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Infections in infants: An update
Converge 2021 session
Febrile Infant Update
Presenter
Russell J. McCulloh, MD
Session summary
Infections in infants aged younger than 90 days have been the subject of intense study in pediatric hospital medicine for many years. With the guidance of our talented presenter Dr. Russell McCulloh of Children’s Hospital & Medical Center in Omaha, Neb., the audience explored the historical perspective and evolution of this scientific question, including successes, special situations, newer screening tests, and description of cutting-edge scoring tools and platforms.
The challenge – Tens of thousands of infants present for care in the setting of fever each year. We know that our physical exam and history-taking skills are unlikely to be helpful in risk stratification. We have been guided by the desire to separate serious bacterial infection (SBI: bone infection, meningitis, pneumonia, urinary tract infection, bacteremia, enteritis) from invasive bacterial infection (IBI: meningitis and bacteremia). Data has shown that no test is 100% sensitive or specific, therefore we have to balance risk of disease to cost and invasiveness of tests. Important questions include whether to test and how to stratify by age, who to admit, and who to provide antibiotics.
The wins and exceptions – Fortunately, the early Boston, Philadelphia, and Rochester criteria set the stage for safely reducing testing. The current American College of Emergency Physicians guidelines for infants aged 29-90 days allows for lumbar puncture to be optional knowing that a look back using prior criteria identified no cases of meningitis in the low risk group. Similarly, in low-risk infants aged less that 29 days in nearly 4,000 cases there were just 2 infants with meningitis. Universal screening of moms for Group B Streptococcus with delivery of antibiotics in appropriate cases has dramatically decreased incidence of SBI. The Hib and pneumovax vaccines have likewise decreased incidence of SBI. Exceptions persist, including knowledge that infants with herpes simplex virus disease will not have fever in 50% of cases and that risk of HSV transmission is highest (25%-60% transmission) in mothers with primary disease. Given risk of HSV CNS disease after 1 week of age, in any high-risk infant less than 21 days, the mantra remains to test and treat.
The cutting edge – Thanks to ongoing research, we now have the PECARN and REVISE study groups to further aid decision-making. With PECARN we know that SBI in infants is extremely unlikely (negative predictive value, 99.7%) with a negative urinalysis , absolute neutrophil count less than 4,090, and procalcitonin less than 1.71. REVISE has revealed that infants with positive viral testing are unlikely to have SBI (7%-12%), particularly with influenza and RSV disease. Procalcitonin has also recently been shown to be an effective tool to rule out disease with the highest negative predictive value among available inflammatory markers. The just-published Aronson rule identifies a scoring system for IBI (using age less than 21 days/1pt; temp 38-38.4° C/2pt; >38.5° C/4pt; abnormal urinalysis/3pt; and absolute neutrophil count >5185/2pt) where any score greater than2 provides a sensitivity of 98.8% and NPV in validation studies of 99.4%. Likewise, multiplex polymerase chain reaction testing of spinal fluid has allowed for additional insight in pretreated cases and has helped us to remove antibiotic treatment from cases where parechovirus and enterovirus are positive because of the low risk for concomitant bacterial meningitis. As we await the release of revised national American Academy of Pediatrics guidelines, it is safe to say great progress has been made in the care of young febrile infants with shorter length of stay and fewer tests for all.
Key takeaways
- Numerous screening tests, rules, and scoring tools have been created to improve identification of infants with IBI, a low-frequency, high-morbidity event. The most recent with negative predictive values of 99.7% and 99.4% are the PECARN and Aronson scoring tools.
- Recent studies of the febrile infant population indicate that the odds of UTI or bacteremia in infants with respiratory symptoms is low, particularly for RSV and influenza.
- Among newer tests developed, a negative procalcitonin has the highest negative predictive value.
- Viral pathogens identified on cerebrospinal fluid molecular testing can be helpful in pretreated cases and indicative of low likelihood of bacterial meningitis allowing for observation off of antibiotics.
Dr. King is a hospitalist, associate director for medical education and associate program director for the pediatrics residency program at Children’s Minnesota in Minneapolis. She has shared some of her resident teaching, presentation skills, and peer-coaching work on a national level.
Converge 2021 session
Febrile Infant Update
Presenter
Russell J. McCulloh, MD
Session summary
Infections in infants aged younger than 90 days have been the subject of intense study in pediatric hospital medicine for many years. With the guidance of our talented presenter Dr. Russell McCulloh of Children’s Hospital & Medical Center in Omaha, Neb., the audience explored the historical perspective and evolution of this scientific question, including successes, special situations, newer screening tests, and description of cutting-edge scoring tools and platforms.
The challenge – Tens of thousands of infants present for care in the setting of fever each year. We know that our physical exam and history-taking skills are unlikely to be helpful in risk stratification. We have been guided by the desire to separate serious bacterial infection (SBI: bone infection, meningitis, pneumonia, urinary tract infection, bacteremia, enteritis) from invasive bacterial infection (IBI: meningitis and bacteremia). Data has shown that no test is 100% sensitive or specific, therefore we have to balance risk of disease to cost and invasiveness of tests. Important questions include whether to test and how to stratify by age, who to admit, and who to provide antibiotics.
The wins and exceptions – Fortunately, the early Boston, Philadelphia, and Rochester criteria set the stage for safely reducing testing. The current American College of Emergency Physicians guidelines for infants aged 29-90 days allows for lumbar puncture to be optional knowing that a look back using prior criteria identified no cases of meningitis in the low risk group. Similarly, in low-risk infants aged less that 29 days in nearly 4,000 cases there were just 2 infants with meningitis. Universal screening of moms for Group B Streptococcus with delivery of antibiotics in appropriate cases has dramatically decreased incidence of SBI. The Hib and pneumovax vaccines have likewise decreased incidence of SBI. Exceptions persist, including knowledge that infants with herpes simplex virus disease will not have fever in 50% of cases and that risk of HSV transmission is highest (25%-60% transmission) in mothers with primary disease. Given risk of HSV CNS disease after 1 week of age, in any high-risk infant less than 21 days, the mantra remains to test and treat.
The cutting edge – Thanks to ongoing research, we now have the PECARN and REVISE study groups to further aid decision-making. With PECARN we know that SBI in infants is extremely unlikely (negative predictive value, 99.7%) with a negative urinalysis , absolute neutrophil count less than 4,090, and procalcitonin less than 1.71. REVISE has revealed that infants with positive viral testing are unlikely to have SBI (7%-12%), particularly with influenza and RSV disease. Procalcitonin has also recently been shown to be an effective tool to rule out disease with the highest negative predictive value among available inflammatory markers. The just-published Aronson rule identifies a scoring system for IBI (using age less than 21 days/1pt; temp 38-38.4° C/2pt; >38.5° C/4pt; abnormal urinalysis/3pt; and absolute neutrophil count >5185/2pt) where any score greater than2 provides a sensitivity of 98.8% and NPV in validation studies of 99.4%. Likewise, multiplex polymerase chain reaction testing of spinal fluid has allowed for additional insight in pretreated cases and has helped us to remove antibiotic treatment from cases where parechovirus and enterovirus are positive because of the low risk for concomitant bacterial meningitis. As we await the release of revised national American Academy of Pediatrics guidelines, it is safe to say great progress has been made in the care of young febrile infants with shorter length of stay and fewer tests for all.
Key takeaways
- Numerous screening tests, rules, and scoring tools have been created to improve identification of infants with IBI, a low-frequency, high-morbidity event. The most recent with negative predictive values of 99.7% and 99.4% are the PECARN and Aronson scoring tools.
- Recent studies of the febrile infant population indicate that the odds of UTI or bacteremia in infants with respiratory symptoms is low, particularly for RSV and influenza.
- Among newer tests developed, a negative procalcitonin has the highest negative predictive value.
- Viral pathogens identified on cerebrospinal fluid molecular testing can be helpful in pretreated cases and indicative of low likelihood of bacterial meningitis allowing for observation off of antibiotics.
Dr. King is a hospitalist, associate director for medical education and associate program director for the pediatrics residency program at Children’s Minnesota in Minneapolis. She has shared some of her resident teaching, presentation skills, and peer-coaching work on a national level.
Converge 2021 session
Febrile Infant Update
Presenter
Russell J. McCulloh, MD
Session summary
Infections in infants aged younger than 90 days have been the subject of intense study in pediatric hospital medicine for many years. With the guidance of our talented presenter Dr. Russell McCulloh of Children’s Hospital & Medical Center in Omaha, Neb., the audience explored the historical perspective and evolution of this scientific question, including successes, special situations, newer screening tests, and description of cutting-edge scoring tools and platforms.
The challenge – Tens of thousands of infants present for care in the setting of fever each year. We know that our physical exam and history-taking skills are unlikely to be helpful in risk stratification. We have been guided by the desire to separate serious bacterial infection (SBI: bone infection, meningitis, pneumonia, urinary tract infection, bacteremia, enteritis) from invasive bacterial infection (IBI: meningitis and bacteremia). Data has shown that no test is 100% sensitive or specific, therefore we have to balance risk of disease to cost and invasiveness of tests. Important questions include whether to test and how to stratify by age, who to admit, and who to provide antibiotics.
The wins and exceptions – Fortunately, the early Boston, Philadelphia, and Rochester criteria set the stage for safely reducing testing. The current American College of Emergency Physicians guidelines for infants aged 29-90 days allows for lumbar puncture to be optional knowing that a look back using prior criteria identified no cases of meningitis in the low risk group. Similarly, in low-risk infants aged less that 29 days in nearly 4,000 cases there were just 2 infants with meningitis. Universal screening of moms for Group B Streptococcus with delivery of antibiotics in appropriate cases has dramatically decreased incidence of SBI. The Hib and pneumovax vaccines have likewise decreased incidence of SBI. Exceptions persist, including knowledge that infants with herpes simplex virus disease will not have fever in 50% of cases and that risk of HSV transmission is highest (25%-60% transmission) in mothers with primary disease. Given risk of HSV CNS disease after 1 week of age, in any high-risk infant less than 21 days, the mantra remains to test and treat.
The cutting edge – Thanks to ongoing research, we now have the PECARN and REVISE study groups to further aid decision-making. With PECARN we know that SBI in infants is extremely unlikely (negative predictive value, 99.7%) with a negative urinalysis , absolute neutrophil count less than 4,090, and procalcitonin less than 1.71. REVISE has revealed that infants with positive viral testing are unlikely to have SBI (7%-12%), particularly with influenza and RSV disease. Procalcitonin has also recently been shown to be an effective tool to rule out disease with the highest negative predictive value among available inflammatory markers. The just-published Aronson rule identifies a scoring system for IBI (using age less than 21 days/1pt; temp 38-38.4° C/2pt; >38.5° C/4pt; abnormal urinalysis/3pt; and absolute neutrophil count >5185/2pt) where any score greater than2 provides a sensitivity of 98.8% and NPV in validation studies of 99.4%. Likewise, multiplex polymerase chain reaction testing of spinal fluid has allowed for additional insight in pretreated cases and has helped us to remove antibiotic treatment from cases where parechovirus and enterovirus are positive because of the low risk for concomitant bacterial meningitis. As we await the release of revised national American Academy of Pediatrics guidelines, it is safe to say great progress has been made in the care of young febrile infants with shorter length of stay and fewer tests for all.
