PROCEDURALISTS INSERTING infection, pneumothorax, and major bleeding) were observed. Conclusions: Hospital medicine physicians canLONG-TERM CENTRAL VENOUS CATHETERS be trained to safely and efficiently place LT-CVCs. WhenIMPROVES THROUGHPUT access to interventional radiology services is limited, LT-Srinivas Bapoje, MD, MPH, Rebecca Allyn, MD, Marshall CVC placement by hospital medicine proceduralistsMiller, MD, Sarah Stella, MD, Diana Mancini, MD, Angela improves throughput.Keniston, MSPH, Robert Allen, MD, Richard Albert, MD, Disclosures:Eugene Chu, MD, FHM; Denver Health Medical Center, Den- S. R. Bapoje - none; R. Allyn - none; M. Miller - none; S. Stella - none; D. Mancini -ver, CO none; K. Angela - none; R. Allen - none; R. K. Albert - none; E. S. Chu - noneBackground: Limited access to interventional radiology (IR)services may delay placement of long-term central venous 18catheters (LT-CVCs). This can impair hospital throughput IMPROVING PATIENT SAFETY DURING BEDSIDEand escalate costs by increasing length of stay. We devel- PROCEDURES: SUCCESSFULLY IMPLEMENTING THEoped and implemented a hospital medicine procedure ser- UNIVERSAL PROTOCOLvice to decrease delays in LT-CVC placements. Methods:We performed a pre–post study at our university-affiliated Jeffrey Barsuk, MD1, Helga Brake, PharmD2, Timothy Caprio,public safety net hospital. In spring 2009, a group of 6 MD1, Cynthia Barnard, MBA2, Denise Anderson, BSN2, Mark Wil-hospital medicine proceduralists (HMPs) underwent a pe- liams, MD1; 1Northwestern University Feinberg School of Medi-riod of formal training by IR attendings in the insertion of cine, Chicago, IL; 2Northwestern Memorial Hospital, Chicago, ILLT-CVCs (Hohn1) using the micropuncture technique and Background: The Universal Protocol was created by thedirected ultrasound guidance. HMPs started inserting LT- Joint Commission to eliminate the occurrence of wrong-site,CVCs in May 2009. We compared data from patients wrong-procedure, and wrong-person surgery. This studybetween 18 and 89 years of age who had single-lumen LT- evaluated the effects of an innovative reengineered processCVCs placed by IR between May 2007 and April 2009, for bedside procedures with an aim of improving compli-with those from patients in whom the LT-CVCs were placed ance with the Universal Protocol (specifically, time-out) and Hospital Medicine 2011 Abstracts S11

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