Transcript ACP Update in Hospital Medicine 2013-2014

ACP Update in Hospital Medicine
2013-2014
November 7, 2014
Kendall Rogers, MD CPE FACP SFHM
Associate Professor and Chief
Patrick Rendon, MD
Assistant Professor
Associate Program Director
Division of Hospital Medicine
University of New Mexico
Disclosures
• Employment with UNM
• No disclosures to report
Audience Composition
Subjects
• Liver disease
– Alcoholic Hepatitis
– Alcohol use
– Hepatic Encephalopathy
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VTE prophylaxis and treatment
Palliative Care and End of Life Issues
Delirium
CT Scanning
Issues in Perioperative Medicine
Transmission of Infection
Patient Experience
Format
• Case Based
• Tag Team
• Audience participation
*
ACP Update in Hospital Medicine
2014
• Roughly covers the period from September 30,
2013 to September 30, 2014
• Goal was to select articles that:
– May change your practice
– Definitely confirm your practice
– Introduce new ideas to your practice
Resources
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BMJ Evidence Updates
Uptodate: “What’s New in Hospital Medicine?”
The Hospitalist
Today’s Hospitalist
Journal of Hospital Medicine
SHM Update in Hospital Medicine
Division of Hospital Medicine Journal Club
ACP Journal Club
NEJM
CASE 1
• 42 yo Hispanic female presents to ED in
alcohol withdrawal with complaint of right
upper quadrant pain and found to have
hepatomegaly, a total bilirubin of 21, and PT
of 18 (DF = 44). No signs of infection or
bleeding at this time.
Do you..?
A. Start pentoxifylline
B. Start prednisolone
C. Start prednisolone and pentoxifylline
D. Discharge her from the Emergency Room
The Study
• Background: Prednisolone or Pentoxifylline (Trental) is
recommended for severe alcoholic hepatitis
• Purpose: to determine whether the addition of
pentoxifylline to prednisolone is more effective than
prednisolone alone in alcoholic hepatitis
• Study Design:
– Multicenter, double-blind, randomized trial (2007 – 2010)
– 270 patients (age 18-70) with severe (DF>32) biopsyproven alcoholic hepatitis
– 6 month follow-up
The Study
• 2 Groups, 28 days
– 40 mg of prednisolone once a day and 400 mg of
pentoxifylline 3 times a day (n=133)
– 40 mg of prednisolone and matching placebo (n=137) for 3
times a day
• Primary Outcome: 6 month survival
• Secondary outcomes:
– Development of hepatorenal syndrome
– Response to therapy (based on Lille model; score<0.45 =
response)
No
significant
difference
in causes of
death
Bottom Line
The addition of pentoxifylline with
prednisolone did not improve survival
compared with prednisolone alone.
Do you..?
A. Start pentoxifylline
B. Start prednisolone
C. Start prednisolone and pentoxifylline
D. Provide supportive care only
*
Case 1 - Continued
• Pt beats the odds and recovers from Etoh hepatitis but
continues drinking and develops liver cirrhosis over
next 3 years.
• Statistics on Etoh Abuse:
– 3rd leading cause of preventable death (4% all deaths)
– 2nd leading cause of liver cirrhosis
– <9% of all US alcoholics on approved medications
• Is there something more we could have done during
her last admission?
Study Design
• 12-week, double-blind, placebo-controlled,
randomized dose-ranging trial
• Subjects: 150 men and women with current
alcohol dependence at a single-site,
outpatient clinic
• Primary Outcomes: complete abstinence and
no heavy drinking
• Secondary: mood, sleep, and craving
• Complete abstinence rate went from 4.1% in
placebo group to 17% on gabapentin
Limitations
• Outpatient small single site study
• Future role for gabapentin on discharge?
Bottom Line
Gabapentin may be an effective
option for our alcoholic patients.
Case 1 - Continued
Our patient with ESLD now presents to the
hospital with worsening hepatic encephalopathy
and abdominal pain. She is found to have large
ascites, confusion, WBC 14, ammonia 125, and
INR 1.9.
She has had 3 admissions with similar
presentations in the last 6 months. She is
adherent to her lactulose.
Case 1 – Continued
Paracentesis is performed and she is found to
have SBP. She is started on antibiotics and q4hr
lactulose. After 3 days of being obtunded and
immobile she is now awake and cooperative but
still very confused. She is having more than 3
stools a day.
What would change her regimen?
A. Continue current regimen and start delirium
prevention measures
B. Lactulose enemas Q2hr
C. Rifaximin PO BID
D. Lactulose Q1hr with NG tube, titrate to 8 stools
daily as she is “not responding”
Study Design
• Design: prospective double-blind randomized
controlled trial
• Intervention: 120 patients with overt HE were
randomized into group A (lactulose plus
rifaximin) and group B(lactulose plus placebo)
• Primary End Point: complete reversal of HE
• Secondary End Points: mortality and hospital
stay.