Key takeaways
- Numerous screening tests, rules, and scoring tools have been created to improve identification of infants with IBI, a low-frequency, high-morbidity event. The most recent with negative predictive values of 99.7% and 99.4% are the PECARN and Aronson scoring tools.
- Recent studies of the febrile infant population indicate that the odds of UTI or bacteremia in infants with respiratory symptoms is low, particularly for RSV and influenza.
- Among newer tests developed, a negative procalcitonin has the highest negative predictive value.
- Viral pathogens identified on cerebrospinal fluid molecular testing can be helpful in pretreated cases and indicative of low likelihood of bacterial meningitis allowing for observation off of antibiotics.
Dr. King is a hospitalist, associate director for medical education and associate program director for the pediatrics residency program at Children’s Minnesota in Minneapolis. She has shared some of her resident teaching, presentation skills, and peer-coaching work on a national level.
FROM SHM CONVERGE 2021
Improving racial and gender equity in pediatric HM programs
Converge 2021 session
Racial and Gender Equity in Your PHM Program
Presenters
Jorge Ganem, MD, FAAP, and Vanessa N. Durand, DO, FAAP
Session summary
Dr. Ganem, associate professor of pediatrics at the University of Texas at Austin and director of pediatric hospital medicine at Dell Children’s Medical Center, and Dr. Durand, assistant professor of pediatrics at Drexel University and pediatric hospitalist at St. Christopher’s Hospital for Children, Philadelphia, presented an engaging session regarding gender equity in the workplace during SHM Converge 2021.
Dr. Ganem and Dr. Durand first presented data to illustrate the gender equity problem. They touched on the mental burden underrepresented minorities face professionally. Dr. Ganem and Dr. Durand discussed cognitive biases, defined allyship, sponsorship, and mentorship and shared how to distinguish between the three. They concluded their session with concrete ways to narrow gaps in equity in hospital medicine programs.
The highlights of this session included evidence-based “best-practices” that pediatric hospital medicine divisions can adopt. One important theme was regarding metrics. Dr. Ganem and Dr. Durand shared how important it is to evaluate divisions for pay and diversity gaps. Armed with these data, programs can be more effective in developing solutions. Some solutions provided by the presenters included “blind” interviews where traditional “cognitive metrics” (i.e., board scores) are not shared with interviewers to minimize anchoring and confirmation biases. Instead, interviewers should focus on the experiences and attributes of the job that the applicant can hopefully embody. This could be accomplished using a holistic review tool from the Association of American Medical Colleges.
One of the most powerful ideas shared in this session was a quote from a Harvard student shown in a video regarding bias and racism where he said, “Nothing in all the world is more dangerous than sincere ignorance and conscious stupidity.” Changes will only happen if we make them happen.
Key takeaways
- Racial and gender equity are problems that are undeniable, even in pediatrics.
- Be wary of conscious biases and the mental burden placed unfairly on underrepresented minorities in your institution.
- Becoming an amplifier, a sponsor, or a champion are ways to make a small individual difference.
- Measure your program’s data and commit to making change using evidence-based actions and assessments aimed at decreasing bias and increasing equity.
References
Association of American Medical Colleges. Holistic Review. 2021. www.aamc.org/services/member-capacity-building/holistic-review.
Dr. Singh is a board-certified pediatric hospitalist at Stanford University and Lucile Packard Children’s Hospital Stanford, both in Palo Alto, Calif. He is a native Texan living in the San Francisco Bay area with his wife and two young boys. His nonclinical passions include bedside communication and inpatient health care information technology.
Converge 2021 session
Racial and Gender Equity in Your PHM Program
Presenters
Jorge Ganem, MD, FAAP, and Vanessa N. Durand, DO, FAAP
Session summary
Dr. Ganem, associate professor of pediatrics at the University of Texas at Austin and director of pediatric hospital medicine at Dell Children’s Medical Center, and Dr. Durand, assistant professor of pediatrics at Drexel University and pediatric hospitalist at St. Christopher’s Hospital for Children, Philadelphia, presented an engaging session regarding gender equity in the workplace during SHM Converge 2021.
Dr. Ganem and Dr. Durand first presented data to illustrate the gender equity problem. They touched on the mental burden underrepresented minorities face professionally. Dr. Ganem and Dr. Durand discussed cognitive biases, defined allyship, sponsorship, and mentorship and shared how to distinguish between the three. They concluded their session with concrete ways to narrow gaps in equity in hospital medicine programs.
The highlights of this session included evidence-based “best-practices” that pediatric hospital medicine divisions can adopt. One important theme was regarding metrics. Dr. Ganem and Dr. Durand shared how important it is to evaluate divisions for pay and diversity gaps. Armed with these data, programs can be more effective in developing solutions. Some solutions provided by the presenters included “blind” interviews where traditional “cognitive metrics” (i.e., board scores) are not shared with interviewers to minimize anchoring and confirmation biases. Instead, interviewers should focus on the experiences and attributes of the job that the applicant can hopefully embody. This could be accomplished using a holistic review tool from the Association of American Medical Colleges.
One of the most powerful ideas shared in this session was a quote from a Harvard student shown in a video regarding bias and racism where he said, “Nothing in all the world is more dangerous than sincere ignorance and conscious stupidity.” Changes will only happen if we make them happen.
Key takeaways
- Racial and gender equity are problems that are undeniable, even in pediatrics.
- Be wary of conscious biases and the mental burden placed unfairly on underrepresented minorities in your institution.
- Becoming an amplifier, a sponsor, or a champion are ways to make a small individual difference.
- Measure your program’s data and commit to making change using evidence-based actions and assessments aimed at decreasing bias and increasing equity.
References
Association of American Medical Colleges. Holistic Review. 2021. www.aamc.org/services/member-capacity-building/holistic-review.
Dr. Singh is a board-certified pediatric hospitalist at Stanford University and Lucile Packard Children’s Hospital Stanford, both in Palo Alto, Calif. He is a native Texan living in the San Francisco Bay area with his wife and two young boys. His nonclinical passions include bedside communication and inpatient health care information technology.
Converge 2021 session
Racial and Gender Equity in Your PHM Program
Presenters
Jorge Ganem, MD, FAAP, and Vanessa N. Durand, DO, FAAP
Session summary
Dr. Ganem, associate professor of pediatrics at the University of Texas at Austin and director of pediatric hospital medicine at Dell Children’s Medical Center, and Dr. Durand, assistant professor of pediatrics at Drexel University and pediatric hospitalist at St. Christopher’s Hospital for Children, Philadelphia, presented an engaging session regarding gender equity in the workplace during SHM Converge 2021.
Dr. Ganem and Dr. Durand first presented data to illustrate the gender equity problem. They touched on the mental burden underrepresented minorities face professionally. Dr. Ganem and Dr. Durand discussed cognitive biases, defined allyship, sponsorship, and mentorship and shared how to distinguish between the three. They concluded their session with concrete ways to narrow gaps in equity in hospital medicine programs.
The highlights of this session included evidence-based “best-practices” that pediatric hospital medicine divisions can adopt. One important theme was regarding metrics. Dr. Ganem and Dr. Durand shared how important it is to evaluate divisions for pay and diversity gaps. Armed with these data, programs can be more effective in developing solutions. Some solutions provided by the presenters included “blind” interviews where traditional “cognitive metrics” (i.e., board scores) are not shared with interviewers to minimize anchoring and confirmation biases. Instead, interviewers should focus on the experiences and attributes of the job that the applicant can hopefully embody. This could be accomplished using a holistic review tool from the Association of American Medical Colleges.
One of the most powerful ideas shared in this session was a quote from a Harvard student shown in a video regarding bias and racism where he said, “Nothing in all the world is more dangerous than sincere ignorance and conscious stupidity.” Changes will only happen if we make them happen.
Key takeaways
- Racial and gender equity are problems that are undeniable, even in pediatrics.
- Be wary of conscious biases and the mental burden placed unfairly on underrepresented minorities in your institution.
- Becoming an amplifier, a sponsor, or a champion are ways to make a small individual difference.
- Measure your program’s data and commit to making change using evidence-based actions and assessments aimed at decreasing bias and increasing equity.
References
Association of American Medical Colleges. Holistic Review. 2021. www.aamc.org/services/member-capacity-building/holistic-review.
Dr. Singh is a board-certified pediatric hospitalist at Stanford University and Lucile Packard Children’s Hospital Stanford, both in Palo Alto, Calif. He is a native Texan living in the San Francisco Bay area with his wife and two young boys. His nonclinical passions include bedside communication and inpatient health care information technology.
FROM SHM CONVERGE 2021
A primer on COVID-19 in hospitalized children
Converge 2021 session
COVID-19 in Children
Presenter
Philip Zachariah, MD, MPH
Session summary
Children have been less severely affected by COVID-19 than adults (hospitalization rates around 5%). However, once hospitalized, ICU admission rates in children have been similar to adults, around 30%. Mortality has been 1%-2%. Risk factors for more severe acute SARS CoV-2 infections include age extremes, minorities, obesity, medical complexity, immunocompromised pediatric patients, and asthma.
Multisystem-inflammatory-syndrome-in-children (MIS-C) continues to present among persistently febrile children with multisystem findings and the history of acute COVID-19 infection in prior 3-6 weeks. There seems to be a link between the immunological defects in type I and II interferon production, as autoantibodies to type I interferon may predispose to severe disease. Dr. Zachariah of Columbia University Medical Center in New York, discussed the recent study exploring intravenous immunoglobulin (IVIG) alone versus IVIG and steroids as treatment options for MIS-C. So far, the failure rates in IVIG-alone group were higher (51%) versus IVIG and steroids (9%).
Besides MIS-C, many neurological manifestations of COVID-19 have been seen among children including GBS, seizures, encephalitis, cranial neuropathies, and demyelination cases. Diabetic ketoacidosis (DKA), secondary hemophagocytic lymphohistiocytosis (HLH), and pseudo-appendicitis have all been described in the literature, however, larger case control studied are needed.
In children, clinical vascular thrombotic events (VTEs) are rare. Anticoagulant thromboprophylaxis is suggested for hospitalized patients with COVID-19–related illness, whose D-dimer is >5 times upper limit of normal values and who have one or more non–COVID-19 related clinical risk factors for hospital acquired VTEs.
Key takeaways
- Once hospitalized, the ICU admission rates for children have been similar to those in adults, ~30%.
- MIS-C is showing lower failure rates if treated with IVIG and steroids, and most reliable laboratory findings should be elevated C-reactive protein, lymphopenia, and elevated brain natriuretic peptide.
- In hospitalized children with COVID-19, clinical VTEs are rare.
Dr. Giordano is an associate professor of pediatrics at Columbia University Medical Center in New York. She is a pediatric hospitalist with expertise in pediatric surgical comanagement
Converge 2021 session
COVID-19 in Children
Presenter
Philip Zachariah, MD, MPH
Session summary
Children have been less severely affected by COVID-19 than adults (hospitalization rates around 5%). However, once hospitalized, ICU admission rates in children have been similar to adults, around 30%. Mortality has been 1%-2%. Risk factors for more severe acute SARS CoV-2 infections include age extremes, minorities, obesity, medical complexity, immunocompromised pediatric patients, and asthma.
Multisystem-inflammatory-syndrome-in-children (MIS-C) continues to present among persistently febrile children with multisystem findings and the history of acute COVID-19 infection in prior 3-6 weeks. There seems to be a link between the immunological defects in type I and II interferon production, as autoantibodies to type I interferon may predispose to severe disease. Dr. Zachariah of Columbia University Medical Center in New York, discussed the recent study exploring intravenous immunoglobulin (IVIG) alone versus IVIG and steroids as treatment options for MIS-C. So far, the failure rates in IVIG-alone group were higher (51%) versus IVIG and steroids (9%).
Besides MIS-C, many neurological manifestations of COVID-19 have been seen among children including GBS, seizures, encephalitis, cranial neuropathies, and demyelination cases. Diabetic ketoacidosis (DKA), secondary hemophagocytic lymphohistiocytosis (HLH), and pseudo-appendicitis have all been described in the literature, however, larger case control studied are needed.
In children, clinical vascular thrombotic events (VTEs) are rare. Anticoagulant thromboprophylaxis is suggested for hospitalized patients with COVID-19–related illness, whose D-dimer is >5 times upper limit of normal values and who have one or more non–COVID-19 related clinical risk factors for hospital acquired VTEs.
Key takeaways
- Once hospitalized, the ICU admission rates for children have been similar to those in adults, ~30%.
- MIS-C is showing lower failure rates if treated with IVIG and steroids, and most reliable laboratory findings should be elevated C-reactive protein, lymphopenia, and elevated brain natriuretic peptide.
- In hospitalized children with COVID-19, clinical VTEs are rare.
Dr. Giordano is an associate professor of pediatrics at Columbia University Medical Center in New York. She is a pediatric hospitalist with expertise in pediatric surgical comanagement
Converge 2021 session
COVID-19 in Children
Presenter
Philip Zachariah, MD, MPH
Session summary
Children have been less severely affected by COVID-19 than adults (hospitalization rates around 5%). However, once hospitalized, ICU admission rates in children have been similar to adults, around 30%. Mortality has been 1%-2%. Risk factors for more severe acute SARS CoV-2 infections include age extremes, minorities, obesity, medical complexity, immunocompromised pediatric patients, and asthma.
Multisystem-inflammatory-syndrome-in-children (MIS-C) continues to present among persistently febrile children with multisystem findings and the history of acute COVID-19 infection in prior 3-6 weeks. There seems to be a link between the immunological defects in type I and II interferon production, as autoantibodies to type I interferon may predispose to severe disease. Dr. Zachariah of Columbia University Medical Center in New York, discussed the recent study exploring intravenous immunoglobulin (IVIG) alone versus IVIG and steroids as treatment options for MIS-C. So far, the failure rates in IVIG-alone group were higher (51%) versus IVIG and steroids (9%).
Besides MIS-C, many neurological manifestations of COVID-19 have been seen among children including GBS, seizures, encephalitis, cranial neuropathies, and demyelination cases. Diabetic ketoacidosis (DKA), secondary hemophagocytic lymphohistiocytosis (HLH), and pseudo-appendicitis have all been described in the literature, however, larger case control studied are needed.
In children, clinical vascular thrombotic events (VTEs) are rare. Anticoagulant thromboprophylaxis is suggested for hospitalized patients with COVID-19–related illness, whose D-dimer is >5 times upper limit of normal values and who have one or more non–COVID-19 related clinical risk factors for hospital acquired VTEs.
Key takeaways
- Once hospitalized, the ICU admission rates for children have been similar to those in adults, ~30%.
- MIS-C is showing lower failure rates if treated with IVIG and steroids, and most reliable laboratory findings should be elevated C-reactive protein, lymphopenia, and elevated brain natriuretic peptide.
- In hospitalized children with COVID-19, clinical VTEs are rare.
Dr. Giordano is an associate professor of pediatrics at Columbia University Medical Center in New York. She is a pediatric hospitalist with expertise in pediatric surgical comanagement
FROM SHM CONVERGE 2021
Medication in heart failure: Pro tips on therapy with the ‘four pillars of survival’
On the medication front, there are now “four pillars of survival” in the setting of heart failure with reduced ejection fraction (EF), a cardiologist told hospitalists recently at SHM Converge, the annual conference of the Society of Hospital Medicine.
The quartet of drugs are beta blockers, angiotensin receptor–neprilysin inhibitors, mineralocorticoid receptor antagonists, and the newest addition – sodium-glucose cotransporter 2 inhibitors.
“If we use all four of these medications, the absolute risk reduction [in mortality] is 25% over a 2-year period,” said cardiologist Celeste T. Williams, MD, of Henry Ford Hospital, Detroit. “So it is very important that we use these medications,” she said.
But managing the medications, she said, can be challenging. Dr. Williams offered these tips about the use of medication in heart failure.
Beta blockers are crucial players
“Beta blockers save lives,” Dr. Williams said, “but there’s always a debate about how much we should titrate beta blockers.”
How can you determine the proper titration? Focus on heart rates, she recommended. “We know that higher heart rates in heart failure patients are associated with worse outcomes. There was subgroup analysis in the BEAUTIFUL study that looked at 5,300 patients with EF less than 40% who had CAD [coronary artery disease]. They found that patients with heart rates greater than 70 had a 34% increased risk of cardiovascular death and a 53% increased risk of heart failure hospitalization compared to heart rates less than 70.”
Focus on getting your patient’s heart rate lower than 70 while maintaining their blood pressure, she said.
“Another question we have is, ‘When these patients come into hospitals, what should we do with the beta blocker? Should we continue it? Should we stop it?’ If you can, you always want to continue the beta blocker or the ACE [angiotensin-converting enzyme] inhibitor, because studies have shown us that the likelihood for patients to be on these medications 90 days later is dismal,” she said. “But you also need to look at the patient. If the patient is in cardiogenic shock, their beta blocker should be stopped.”
Consider multiple factors when titrating various medications
“In the hospital, we always will look at hemodynamic compromise in the patient. Is the patient in cardiogenic shock?” Dr. Williams said. “We also must think about compliance concerns. Are the patients even taking their medication? And if they are taking their medications, are they tolerating standard medical therapy? Are they hypotensive? Are they only able to tolerate minimal meds? Have you seen that their creatine continues to rise? Or are they having poor diuresis with the rise in diuretics?”
All these questions are useful, she said, as you determine whether you should titrate medication yourself or refer the patient to an advanced heart failure specialist.
Understand when to stick with guideline-directed medical therapy
Dr. Williams said another question often arises: “If your patient’s EF recovers, should you stop guideline-directed medical therapy [GDMT]?” She highlighted a TRED-HF study that evaluated patients who had recovered from dilated, nonischemic cardiomyopathy and were receiving GDMT. “They withdrew GDMT for half of the patients and looked at their echoes 6 months later. They found that 40% of the patients relapsed. Their EFs went below 40% again. Stopping medications is not the best idea for most of these patients.”
However, she said, there are scenarios in which GDMT may be withdrawn, such as for patients with tachycardia-induced cardiomyopathies whose EF recovers after ablation, those whose EF recovers after alcoholic cardiomyopathy, and those who receive valve replacements. “We need to remember that a lot of the patients who develop stage C heart failure have risk factors. Even though their heart failure has recovered, they have risks that need to be treated, and you can use the same medications that you use for heart failure to control their risk. Therefore, you would not get into trouble by withdrawing their medications.”
She added: “If you’re unable to titrate GDMT because the blood pressure is too soft, the creatine continues to rise, or the patient just has a lot of heart failure symptoms, this is indicative that the patient is sicker than they may appear.” At this point, defer to a heart failure specialist, she said.
Consider ivabradine as an add-on when appropriate
In some cases, a heart rate of less than 70 bpm will not be achieved even with GDMT and maximum tolerated doses, Dr. Williams said. “If they’re in sinus, you can add on a medication called ivabradine, which was studied in the SHIFT study. This looked at patients with EF of less than 35% who had class 2-3 heart failure in sinus rhythm. They had to have a hospitalization within the last 12 months. The patients were randomized to either ivabradine or placebo. The primary outcome was [cardiovascular] death or heart failure hospitalization. They found that patients who had ivabradine had a decrease in heart failure hospitalization.”
The lesson, she said, is that “ivabradine is a great medication to add on to patients who are still tachycardic in sinus when you cannot titrate up the beta blocker.”
Dr. Williams reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
On the medication front, there are now “four pillars of survival” in the setting of heart failure with reduced ejection fraction (EF), a cardiologist told hospitalists recently at SHM Converge, the annual conference of the Society of Hospital Medicine.
The quartet of drugs are beta blockers, angiotensin receptor–neprilysin inhibitors, mineralocorticoid receptor antagonists, and the newest addition – sodium-glucose cotransporter 2 inhibitors.
“If we use all four of these medications, the absolute risk reduction [in mortality] is 25% over a 2-year period,” said cardiologist Celeste T. Williams, MD, of Henry Ford Hospital, Detroit. “So it is very important that we use these medications,” she said.
But managing the medications, she said, can be challenging. Dr. Williams offered these tips about the use of medication in heart failure.
Beta blockers are crucial players
“Beta blockers save lives,” Dr. Williams said, “but there’s always a debate about how much we should titrate beta blockers.”
How can you determine the proper titration? Focus on heart rates, she recommended. “We know that higher heart rates in heart failure patients are associated with worse outcomes. There was subgroup analysis in the BEAUTIFUL study that looked at 5,300 patients with EF less than 40% who had CAD [coronary artery disease]. They found that patients with heart rates greater than 70 had a 34% increased risk of cardiovascular death and a 53% increased risk of heart failure hospitalization compared to heart rates less than 70.”
Focus on getting your patient’s heart rate lower than 70 while maintaining their blood pressure, she said.
“Another question we have is, ‘When these patients come into hospitals, what should we do with the beta blocker? Should we continue it? Should we stop it?’ If you can, you always want to continue the beta blocker or the ACE [angiotensin-converting enzyme] inhibitor, because studies have shown us that the likelihood for patients to be on these medications 90 days later is dismal,” she said. “But you also need to look at the patient. If the patient is in cardiogenic shock, their beta blocker should be stopped.”
Consider multiple factors when titrating various medications
“In the hospital, we always will look at hemodynamic compromise in the patient. Is the patient in cardiogenic shock?” Dr. Williams said. “We also must think about compliance concerns. Are the patients even taking their medication? And if they are taking their medications, are they tolerating standard medical therapy? Are they hypotensive? Are they only able to tolerate minimal meds? Have you seen that their creatine continues to rise? Or are they having poor diuresis with the rise in diuretics?”
All these questions are useful, she said, as you determine whether you should titrate medication yourself or refer the patient to an advanced heart failure specialist.
Understand when to stick with guideline-directed medical therapy
Dr. Williams said another question often arises: “If your patient’s EF recovers, should you stop guideline-directed medical therapy [GDMT]?” She highlighted a TRED-HF study that evaluated patients who had recovered from dilated, nonischemic cardiomyopathy and were receiving GDMT. “They withdrew GDMT for half of the patients and looked at their echoes 6 months later. They found that 40% of the patients relapsed. Their EFs went below 40% again. Stopping medications is not the best idea for most of these patients.”