Results
• Compared to lactulose alone, the addition of
rifaximin resulted in:
– Increase in reversal of HE from 44% to 76%
– Hospital LOS decrease from 8.2 to 5.8
• Decrease in mortality from 49.1% to 23.8%
Bottom Line
Rifaximin in addition to lactulose results in
higher rates of complete resolution of hepatic
encephalopathy and dramatically cuts
inpatient mortality.
What would change her regimen?
A. Continue current regimen and start delirium
prevention measures
B. Lactulose enemas Q2hr
C. Rifaximin PO BID
D. Lactulose Q1hr with NG tube, titrate to 8 stools
daily as she is “not responding”
*
Case 1 -Continued
• Pt responds to rifaximin and begins to
improve, she is now alert and able to converse
with family, however her condition continues
to worsen with refractory ascites and
worsening liver failure. She is not interested
in a liver transplant. She complains of leg pain
and an ultrasound shows a LE DVT.
She does have decreased mobility, should
she have been on VTE prophylaxis?
A. Yes, ALL patients should be on VTE prophylaxis
B. Yes, she is lower risk for bleeding due to an INR of <2
(currently 1.9) and still has risk of developing a VTE
C. No, we should never use VTE prophylaxis in patients
with liver disease
D. You know, that would be a great question for my
medical student, I’ll have her “look it up” and get back
to you
The Study
• Background: Incidence of VTE in chronic liver
disease has been reported to be 0.5% to 6.3%
• The hypothesis that CLD patients are “autoanticoagulated” and therefore protected
against VTE has not been proven
• Purpose: to describe the use of VTE
prophylaxis in CLD patients
The Study
• Study Design:
– Retrospective chart review of 410 patients with INR
>/= 1.4
– Pharmacologic, mechanical prophylaxis, both, none
• Primary Outcomes:
–
–
–
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Initiation and type of VTE prophylaxis
Incidence of VTE
In- hospital mortality
Bleeding events
Results
55% of patients (225/410) received any VTE prophylaxis
Less VTE prophylaxis in patients with INR >2
Results
• Incidence of in-hospital VTE was 3 patients (0.7%)
• Higher mortality rates in patients receiving
prophylaxis vs those receiving none (p<0.001)
• 15 bleeding events occurred (3.7%)
– Most on mechanical or no prophylaxis with INR>2
– No increase in bleeding in chronic liver disease
patients with INR </= 2
Bottom Line
The use of VTE prophylaxis (mechanical and
pharmacologic) remains suboptimal
She does have decreased mobility, should
she have been on VTE prophylaxis?
A. Yes, ALL patients should be on VTE prophylaxis
B. Yes, she is lower risk for bleeding due to an INR of <2
and still has risk of developing a VTE
C. No, we should never use VTE prophylaxis in patients
with liver disease
D. You know, that would be a great question for my
medical student, I’ll have her “look it up” and get back
to you
Case 1 - Continued
• Remember that VTE?
• Is liver disease a contraindication to
coumadin?
Quick Take
Study Design
• Study Design: Analysis of existing VA data of
>1700 patients with chronic liver disease on
Coumadin
• Purpose: To determine predictors of
anticoagulation control and major
hemorrhagic events
Results
• Patients with any liver disease had increased
incidence of major hemorrhage
• Statistical analysis revealed creatinine and
albumin were the most meaningful predictors
of bleeding risk
Bottom Line
• Is liver disease a contraindication to
coumadin? No, just depends on the score as
to whether risk outweighs the benefit
*
Case 1 – Continued
• The patient continues to worsen with
creatinine above 2.5 and given the overall
progression of illness she does not start
coumadin and Palliative Care is consulted.
The patient and family elect for comfort care
and the patient is sent home with hospice.
• Should palliative been involved sooner in her
case?
A Sentinel Hospitalization:
a hospitalization in the disease course that
heralds a need to reassess prognosis, treatment
options and intensity, and goals of care.
• Authors suggest that its recognition provides
an important opportunity for hospitalists to
actively integrate palliative care into patients’
chronic disease management programs, with
inputs from patients, their families, their
primary physicians and subspecialists, as well
as palliative care specialists.
Bottom Line
Hospitalists should recognize sentinel
hospitalizations and take an active role in
re-evaluating patient care and goals.
Survey Design
• Telephone interviews conducted with
nationally representative sample of ~2000
Americans
NM Physician Aid in Dying
• "This court cannot envision a right more
fundamental, more private or more integral to
the liberty, safety and happiness of a New
Mexican than the right of a competent,
terminally ill patient to choose aid in dying"
Many Issues Unresolved
• Bernalillo or NM State?