However, she said, there are scenarios in which GDMT may be withdrawn, such as for patients with tachycardia-induced cardiomyopathies whose EF recovers after ablation, those whose EF recovers after alcoholic cardiomyopathy, and those who receive valve replacements. “We need to remember that a lot of the patients who develop stage C heart failure have risk factors. Even though their heart failure has recovered, they have risks that need to be treated, and you can use the same medications that you use for heart failure to control their risk. Therefore, you would not get into trouble by withdrawing their medications.”
She added: “If you’re unable to titrate GDMT because the blood pressure is too soft, the creatine continues to rise, or the patient just has a lot of heart failure symptoms, this is indicative that the patient is sicker than they may appear.” At this point, defer to a heart failure specialist, she said.
Consider ivabradine as an add-on when appropriate
In some cases, a heart rate of less than 70 bpm will not be achieved even with GDMT and maximum tolerated doses, Dr. Williams said. “If they’re in sinus, you can add on a medication called ivabradine, which was studied in the SHIFT study. This looked at patients with EF of less than 35% who had class 2-3 heart failure in sinus rhythm. They had to have a hospitalization within the last 12 months. The patients were randomized to either ivabradine or placebo. The primary outcome was [cardiovascular] death or heart failure hospitalization. They found that patients who had ivabradine had a decrease in heart failure hospitalization.”
The lesson, she said, is that “ivabradine is a great medication to add on to patients who are still tachycardic in sinus when you cannot titrate up the beta blocker.”
Dr. Williams reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
On the medication front, there are now “four pillars of survival” in the setting of heart failure with reduced ejection fraction (EF), a cardiologist told hospitalists recently at SHM Converge, the annual conference of the Society of Hospital Medicine.
The quartet of drugs are beta blockers, angiotensin receptor–neprilysin inhibitors, mineralocorticoid receptor antagonists, and the newest addition – sodium-glucose cotransporter 2 inhibitors.
“If we use all four of these medications, the absolute risk reduction [in mortality] is 25% over a 2-year period,” said cardiologist Celeste T. Williams, MD, of Henry Ford Hospital, Detroit. “So it is very important that we use these medications,” she said.
But managing the medications, she said, can be challenging. Dr. Williams offered these tips about the use of medication in heart failure.
Beta blockers are crucial players
“Beta blockers save lives,” Dr. Williams said, “but there’s always a debate about how much we should titrate beta blockers.”
How can you determine the proper titration? Focus on heart rates, she recommended. “We know that higher heart rates in heart failure patients are associated with worse outcomes. There was subgroup analysis in the BEAUTIFUL study that looked at 5,300 patients with EF less than 40% who had CAD [coronary artery disease]. They found that patients with heart rates greater than 70 had a 34% increased risk of cardiovascular death and a 53% increased risk of heart failure hospitalization compared to heart rates less than 70.”
Focus on getting your patient’s heart rate lower than 70 while maintaining their blood pressure, she said.
“Another question we have is, ‘When these patients come into hospitals, what should we do with the beta blocker? Should we continue it? Should we stop it?’ If you can, you always want to continue the beta blocker or the ACE [angiotensin-converting enzyme] inhibitor, because studies have shown us that the likelihood for patients to be on these medications 90 days later is dismal,” she said. “But you also need to look at the patient. If the patient is in cardiogenic shock, their beta blocker should be stopped.”
Consider multiple factors when titrating various medications
“In the hospital, we always will look at hemodynamic compromise in the patient. Is the patient in cardiogenic shock?” Dr. Williams said. “We also must think about compliance concerns. Are the patients even taking their medication? And if they are taking their medications, are they tolerating standard medical therapy? Are they hypotensive? Are they only able to tolerate minimal meds? Have you seen that their creatine continues to rise? Or are they having poor diuresis with the rise in diuretics?”
All these questions are useful, she said, as you determine whether you should titrate medication yourself or refer the patient to an advanced heart failure specialist.
Understand when to stick with guideline-directed medical therapy
Dr. Williams said another question often arises: “If your patient’s EF recovers, should you stop guideline-directed medical therapy [GDMT]?” She highlighted a TRED-HF study that evaluated patients who had recovered from dilated, nonischemic cardiomyopathy and were receiving GDMT. “They withdrew GDMT for half of the patients and looked at their echoes 6 months later. They found that 40% of the patients relapsed. Their EFs went below 40% again. Stopping medications is not the best idea for most of these patients.”
However, she said, there are scenarios in which GDMT may be withdrawn, such as for patients with tachycardia-induced cardiomyopathies whose EF recovers after ablation, those whose EF recovers after alcoholic cardiomyopathy, and those who receive valve replacements. “We need to remember that a lot of the patients who develop stage C heart failure have risk factors. Even though their heart failure has recovered, they have risks that need to be treated, and you can use the same medications that you use for heart failure to control their risk. Therefore, you would not get into trouble by withdrawing their medications.”
She added: “If you’re unable to titrate GDMT because the blood pressure is too soft, the creatine continues to rise, or the patient just has a lot of heart failure symptoms, this is indicative that the patient is sicker than they may appear.” At this point, defer to a heart failure specialist, she said.
Consider ivabradine as an add-on when appropriate
In some cases, a heart rate of less than 70 bpm will not be achieved even with GDMT and maximum tolerated doses, Dr. Williams said. “If they’re in sinus, you can add on a medication called ivabradine, which was studied in the SHIFT study. This looked at patients with EF of less than 35% who had class 2-3 heart failure in sinus rhythm. They had to have a hospitalization within the last 12 months. The patients were randomized to either ivabradine or placebo. The primary outcome was [cardiovascular] death or heart failure hospitalization. They found that patients who had ivabradine had a decrease in heart failure hospitalization.”
The lesson, she said, is that “ivabradine is a great medication to add on to patients who are still tachycardic in sinus when you cannot titrate up the beta blocker.”
Dr. Williams reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Better ways to handle in-hospital conflicts
Imagine a hospitalist, part of a group with 35 hospitalists, is in her second year of practice and is caring for a 55-year-old woman with a history of congestive heart failure and cirrhosis from hepatitis C due to heroin use. The patient was hospitalized with acute back pain and found to have vertebral osteomyelitis confirmed on MRI.
The hospitalist calls a surgeon to get a biopsy so that antibiotic therapy can be chosen. The surgeon says it’s the second time the patient has been hospitalized for this condition, and asks, “Why do you need me to see this patient?” He says the hospitalist should just give IV antibiotics and consult infectious disease.
The hospitalist says, “The patient needs this biopsy. I’ll just call your chair.”
In the course of a busy day, conflicts arise all the time in the hospital – between clinicians, between patients and clinicians, and as internal battles when clinicians face uncertain situations. There are ways to make these conflicts less tense and more in tune with patient care, panelists said recently during a session at SHM Converge, the annual conference of the Society of Hospital Medicine.
In the case of vertebral osteomyelitis, for instance, the hospitalist was using a “position-based” strategy to deal with the conflict with the surgeon – she came in knowing she wanted a biopsy – rather than an “interest-based” strategy, or what is in the patient’s interest, said Patrick Rendon, MD, FHM, assistant professor in the hospital medicine division at the University of New Mexico, Albuquerque.
“What we really need to do is realign the thinking from both the hospitalist as well as the consult perspective,” Dr. Rendon said. “It is not us versus the consultant or the consult versus us. It should be both, together, versus the problem.”
Instead of saying something like, “I need this biopsy,” it might be better to ask for an evaluation, he said.
Handling conflicts better can improve patient care but can also benefit the clinicians themselves. While hospitalists say they routinely experience “pushback” when making a request of a consultant, they also say that they prefer to receive instruction when consulting about a case. Dr. Rendon said that hospitalists also say they want this teaching done “in the right way,” and consultants routinely say that their instruction, when they give it, is often met with resistance.
“The idea here is to open up perspectives,” Dr. Rendon said.
Emily Gottenborg, MD, hospitalist and assistant professor of medicine at the University of Colorado, discussed the case of an intern caring for a patient who says something offensive.
Conflicts, she said, come in all sorts – intimidation, harassment, bias. And they can be based on race, gender, disability, and hierarchy, she said. When on the receiving end of offensive remarks from patients, it’s important for a clinician to set boundaries and quickly move on, with responses such as, “I care about you as a person, but I will not tolerate offensive behavior. Let’s focus on how I can help you today.”
“Practice that behavior so that you have a script in your mind and then use it when needed so that you can nip this behavior in the bud,” Dr. Gottenborg said.
In her hypothetical case, the intern asks for help from her program, and monthly morbidity and mortality workshops on bias and harassment are scheduled. She also receives counseling, and faculty and staff receive discrimination and bias training. Getting help from the institution can help systematically reduce these problems, Dr. Gottenborg said.
Ernie Esquivel, MD, SFHM, hospitalist and assistant professor of clinical medicine at Weill Cornell Medicine, New York, said internal conflicts test physicians routinely – and this has been especially true during the COVID-19 pandemic, in which urgent clinical situations arose with no clear answers.
“In the past year, physicians have experienced an incredible amount of anxiety and stress,” he said. “Tolerating uncertainty is probably one of the most mature skills that we need to learn as a physician.”
The culture of medicine, to a large degree, promotes the opposite tendency: value is placed on nailing down the diagnosis or achieving certainty. Confidence levels of physicians tend not to waver, even in the face of difficult cases full of uncertainty, Dr. Esquivel said.
He urged physicians to practice “deliberate clinical inertia” – to resist a quick response and to think more deeply and systematically about a situation. To show the importance of this, he asks residents to rank diagnoses, using sticky notes, as information about a case is provided. By the fourth round, when much more information is available, the diagnoses have changed dramatically.
Dr. Esquivel suggested physicians switch from thinking in terms of “diagnoses” to thinking in terms of “hypotheses.” That approach can help clinicians tolerate uncertainty, because it reinforces the idea that they are dealing with an “iterative process.”
“There may not be one diagnosis to consider,” he said, “but several in play at once.”
A version of this article first appeared on Medscape.com.
Imagine a hospitalist, part of a group with 35 hospitalists, is in her second year of practice and is caring for a 55-year-old woman with a history of congestive heart failure and cirrhosis from hepatitis C due to heroin use. The patient was hospitalized with acute back pain and found to have vertebral osteomyelitis confirmed on MRI.
The hospitalist calls a surgeon to get a biopsy so that antibiotic therapy can be chosen. The surgeon says it’s the second time the patient has been hospitalized for this condition, and asks, “Why do you need me to see this patient?” He says the hospitalist should just give IV antibiotics and consult infectious disease.
The hospitalist says, “The patient needs this biopsy. I’ll just call your chair.”
In the course of a busy day, conflicts arise all the time in the hospital – between clinicians, between patients and clinicians, and as internal battles when clinicians face uncertain situations. There are ways to make these conflicts less tense and more in tune with patient care, panelists said recently during a session at SHM Converge, the annual conference of the Society of Hospital Medicine.
In the case of vertebral osteomyelitis, for instance, the hospitalist was using a “position-based” strategy to deal with the conflict with the surgeon – she came in knowing she wanted a biopsy – rather than an “interest-based” strategy, or what is in the patient’s interest, said Patrick Rendon, MD, FHM, assistant professor in the hospital medicine division at the University of New Mexico, Albuquerque.
“What we really need to do is realign the thinking from both the hospitalist as well as the consult perspective,” Dr. Rendon said. “It is not us versus the consultant or the consult versus us. It should be both, together, versus the problem.”
Instead of saying something like, “I need this biopsy,” it might be better to ask for an evaluation, he said.
Handling conflicts better can improve patient care but can also benefit the clinicians themselves. While hospitalists say they routinely experience “pushback” when making a request of a consultant, they also say that they prefer to receive instruction when consulting about a case. Dr. Rendon said that hospitalists also say they want this teaching done “in the right way,” and consultants routinely say that their instruction, when they give it, is often met with resistance.
“The idea here is to open up perspectives,” Dr. Rendon said.
Emily Gottenborg, MD, hospitalist and assistant professor of medicine at the University of Colorado, discussed the case of an intern caring for a patient who says something offensive.
Conflicts, she said, come in all sorts – intimidation, harassment, bias. And they can be based on race, gender, disability, and hierarchy, she said. When on the receiving end of offensive remarks from patients, it’s important for a clinician to set boundaries and quickly move on, with responses such as, “I care about you as a person, but I will not tolerate offensive behavior. Let’s focus on how I can help you today.”
“Practice that behavior so that you have a script in your mind and then use it when needed so that you can nip this behavior in the bud,” Dr. Gottenborg said.
In her hypothetical case, the intern asks for help from her program, and monthly morbidity and mortality workshops on bias and harassment are scheduled. She also receives counseling, and faculty and staff receive discrimination and bias training. Getting help from the institution can help systematically reduce these problems, Dr. Gottenborg said.
Ernie Esquivel, MD, SFHM, hospitalist and assistant professor of clinical medicine at Weill Cornell Medicine, New York, said internal conflicts test physicians routinely – and this has been especially true during the COVID-19 pandemic, in which urgent clinical situations arose with no clear answers.
“In the past year, physicians have experienced an incredible amount of anxiety and stress,” he said. “Tolerating uncertainty is probably one of the most mature skills that we need to learn as a physician.”
The culture of medicine, to a large degree, promotes the opposite tendency: value is placed on nailing down the diagnosis or achieving certainty. Confidence levels of physicians tend not to waver, even in the face of difficult cases full of uncertainty, Dr. Esquivel said.
He urged physicians to practice “deliberate clinical inertia” – to resist a quick response and to think more deeply and systematically about a situation. To show the importance of this, he asks residents to rank diagnoses, using sticky notes, as information about a case is provided. By the fourth round, when much more information is available, the diagnoses have changed dramatically.
Dr. Esquivel suggested physicians switch from thinking in terms of “diagnoses” to thinking in terms of “hypotheses.” That approach can help clinicians tolerate uncertainty, because it reinforces the idea that they are dealing with an “iterative process.”
“There may not be one diagnosis to consider,” he said, “but several in play at once.”
A version of this article first appeared on Medscape.com.
Imagine a hospitalist, part of a group with 35 hospitalists, is in her second year of practice and is caring for a 55-year-old woman with a history of congestive heart failure and cirrhosis from hepatitis C due to heroin use. The patient was hospitalized with acute back pain and found to have vertebral osteomyelitis confirmed on MRI.
The hospitalist calls a surgeon to get a biopsy so that antibiotic therapy can be chosen. The surgeon says it’s the second time the patient has been hospitalized for this condition, and asks, “Why do you need me to see this patient?” He says the hospitalist should just give IV antibiotics and consult infectious disease.
The hospitalist says, “The patient needs this biopsy. I’ll just call your chair.”
In the course of a busy day, conflicts arise all the time in the hospital – between clinicians, between patients and clinicians, and as internal battles when clinicians face uncertain situations. There are ways to make these conflicts less tense and more in tune with patient care, panelists said recently during a session at SHM Converge, the annual conference of the Society of Hospital Medicine.
In the case of vertebral osteomyelitis, for instance, the hospitalist was using a “position-based” strategy to deal with the conflict with the surgeon – she came in knowing she wanted a biopsy – rather than an “interest-based” strategy, or what is in the patient’s interest, said Patrick Rendon, MD, FHM, assistant professor in the hospital medicine division at the University of New Mexico, Albuquerque.
“What we really need to do is realign the thinking from both the hospitalist as well as the consult perspective,” Dr. Rendon said. “It is not us versus the consultant or the consult versus us. It should be both, together, versus the problem.”
Instead of saying something like, “I need this biopsy,” it might be better to ask for an evaluation, he said.
Handling conflicts better can improve patient care but can also benefit the clinicians themselves. While hospitalists say they routinely experience “pushback” when making a request of a consultant, they also say that they prefer to receive instruction when consulting about a case. Dr. Rendon said that hospitalists also say they want this teaching done “in the right way,” and consultants routinely say that their instruction, when they give it, is often met with resistance.
“The idea here is to open up perspectives,” Dr. Rendon said.
Emily Gottenborg, MD, hospitalist and assistant professor of medicine at the University of Colorado, discussed the case of an intern caring for a patient who says something offensive.
Conflicts, she said, come in all sorts – intimidation, harassment, bias. And they can be based on race, gender, disability, and hierarchy, she said. When on the receiving end of offensive remarks from patients, it’s important for a clinician to set boundaries and quickly move on, with responses such as, “I care about you as a person, but I will not tolerate offensive behavior. Let’s focus on how I can help you today.”
“Practice that behavior so that you have a script in your mind and then use it when needed so that you can nip this behavior in the bud,” Dr. Gottenborg said.
In her hypothetical case, the intern asks for help from her program, and monthly morbidity and mortality workshops on bias and harassment are scheduled. She also receives counseling, and faculty and staff receive discrimination and bias training. Getting help from the institution can help systematically reduce these problems, Dr. Gottenborg said.
Ernie Esquivel, MD, SFHM, hospitalist and assistant professor of clinical medicine at Weill Cornell Medicine, New York, said internal conflicts test physicians routinely – and this has been especially true during the COVID-19 pandemic, in which urgent clinical situations arose with no clear answers.
“In the past year, physicians have experienced an incredible amount of anxiety and stress,” he said. “Tolerating uncertainty is probably one of the most mature skills that we need to learn as a physician.”
The culture of medicine, to a large degree, promotes the opposite tendency: value is placed on nailing down the diagnosis or achieving certainty. Confidence levels of physicians tend not to waver, even in the face of difficult cases full of uncertainty, Dr. Esquivel said.
He urged physicians to practice “deliberate clinical inertia” – to resist a quick response and to think more deeply and systematically about a situation. To show the importance of this, he asks residents to rank diagnoses, using sticky notes, as information about a case is provided. By the fourth round, when much more information is available, the diagnoses have changed dramatically.
Dr. Esquivel suggested physicians switch from thinking in terms of “diagnoses” to thinking in terms of “hypotheses.” That approach can help clinicians tolerate uncertainty, because it reinforces the idea that they are dealing with an “iterative process.”
“There may not be one diagnosis to consider,” he said, “but several in play at once.”
A version of this article first appeared on Medscape.com.
FROM SHM CONVERGE 2021
In-hospital resuscitation: Focus on effective chest pumps, prompt shocks
The keys to effective resuscitation in the hospital setting include effective compression and early defibrillation, according to Jessica Nave Allen, MD, FHM, a hospitalist with Emory University Hospital in Atlanta. She spoke about best practices in resuscitation medicine recently at SHM Converge, the annual conference of the Society of Hospital Medicine.
“We know CPR [cardiopulmonary resuscitation] and shocking are the two biggest determinants of outcomes, so really strive to make those chest compressions really high quality,” said Dr. Allen. She urged hospitalists to consider mechanical piston compressions and even “reverse CPR” when appropriate.
Dr. Allen offered several other tips about effective in-hospital resuscitation.
Don’t overcrowd the hospital room
There shouldn’t be more than eight people inside the room during a code, she said. If you’re the code leader, “make sure that somebody has already started high-quality chest compressions. You want to make sure that somebody is already on the airway. It’s usually two people, one person to actually hold the mask down to make sure there’s a good seal, and the other person to deliver the breaths.”
Two to three people should be assigned to chest compressions, Dr. Allen said, “and you need one or two nurses for medication delivery and grabbing things from the runners. And then you need to have a recorder and the code leader. Everyone else who’s not in one of those formalized roles needs to be outside the room. That includes the pharmacist, who usually stands at the door if you don’t have a code pharmacist at your institution.”
A helpful mnemonic for the resuscitation process is I(CA)RAMBO, which was developed at Tufts Medical Center and published in 2020, she said. The mnemonic stands for the following:
- I: Identify yourself as code leader.
- CA: Compression, Airway.
- R: Roles (assign roles in the resuscitation).
- A: Access (intravenous access is preferred to intraosseous, per the American Heart Association’s , unless intravenous access is unavailable, Dr. Allen noted).
- M: Monitor (make sure pads are placed correctly; turn the defibrillator on).
- B: Backboard.
- O: Oxygen.
Focus on high-quality chest compressions
The number of chest compressions must be 100-120 per minute, Dr. Allen said. You can time them to the beat of a song, such as “Stayin’ Alive,” or with a metronome, she said, “but whatever it is, you need to stay in that window.”
The correct compression depth is 2-2.4 inches. “That’s very difficult to do during the middle of a code, which is why it’s important to allow full recoil,” she said. “This doesn’t mean taking your hands off of the chest: You should actually never take your hands off of the chest. But you should allow the chest wall to return to its normal state. Also, make sure you aren’t off the chest for more for 10 seconds whenever you’re doing a rhythm check.”
Audiovisual feedback devices can provide insight into the quality of chest compressions. For example, some defibrillators are equipped with sensors that urge users to push harder and faster when appropriate. “Studies have shown that the quality of chest compressions goes up when you use these devices,” she said.
Don’t be afraid of mechanical chest compression
Although early research raised questions about the quality of resuscitation outcomes when mechanical piston chest compression devices are used, a 2015 systematic review and meta-analysis found that “man was equal to machine,” Dr. Allen said. “The bottom line is that these devices may be a reasonable alternative to conventional CPR in specific settings.”
American Heart Association guidelines state that mechanical compressions may be appropriate in certain specific situations “where the delivery of high-quality manual compressions may be challenging or dangerous for the provider.”
According to Dr. Allen, “there are times when it’s useful,” such as for a patient with COVID-19, in the cath lab, or in a medical helicopter.
Move quickly to defibrillation
“Most of us know that you want to shock as early as possible in shockable rhythms,” Dr. Allen said. Support, she said, comes from a 2008 study that linked delayed defibrillation to lower survival rates. “We want to shock as soon as possible, because your chances of surviving go down for every minute you wait.”
Take special care for patients with confirmed or suspected COVID-19
“Not surprisingly, the goals here are to minimize exposure to staff,” Dr. Allen said.
Put on personal protective equipment before entering the room even if care is delayed, she advised, and reduce the number of staff members in the room below the typical maximum of eight. “In COVID, it should be a maximum of six, and some institutions have even gotten it down to four where the code leaders are outside the room with an iPad.”