• State Court Challenge
• UNM Stance: “Given the lack of judicial clarity
and legislative definition, the UNMH Medical
Staff does not provide “physician aid in dying”
services, as presented in Morris v. New Mexico
(The “Nash Decision”)”
Bottom Line
Patient views on death and end of life care are
varied and changing.
NM Physicians should be aware of the new legal
conditions that exist in New Mexico.
Our Recommendations:
• Stop
– Using combination prednisolone/pentoxifylline for alcoholic hepatitis
• Start
– Considering the use of gabapentin for alcoholics
– Using Rifaximin for refractory HE in combination with lactulose
– Using [any] VTE prophylaxis more often for liver patients with INR <2
and high risk VTE (benefit>risk)
– Using coumadin in liver patients with creatinine <2 and Albumin >2.5
if benefit > risk
– Consulting or discussing palliative care during ‘sentinel hospitalization’
– Discussing end of life issues with patients considering age and
ethnicity differences
– Coming up with your response to patient request for assisted suicide
*
Case 2
52 M with h/o DM and HTN presents to the ER
with flank pain radiating to the groin. Urinalysis
reveals small blood in the urine. It is suspected
that the patient has a kidney stone.
What is the best next step in
management?
A. Order a non-contrasted CT abdomen to confirm the
diagnosis
B. The Emergency Room physician should perform a
bedside ultrasound and order follow up testing if
needed
C. Order an ultrasound of the abdomen via Radiology
D. Admit the patient since you know that he is going to
“come in anyway”
The Study
• The use of CT for the diagnosis of suspected renal stones is
increased by a factor of 10 or the past 15 years in the US
• No evidence has shown that increased CT use is associated
with improved patient outcomes
• Study Design: Randomized Control Trial (2011-2013)
• 2759 patients (age 18-76) with suspected nephrolithiasis:
– Point-of-care ultrasound (908)
– Radiology ultrasonography (893)
– CT abdomen/pelvis (958)
The Study
• Primary Outcomes:
– 30-day incidence of high-risk diagnoses with
complications
– 6 month cumulative radiation exposure
• Secondary outcomes:
– Serious adverse events
– Hospitalizations after discharge from ER
– Diagnostic accuracy for nephrolithiasis
Results
• Patients in the ultrasonography groups
more likely than CT group to undergo
additional diagnostic testing during the
initial emergency room visit
• Ultrasonography: lower sensitivity and
higher specificity vs CT
Serious adverse
events: untoward
medical occurrences
that resulted in
death, were lifethreatening, required
hospitalization,
caused persistent or
clinically significant
disability
What is the next best step in
management?
A. Order a non-contrasted CT abdomen to confirm the
diagnosis
B. Order an ultrasound of the abdomen in Radiology in order
to rule out additional dangerous causes
C. The Emergency Room physician should perform a
bedside ultrasound and order follow up testing if needed
D. Admit the patient since you know that he is going to
“come in anyway”
Bottom Line
Ultrasonography should be used as the initial
diagnostic imaging test, with further imaging
obtained based on clinical judgment
Case 2 - Continued
The patient is admitted due to requirement of IV
medications for pain control as he is passing his
stone. The intern pre-rounds on him the next
day only to find that the patient is delirious.
There are no cranial nerve or other neurologic
deficits. He presents his plan on rounds, stating
that on he “would like to obtain a head CT to
rule out organic causes.” Should this test be
performed?
The Study
• Delirium develops in up to 56% of patients during hospitalization
Guidelines
“Head imaging is recommended for patients with acute neurologic
deficit, recent head trauma, or recent fall as well as in cases where the
cause is unidentified after appropriate medical testing or where
delirium continues despite treatment”
• Purpose: To determine evaluation strategies for patients who do
not meet the above guideline
• Study Design: Retrospective observational cohort study (medical
record review)
The Study
• Intervention:
– Studies performed for an indication of delirium,
altered mental status, confusion, encephalopathy,
somnolence, or unresponsiveness in patients
admitted for greater than 24 hours
• Primary Outcome:
– “Positive” head CT: an intracranial process that could
explain delirium (e.g intracranial hemorrhage or
stroke).
Only 7% of CTs identified an acute
intracranial process
Bottom line
• Head imaging is unnecessary in the majority
of cases of delirium and routine use of head
CT in the evaluation of delirium in hospitalized
patients is likely to cost more rather than
provide patient benefit
Case 2 - Continued
• You dissuade the intern from ordering a CT
Scan. Delirium resolved once narcotics were
discontinued. Patient improves and is
discharged home.