Use mechanical compression devices, she advised, and place patients on ventilators as soon as possible. She added: “Use a HEPA [high-efficiency particulate air] filter for all your airway modalities.”
CPR may be challenging in some cases, such as when a large, intubated patient is prone and cannot be quickly or safely flipped over. In those cases, consider posterior chest compressions, also known as reverse CPR, at vertebral positions T7-T10. “We have done reverse CPR on several COVID patients throughout the Emory system,” she said.
Debrief right after codes
“You really want to debrief with the code team,” Dr. Allen said. “If you don’t already have a policy in place at your institution, you should help come up with one where you sit down with the team and talk about what could you have done better as a group. It’s not a time to place blame. It’s a time to learn.”
Dr. Allen has disclosed no relevant financial relationships.
This article was updated 7/26/21.
A version of this article first appeared on Medscape.com.
The keys to effective resuscitation in the hospital setting include effective compression and early defibrillation, according to Jessica Nave Allen, MD, FHM, a hospitalist with Emory University Hospital in Atlanta. She spoke about best practices in resuscitation medicine recently at SHM Converge, the annual conference of the Society of Hospital Medicine.
“We know CPR [cardiopulmonary resuscitation] and shocking are the two biggest determinants of outcomes, so really strive to make those chest compressions really high quality,” said Dr. Allen. She urged hospitalists to consider mechanical piston compressions and even “reverse CPR” when appropriate.
Dr. Allen offered several other tips about effective in-hospital resuscitation.
Don’t overcrowd the hospital room
There shouldn’t be more than eight people inside the room during a code, she said. If you’re the code leader, “make sure that somebody has already started high-quality chest compressions. You want to make sure that somebody is already on the airway. It’s usually two people, one person to actually hold the mask down to make sure there’s a good seal, and the other person to deliver the breaths.”
Two to three people should be assigned to chest compressions, Dr. Allen said, “and you need one or two nurses for medication delivery and grabbing things from the runners. And then you need to have a recorder and the code leader. Everyone else who’s not in one of those formalized roles needs to be outside the room. That includes the pharmacist, who usually stands at the door if you don’t have a code pharmacist at your institution.”
A helpful mnemonic for the resuscitation process is I(CA)RAMBO, which was developed at Tufts Medical Center and published in 2020, she said. The mnemonic stands for the following:
- I: Identify yourself as code leader.
- CA: Compression, Airway.
- R: Roles (assign roles in the resuscitation).
- A: Access (intravenous access is preferred to intraosseous, per the American Heart Association’s , unless intravenous access is unavailable, Dr. Allen noted).
- M: Monitor (make sure pads are placed correctly; turn the defibrillator on).
- B: Backboard.
- O: Oxygen.
Focus on high-quality chest compressions
The number of chest compressions must be 100-120 per minute, Dr. Allen said. You can time them to the beat of a song, such as “Stayin’ Alive,” or with a metronome, she said, “but whatever it is, you need to stay in that window.”
The correct compression depth is 2-2.4 inches. “That’s very difficult to do during the middle of a code, which is why it’s important to allow full recoil,” she said. “This doesn’t mean taking your hands off of the chest: You should actually never take your hands off of the chest. But you should allow the chest wall to return to its normal state. Also, make sure you aren’t off the chest for more for 10 seconds whenever you’re doing a rhythm check.”
Audiovisual feedback devices can provide insight into the quality of chest compressions. For example, some defibrillators are equipped with sensors that urge users to push harder and faster when appropriate. “Studies have shown that the quality of chest compressions goes up when you use these devices,” she said.
Don’t be afraid of mechanical chest compression
Although early research raised questions about the quality of resuscitation outcomes when mechanical piston chest compression devices are used, a 2015 systematic review and meta-analysis found that “man was equal to machine,” Dr. Allen said. “The bottom line is that these devices may be a reasonable alternative to conventional CPR in specific settings.”
American Heart Association guidelines state that mechanical compressions may be appropriate in certain specific situations “where the delivery of high-quality manual compressions may be challenging or dangerous for the provider.”
According to Dr. Allen, “there are times when it’s useful,” such as for a patient with COVID-19, in the cath lab, or in a medical helicopter.
Move quickly to defibrillation
“Most of us know that you want to shock as early as possible in shockable rhythms,” Dr. Allen said. Support, she said, comes from a 2008 study that linked delayed defibrillation to lower survival rates. “We want to shock as soon as possible, because your chances of surviving go down for every minute you wait.”
Take special care for patients with confirmed or suspected COVID-19
“Not surprisingly, the goals here are to minimize exposure to staff,” Dr. Allen said.
Put on personal protective equipment before entering the room even if care is delayed, she advised, and reduce the number of staff members in the room below the typical maximum of eight. “In COVID, it should be a maximum of six, and some institutions have even gotten it down to four where the code leaders are outside the room with an iPad.”
Use mechanical compression devices, she advised, and place patients on ventilators as soon as possible. She added: “Use a HEPA [high-efficiency particulate air] filter for all your airway modalities.”
CPR may be challenging in some cases, such as when a large, intubated patient is prone and cannot be quickly or safely flipped over. In those cases, consider posterior chest compressions, also known as reverse CPR, at vertebral positions T7-T10. “We have done reverse CPR on several COVID patients throughout the Emory system,” she said.
Debrief right after codes
“You really want to debrief with the code team,” Dr. Allen said. “If you don’t already have a policy in place at your institution, you should help come up with one where you sit down with the team and talk about what could you have done better as a group. It’s not a time to place blame. It’s a time to learn.”
Dr. Allen has disclosed no relevant financial relationships.
This article was updated 7/26/21.
A version of this article first appeared on Medscape.com.
The keys to effective resuscitation in the hospital setting include effective compression and early defibrillation, according to Jessica Nave Allen, MD, FHM, a hospitalist with Emory University Hospital in Atlanta. She spoke about best practices in resuscitation medicine recently at SHM Converge, the annual conference of the Society of Hospital Medicine.
“We know CPR [cardiopulmonary resuscitation] and shocking are the two biggest determinants of outcomes, so really strive to make those chest compressions really high quality,” said Dr. Allen. She urged hospitalists to consider mechanical piston compressions and even “reverse CPR” when appropriate.
Dr. Allen offered several other tips about effective in-hospital resuscitation.
Don’t overcrowd the hospital room
There shouldn’t be more than eight people inside the room during a code, she said. If you’re the code leader, “make sure that somebody has already started high-quality chest compressions. You want to make sure that somebody is already on the airway. It’s usually two people, one person to actually hold the mask down to make sure there’s a good seal, and the other person to deliver the breaths.”
Two to three people should be assigned to chest compressions, Dr. Allen said, “and you need one or two nurses for medication delivery and grabbing things from the runners. And then you need to have a recorder and the code leader. Everyone else who’s not in one of those formalized roles needs to be outside the room. That includes the pharmacist, who usually stands at the door if you don’t have a code pharmacist at your institution.”
A helpful mnemonic for the resuscitation process is I(CA)RAMBO, which was developed at Tufts Medical Center and published in 2020, she said. The mnemonic stands for the following:
- I: Identify yourself as code leader.
- CA: Compression, Airway.
- R: Roles (assign roles in the resuscitation).
- A: Access (intravenous access is preferred to intraosseous, per the American Heart Association’s , unless intravenous access is unavailable, Dr. Allen noted).
- M: Monitor (make sure pads are placed correctly; turn the defibrillator on).
- B: Backboard.
- O: Oxygen.
Focus on high-quality chest compressions
The number of chest compressions must be 100-120 per minute, Dr. Allen said. You can time them to the beat of a song, such as “Stayin’ Alive,” or with a metronome, she said, “but whatever it is, you need to stay in that window.”
The correct compression depth is 2-2.4 inches. “That’s very difficult to do during the middle of a code, which is why it’s important to allow full recoil,” she said. “This doesn’t mean taking your hands off of the chest: You should actually never take your hands off of the chest. But you should allow the chest wall to return to its normal state. Also, make sure you aren’t off the chest for more for 10 seconds whenever you’re doing a rhythm check.”
Audiovisual feedback devices can provide insight into the quality of chest compressions. For example, some defibrillators are equipped with sensors that urge users to push harder and faster when appropriate. “Studies have shown that the quality of chest compressions goes up when you use these devices,” she said.
Don’t be afraid of mechanical chest compression
Although early research raised questions about the quality of resuscitation outcomes when mechanical piston chest compression devices are used, a 2015 systematic review and meta-analysis found that “man was equal to machine,” Dr. Allen said. “The bottom line is that these devices may be a reasonable alternative to conventional CPR in specific settings.”
American Heart Association guidelines state that mechanical compressions may be appropriate in certain specific situations “where the delivery of high-quality manual compressions may be challenging or dangerous for the provider.”
According to Dr. Allen, “there are times when it’s useful,” such as for a patient with COVID-19, in the cath lab, or in a medical helicopter.
Move quickly to defibrillation
“Most of us know that you want to shock as early as possible in shockable rhythms,” Dr. Allen said. Support, she said, comes from a 2008 study that linked delayed defibrillation to lower survival rates. “We want to shock as soon as possible, because your chances of surviving go down for every minute you wait.”
Take special care for patients with confirmed or suspected COVID-19
“Not surprisingly, the goals here are to minimize exposure to staff,” Dr. Allen said.
Put on personal protective equipment before entering the room even if care is delayed, she advised, and reduce the number of staff members in the room below the typical maximum of eight. “In COVID, it should be a maximum of six, and some institutions have even gotten it down to four where the code leaders are outside the room with an iPad.”
Use mechanical compression devices, she advised, and place patients on ventilators as soon as possible. She added: “Use a HEPA [high-efficiency particulate air] filter for all your airway modalities.”
CPR may be challenging in some cases, such as when a large, intubated patient is prone and cannot be quickly or safely flipped over. In those cases, consider posterior chest compressions, also known as reverse CPR, at vertebral positions T7-T10. “We have done reverse CPR on several COVID patients throughout the Emory system,” she said.
Debrief right after codes
“You really want to debrief with the code team,” Dr. Allen said. “If you don’t already have a policy in place at your institution, you should help come up with one where you sit down with the team and talk about what could you have done better as a group. It’s not a time to place blame. It’s a time to learn.”
Dr. Allen has disclosed no relevant financial relationships.
This article was updated 7/26/21.
A version of this article first appeared on Medscape.com.
FROM SHM CONVERGE 2021
Avoiding excess oxygen in mechanically ventilated patients ‘seems sensible’
The respiratory therapists at Mount Sinai Beth Israel, New York, know when Lina Miyakawa, MD, starts a week in the ICU, because she turns down the fraction of inspired oxygen (FiO2) levels if patients tolerate it.
“Hyperoxia in mechanical ventilation is a topic that’s near and dear to my heart,” Dr. Miyakawa, a pulmonary and critical care medicine specialist at Mount Sinai Beth Israel, said during SHM Converge, the annual conference of the Society of Hospital Medicine. “You can always find ‘wean down FiO2’ in my consult notes.”
While it is believed that humans have built up evolutionary defenses against hypoxia but not against hyperoxia, medical literature on the topic of hyperoxia with supplemental oxygen is fairly young. “In medical school we were taught to give oxygen for anybody with chest pain and concern about acute coronary syndrome,” she said. “This was until recent data suggested harm from liberal oxygen use.”
In a single-center trial of 434 critical care patients with an ICU length of stay of 72 hours or longer, Italian researchers examined the effects of a conservative protocol for oxygen therapy versus conventional therapy on ICU mortality (JAMA. 2016;316[15]:1583-9). The trial was stopped because the patients who were assigned to receive conservative therapy had a significantly lower mortality than the ones who received usual care (P = .01). “The study was not perfect, and the premature stoppage likely exaggerated the effect size,” said Dr. Miyakawa, who was not affiliated with the trial. “However, subsequent retrospective studies continue to support a benefit with conservative oxygen use, especially in different groups of patients. One of note is hyperoxia following cardiac arrest. There’s something called a two-hit model that speaks to worsening ischemia with reperfusion injury after the initial hypoxic event from the cardiac arrest itself” (See Intensive Care Med. 2015;41:534-6).
In a multicenter cohort study that drew from the Project IMPACT critical care database of ICUs at 120 U.S. hospitals between 2001 and 2005, researchers led by J. Hope Kilgannon, MD, tested the hypothesis that post-resuscitation hyperoxia is associated with increased in-hospital mortality (JAMA. 2010;303[21]:2165-71). The study population consisted of 6,326 patients who were divided into three groups: the hypoxic group (a PaO2 of less than 60 mm Hg); the normoxic group (a PaO2 of 60-299 mm Hg), and the hyperoxic group (a PaO2 of over 300 mm Hg). The mortality for the hyperoxic group was 63%, the hypoxic group at 57%, and the normoxic group at 45%.
More recently, the ICU-ROX Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group evaluated conservative versus liberal approaches in providing oxygen to 965 patients who were mechanically ventilated between 2015 and 2018 at 21 ICUs (N Eng J Med. 2020;382:989-98). Of the 965 patients, 484 were randomly assigned to the conservative oxygen group (defined as an SpO2 of 97% or lower) and 481 were assigned to the usual oxygen group (defined as having no specific measures limiting FiO2 or the SpO2). The primary outcome was the number of ventilator-free days from randomization until day 28, while the secondary outcome was mortality at 180 days. The researchers also performed a subgroup analysis of patients at risk for hypoxic-ischemic encephalopathy.
No significant differences were observed in the number of ventilator days between the two group (a median of 21 days in the conservative oxygen group versus 22 days in the usual oxygen group, respectively; P = .80) nor in mortality at 180 days (35.7% vs. 34.5%). However, in the subgroup analysis, patients with hypoxic-ischemic encephalopathy were noted to have more ventilator-free days (21 vs. 0 days), improved 180-day mortality (43% vs. 59%), and less functional impairment (55% vs. 68%) in the conservative-oxygen group.
“The results of this study suggest that conservative oxygen therapy has no additional advantage over standard oxygen therapy, but there may be benefits in those vulnerable to hyperoxia, which warrants further investigation,” Dr. Miyakawa said. “There are a few points to note on this topic. First, many of the previous studies had more liberal oxygen strategies than the ones used in this study, which could be the reason why we are seeing these results. In addition, O2 titration relies on imperfect approximations. PaO2 cannot be measured continuously; we really depend on the SpO2 on a minute-by-minute basis. Critically ill patients can also undergo episodes of hypoperfusion and shock state minute-by-minute. That’s when they’re at risk for hypoxemia. This would not be captured continuously with just O2 saturations.”
Dr. Miyakawa also highlighted the Liberal Oxygenation versus Conservative Oxygenation in Acute Respiratory Distress Syndrome trial (LOCO2) a prospective, multicenter, randomized, open-label trial involving patients with ARDS. It was carried out at 13 ICUs in France between June 2016 and September 2018 in an effort determine whether conservative oxygenation would reduce mortality at 28 days compared with the usual liberal-oxygen strategy (N Eng J Med. 2020;382:999-1008). The researchers detected a signal of increased mortality in the conservative oxygen group (34% vs. 27%), which led to a premature stoppage of the trial. “I’d like to postulate that the higher incidence of proning in the liberal oxygenation group compared to the conservative oxygen group (51% to 34%) may be the reason for the difference in mortality,” said Dr. Miyakawa, who was not affiliated with LOCO2. “This is supported from the 2013 PROSEVA Study Group, which reported that prone positioning in ARDS significantly decreases 28- and 90-day mortality” (see N Engl J Med. 2013; 368:2159-68).
She said that future trials on this topic “will have to address how a particular [oxygenation] target is both set and achieved in each group of patients, particularly those with specific organ injuries. In the meantime, in my opinion, avoiding excess oxygen seems sensible.”
Dr. Miyakawa reported having no financial disclosures.
The respiratory therapists at Mount Sinai Beth Israel, New York, know when Lina Miyakawa, MD, starts a week in the ICU, because she turns down the fraction of inspired oxygen (FiO2) levels if patients tolerate it.
“Hyperoxia in mechanical ventilation is a topic that’s near and dear to my heart,” Dr. Miyakawa, a pulmonary and critical care medicine specialist at Mount Sinai Beth Israel, said during SHM Converge, the annual conference of the Society of Hospital Medicine. “You can always find ‘wean down FiO2’ in my consult notes.”
While it is believed that humans have built up evolutionary defenses against hypoxia but not against hyperoxia, medical literature on the topic of hyperoxia with supplemental oxygen is fairly young. “In medical school we were taught to give oxygen for anybody with chest pain and concern about acute coronary syndrome,” she said. “This was until recent data suggested harm from liberal oxygen use.”
In a single-center trial of 434 critical care patients with an ICU length of stay of 72 hours or longer, Italian researchers examined the effects of a conservative protocol for oxygen therapy versus conventional therapy on ICU mortality (JAMA. 2016;316[15]:1583-9). The trial was stopped because the patients who were assigned to receive conservative therapy had a significantly lower mortality than the ones who received usual care (P = .01). “The study was not perfect, and the premature stoppage likely exaggerated the effect size,” said Dr. Miyakawa, who was not affiliated with the trial. “However, subsequent retrospective studies continue to support a benefit with conservative oxygen use, especially in different groups of patients. One of note is hyperoxia following cardiac arrest. There’s something called a two-hit model that speaks to worsening ischemia with reperfusion injury after the initial hypoxic event from the cardiac arrest itself” (See Intensive Care Med. 2015;41:534-6).
In a multicenter cohort study that drew from the Project IMPACT critical care database of ICUs at 120 U.S. hospitals between 2001 and 2005, researchers led by J. Hope Kilgannon, MD, tested the hypothesis that post-resuscitation hyperoxia is associated with increased in-hospital mortality (JAMA. 2010;303[21]:2165-71). The study population consisted of 6,326 patients who were divided into three groups: the hypoxic group (a PaO2 of less than 60 mm Hg); the normoxic group (a PaO2 of 60-299 mm Hg), and the hyperoxic group (a PaO2 of over 300 mm Hg). The mortality for the hyperoxic group was 63%, the hypoxic group at 57%, and the normoxic group at 45%.
More recently, the ICU-ROX Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group evaluated conservative versus liberal approaches in providing oxygen to 965 patients who were mechanically ventilated between 2015 and 2018 at 21 ICUs (N Eng J Med. 2020;382:989-98). Of the 965 patients, 484 were randomly assigned to the conservative oxygen group (defined as an SpO2 of 97% or lower) and 481 were assigned to the usual oxygen group (defined as having no specific measures limiting FiO2 or the SpO2). The primary outcome was the number of ventilator-free days from randomization until day 28, while the secondary outcome was mortality at 180 days. The researchers also performed a subgroup analysis of patients at risk for hypoxic-ischemic encephalopathy.
No significant differences were observed in the number of ventilator days between the two group (a median of 21 days in the conservative oxygen group versus 22 days in the usual oxygen group, respectively; P = .80) nor in mortality at 180 days (35.7% vs. 34.5%). However, in the subgroup analysis, patients with hypoxic-ischemic encephalopathy were noted to have more ventilator-free days (21 vs. 0 days), improved 180-day mortality (43% vs. 59%), and less functional impairment (55% vs. 68%) in the conservative-oxygen group.
“The results of this study suggest that conservative oxygen therapy has no additional advantage over standard oxygen therapy, but there may be benefits in those vulnerable to hyperoxia, which warrants further investigation,” Dr. Miyakawa said. “There are a few points to note on this topic. First, many of the previous studies had more liberal oxygen strategies than the ones used in this study, which could be the reason why we are seeing these results. In addition, O2 titration relies on imperfect approximations. PaO2 cannot be measured continuously; we really depend on the SpO2 on a minute-by-minute basis. Critically ill patients can also undergo episodes of hypoperfusion and shock state minute-by-minute. That’s when they’re at risk for hypoxemia. This would not be captured continuously with just O2 saturations.”
Dr. Miyakawa also highlighted the Liberal Oxygenation versus Conservative Oxygenation in Acute Respiratory Distress Syndrome trial (LOCO2) a prospective, multicenter, randomized, open-label trial involving patients with ARDS. It was carried out at 13 ICUs in France between June 2016 and September 2018 in an effort determine whether conservative oxygenation would reduce mortality at 28 days compared with the usual liberal-oxygen strategy (N Eng J Med. 2020;382:999-1008). The researchers detected a signal of increased mortality in the conservative oxygen group (34% vs. 27%), which led to a premature stoppage of the trial. “I’d like to postulate that the higher incidence of proning in the liberal oxygenation group compared to the conservative oxygen group (51% to 34%) may be the reason for the difference in mortality,” said Dr. Miyakawa, who was not affiliated with LOCO2. “This is supported from the 2013 PROSEVA Study Group, which reported that prone positioning in ARDS significantly decreases 28- and 90-day mortality” (see N Engl J Med. 2013; 368:2159-68).
She said that future trials on this topic “will have to address how a particular [oxygenation] target is both set and achieved in each group of patients, particularly those with specific organ injuries. In the meantime, in my opinion, avoiding excess oxygen seems sensible.”
Dr. Miyakawa reported having no financial disclosures.
The respiratory therapists at Mount Sinai Beth Israel, New York, know when Lina Miyakawa, MD, starts a week in the ICU, because she turns down the fraction of inspired oxygen (FiO2) levels if patients tolerate it.
“Hyperoxia in mechanical ventilation is a topic that’s near and dear to my heart,” Dr. Miyakawa, a pulmonary and critical care medicine specialist at Mount Sinai Beth Israel, said during SHM Converge, the annual conference of the Society of Hospital Medicine. “You can always find ‘wean down FiO2’ in my consult notes.”
While it is believed that humans have built up evolutionary defenses against hypoxia but not against hyperoxia, medical literature on the topic of hyperoxia with supplemental oxygen is fairly young. “In medical school we were taught to give oxygen for anybody with chest pain and concern about acute coronary syndrome,” she said. “This was until recent data suggested harm from liberal oxygen use.”