*
Case 2 - Continued
• Pt is an avid balloonist and one year later the
patient presents to the ED after an accident
• Pt suffers a traumatic hip fracture, due to the
patient having DM and HTN (on lisinopril),
medicine is called to ‘clear the patient for
surgery’
• You pull out your tattered but handy 2007 ACC
pre-op eval algorithm, hasn’t anyone updated
this yet?
Bottom Line
New pre-operative algorithm exists that
incorporates a risk calculator and overall
simplifies evaluations.
Case 2 - Continued
• Pt is deemed low risk for surgery with
recommendations to proceed. But what
about his medication recommendations?
*
Beta-blockers
• Pre-operatively
• Peri-operatively
• Post-operatively
So at the end of the day…
Recommendation
Class of
Recommendation
Level of
Evidence
Continue beta blockers in patients who are on
beta blockers chronically
I
B
Beta blocker therapy should not be started on
the day of surgery
III: Harm
B
ACE Inhibitors and Angiotensin
Receptor Blockers
Recommendation
Class of
Recommendation
Level of
Evidence
Continuation of ACE inhibitors or ARBs
peri-operatively is reasonable
IIa
B
If ACE inhibitors or ARBs are held
before surgery, it is reasonable to
restart as soon as clinically feasible
postoperatively
IIa
C
Case 2 - Continued
• The patient is scheduled for surgery the next
day and his lisinopril is continued.
• The next day the patient complains of terrible
sleep in the hospital stating the nurses woke
him up ‘a hundred times.’ He is pretty stable
so you wonder what evidence there is to
check vitals overnight?
The Study
• Background: Disruptions are prevalent among patients
and are associated several negative health outcomes,
including elevated blood pressure and delirium
• Study design: prospective cohort study with calculation
of MEWS (Modified Early Warning Score)
• 54,096 patients
• Nighttime: 11 PM to 6 AM
Results
• The adverse event rate increased with higher
evening MEWS
• Overnight vital signs are collected frequently
among the ward patients regardless of their
risk of clinical deterioration
Bottom Line
The study suggests that nighttime frequency of
vital sign monitoring for low-risk medical
inpatients might be reduced
*
Case 2 - Continued
• Night time vitals are adjusted, but
unfortunately the surgery is scheduled and
cancelled on 2 subsequent days (told more
urgent cases came in), on the 4th day of
admission the pt undergoes hip repair.
• On day 10 patient develops a DVT in affected
leg though he has been on VTE prophylaxis.
Study Design
• Design: prospectively collected data on 202
trauma and gen surg patients
Results
• The overall incidence of DVT was 15.8%.
• 58.9% of patients missed at least 1 dose of enoxaparin
• The DVTs occurred in 23.5% of patients who missed at
least 1 dose and in 4.8% of patients who did not (P <
.01)
• Age 50 years or older and interrupted enoxaparin
therapy as the only independent risk factors for DVT
formation.
• The DVT rate did not differ between trauma and
general surgery populations or in patients receiving
once-daily vs twice-daily dosing regimens.
Bottom Line
Missed doses of LMWH for high risk patients
causes harm and should be avoided.
*
Case 2 - Continued
• Pt is started on VTE treatment, is discharged to PT
and does well.
• Drs. Rogers and Rendon start a quality project to
decrease missed doses of LMWH in surgical
patients and they improve communication and
decrease missed dose rates at UNMH
• They win a prestigious award in the hospital for
their efforts.
How should they accept this award from the
CEO after a long day seeing patients? (assuming
they don’t want to pass an infection to him)
A.
B.
C.
D.
Shake Hands with CEO
High Five CEO
Fist Bump CEO
Hug CEO
Does the Fist Bump Really Prevent
Transmission of Pathogens?
Main Points
• Approximately 80% of individuals retained some
disease causing bacteria after washing
• Used agar plates to measure amount of bacteria
acquired after handshake and fist bump
• Total colonization of the palmar surface of the hand
was 4x greater than that of the fist (187.5 vs 42.5)
• Bottom line: fist bumps should be performed with all
CEOs
Our Recommendations:
• Start
– Using ultrasound instead of CT for the initial evaluation of nephrolithiasis
– Using the new 2014 ACC guidelines in your operative risk assessment and
bookmark a pre-op calculator
– Continue betablockers and ACE-Is if patient currently on them (and do not
start betablocker on day of surgery)
• Stop
– Ordering CT scans in the routine workup of delirium
– Missing doses of VTE prophylaxis in high risk patients
– Waking up low risk patients at night to perform vitals
• Definitely Start
– Fist bumping with your colleagues (and CEOs) in and out of the hospital to
decrease transmission of pathogens
Questions
Thank You!