In a single-center trial of 434 critical care patients with an ICU length of stay of 72 hours or longer, Italian researchers examined the effects of a conservative protocol for oxygen therapy versus conventional therapy on ICU mortality (JAMA. 2016;316[15]:1583-9). The trial was stopped because the patients who were assigned to receive conservative therapy had a significantly lower mortality than the ones who received usual care (P = .01). “The study was not perfect, and the premature stoppage likely exaggerated the effect size,” said Dr. Miyakawa, who was not affiliated with the trial. “However, subsequent retrospective studies continue to support a benefit with conservative oxygen use, especially in different groups of patients. One of note is hyperoxia following cardiac arrest. There’s something called a two-hit model that speaks to worsening ischemia with reperfusion injury after the initial hypoxic event from the cardiac arrest itself” (See Intensive Care Med. 2015;41:534-6).
In a multicenter cohort study that drew from the Project IMPACT critical care database of ICUs at 120 U.S. hospitals between 2001 and 2005, researchers led by J. Hope Kilgannon, MD, tested the hypothesis that post-resuscitation hyperoxia is associated with increased in-hospital mortality (JAMA. 2010;303[21]:2165-71). The study population consisted of 6,326 patients who were divided into three groups: the hypoxic group (a PaO2 of less than 60 mm Hg); the normoxic group (a PaO2 of 60-299 mm Hg), and the hyperoxic group (a PaO2 of over 300 mm Hg). The mortality for the hyperoxic group was 63%, the hypoxic group at 57%, and the normoxic group at 45%.
More recently, the ICU-ROX Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group evaluated conservative versus liberal approaches in providing oxygen to 965 patients who were mechanically ventilated between 2015 and 2018 at 21 ICUs (N Eng J Med. 2020;382:989-98). Of the 965 patients, 484 were randomly assigned to the conservative oxygen group (defined as an SpO2 of 97% or lower) and 481 were assigned to the usual oxygen group (defined as having no specific measures limiting FiO2 or the SpO2). The primary outcome was the number of ventilator-free days from randomization until day 28, while the secondary outcome was mortality at 180 days. The researchers also performed a subgroup analysis of patients at risk for hypoxic-ischemic encephalopathy.
No significant differences were observed in the number of ventilator days between the two group (a median of 21 days in the conservative oxygen group versus 22 days in the usual oxygen group, respectively; P = .80) nor in mortality at 180 days (35.7% vs. 34.5%). However, in the subgroup analysis, patients with hypoxic-ischemic encephalopathy were noted to have more ventilator-free days (21 vs. 0 days), improved 180-day mortality (43% vs. 59%), and less functional impairment (55% vs. 68%) in the conservative-oxygen group.
“The results of this study suggest that conservative oxygen therapy has no additional advantage over standard oxygen therapy, but there may be benefits in those vulnerable to hyperoxia, which warrants further investigation,” Dr. Miyakawa said. “There are a few points to note on this topic. First, many of the previous studies had more liberal oxygen strategies than the ones used in this study, which could be the reason why we are seeing these results. In addition, O2 titration relies on imperfect approximations. PaO2 cannot be measured continuously; we really depend on the SpO2 on a minute-by-minute basis. Critically ill patients can also undergo episodes of hypoperfusion and shock state minute-by-minute. That’s when they’re at risk for hypoxemia. This would not be captured continuously with just O2 saturations.”
Dr. Miyakawa also highlighted the Liberal Oxygenation versus Conservative Oxygenation in Acute Respiratory Distress Syndrome trial (LOCO2) a prospective, multicenter, randomized, open-label trial involving patients with ARDS. It was carried out at 13 ICUs in France between June 2016 and September 2018 in an effort determine whether conservative oxygenation would reduce mortality at 28 days compared with the usual liberal-oxygen strategy (N Eng J Med. 2020;382:999-1008). The researchers detected a signal of increased mortality in the conservative oxygen group (34% vs. 27%), which led to a premature stoppage of the trial. “I’d like to postulate that the higher incidence of proning in the liberal oxygenation group compared to the conservative oxygen group (51% to 34%) may be the reason for the difference in mortality,” said Dr. Miyakawa, who was not affiliated with LOCO2. “This is supported from the 2013 PROSEVA Study Group, which reported that prone positioning in ARDS significantly decreases 28- and 90-day mortality” (see N Engl J Med. 2013; 368:2159-68).
She said that future trials on this topic “will have to address how a particular [oxygenation] target is both set and achieved in each group of patients, particularly those with specific organ injuries. In the meantime, in my opinion, avoiding excess oxygen seems sensible.”
Dr. Miyakawa reported having no financial disclosures.
FROM SHM CONVERGE 2021
Hospitalists innovate in ICU management
With intensive care units stretched to their limits – and beyond – during the COVID-19 pandemic, hospitalists became more central than ever in orchestrating the response.
At SHM Converge, the annual conference of the Society of Hospital Medicine, two hospitalists shared how their teams helped to develop new critical care units and strategies for best managing and allocating care to COVID patients in the ICU.
“The pandemic has been a selective pressure on us as a specialty,” said Jason Stein, MD, SFHM, a full-time clinical hospitalist at Roper Hospital, a 332-bed facility in Charleston, S.C.
Dr. Stein explained how hospitalists at Roper helped create the Progressive Care Unit – a negative-pressure unit with 12 high-flow oxygen beds overseen by a hospital medicine team, with the help of a respiratory therapist, pharmacist, and nurses. Patients in this unit had escalating acuity – quickly increasing oxygen needs – or deescalating acuity, such as ICU transfers, Dr. Stein said. Cardiac catheterization space was converted for the unit, which was intended to preserve beds in the hospital ICU for patients needing mechanical ventilation or vasoactive medication.
Interdisciplinary rounds – to assess oxygen and inflammatory marker trends, and run through a COVID care checklist – took place every day at 10 a.m.
“Consistency was the key,” Dr. Stein said.
At Weill Cornell Medical Center in New York, hospitalists helped build the COVID Recovery Unit, which was dedicated to the care of patients coming out of the ICU, said Vishwas Anand Singh, MD, MS, FHM, cochief of hospital medicine at New York Presbyterian–Lower Manhattan Hospital.
“The pandemic created an unprecedented need for critical care, and post-ICU care,” Dr. Singh said. “After extubation, patients remain very complicated and they have unique needs.”
The 30-bed COVID Recovery Unit – converted from a behavioral health unit – was designed to meet those needs. It was staffed by one lead hospitalist, 3 hospitalist physicians, 3 advanced practitioners, about 12 nurses and a neurologist, psychiatrist, and neuropsychologist.
The idea was to integrate medical care with careful attention to rehab and neuropsychological needs, Dr. Singh said. To be in the unit, patients had to be medically stable but with ongoing medical and rehabilitation needs and able to tolerate about half an hour of physical or occupational therapy each day.
The space was set up so that patients could interact with each other as well as staff, and this ability to share their experiences of trauma and recovery “led to an improved sense of psychological well-being and to healing,” according to Dr. Singh. Group therapy and meditation were also held several times a week.
“All this together, we thought we were really meeting the need for a lot of these patients from medical to psychosocial,” he said.
New York Presbyterian––Lower Manhattan Hospital also established a program called ICU Outreach to give hospitalists a “bird’s eye view” of the ICU in order to help move patients from unit to unit for optimized care. One hospitalist acted as a bridge between the ICU, the floors, and the emergency room.
The hospitalist on duty touched based with the ICU each day at 10 a.m., assessed the available beds, compiled a list of patients being discharged, met with all of the hospitalists and individual teams in inpatient and emergency services, and compiled a list of “watchers” – the sickest patients who needed help being managed.
The broad perspective was important, Dr. Singh said.
“We quickly found that each individual team or provider only knew the patients they were caring for, and the ICU Outreach person knew the whole big picture and could put the pieces together,” he said. “They could answer who was next in line for a bed, who benefited from a goals of care discussion, who could be managed on the floor with assistance. And this bridge, having this person fill this role, allowed the intensivists to focus on the patients they had in the unit.”
Palliative care and patient flow
Dr. Singh also described how hospitalists played an important role in palliative care for COVID patients. The hospital medicine team offered hospitalist palliative care services, which included COVIDtalk, a course on communicating about end of life, which helped to expand the pool of palliative care providers. Those trained were taught that these difficult conversations had to be honest and clear, with the goals of care addressed very early in the admission, should a patient decompensate soon after arrival.
A palliative “rapid response team” included a virtual hospitalist, a palliative care nurse practitioner, and a virtual psychiatrist – a team available 24 hours a day to have longer conversations so that clinicians could better tend to their patients when the in-person palliative care service was stretched thin, or at off hours like the middle of the night.
These innovations not only helped serve patients and families better, but also gave hospitalists training and experience in palliative care.
At Roper Hospital, Dr. Stein explained how hospitalists helped improve management of COVID patient flow. Depending on the time of day and the staffing on duty, there could be considerable confusion about where patients should go after the ED, or the COVID progressive unit, or the floor.
Hospitalists helped develop hospitalwide algorithms for escalating and deescalating acuity, Dr. Stein said, providing a “shared mental model for where a patient should go.”
“There are many ways hospitalists can and did rise to meet the unique demands of COVID,” Dr. Singh said, “whether it was innovating a new unit or service or work flow or leading a multidisciplinary team to extend or support other services that may have been strained.”
With intensive care units stretched to their limits – and beyond – during the COVID-19 pandemic, hospitalists became more central than ever in orchestrating the response.
At SHM Converge, the annual conference of the Society of Hospital Medicine, two hospitalists shared how their teams helped to develop new critical care units and strategies for best managing and allocating care to COVID patients in the ICU.
“The pandemic has been a selective pressure on us as a specialty,” said Jason Stein, MD, SFHM, a full-time clinical hospitalist at Roper Hospital, a 332-bed facility in Charleston, S.C.
Dr. Stein explained how hospitalists at Roper helped create the Progressive Care Unit – a negative-pressure unit with 12 high-flow oxygen beds overseen by a hospital medicine team, with the help of a respiratory therapist, pharmacist, and nurses. Patients in this unit had escalating acuity – quickly increasing oxygen needs – or deescalating acuity, such as ICU transfers, Dr. Stein said. Cardiac catheterization space was converted for the unit, which was intended to preserve beds in the hospital ICU for patients needing mechanical ventilation or vasoactive medication.
Interdisciplinary rounds – to assess oxygen and inflammatory marker trends, and run through a COVID care checklist – took place every day at 10 a.m.
“Consistency was the key,” Dr. Stein said.
At Weill Cornell Medical Center in New York, hospitalists helped build the COVID Recovery Unit, which was dedicated to the care of patients coming out of the ICU, said Vishwas Anand Singh, MD, MS, FHM, cochief of hospital medicine at New York Presbyterian–Lower Manhattan Hospital.
“The pandemic created an unprecedented need for critical care, and post-ICU care,” Dr. Singh said. “After extubation, patients remain very complicated and they have unique needs.”
The 30-bed COVID Recovery Unit – converted from a behavioral health unit – was designed to meet those needs. It was staffed by one lead hospitalist, 3 hospitalist physicians, 3 advanced practitioners, about 12 nurses and a neurologist, psychiatrist, and neuropsychologist.
The idea was to integrate medical care with careful attention to rehab and neuropsychological needs, Dr. Singh said. To be in the unit, patients had to be medically stable but with ongoing medical and rehabilitation needs and able to tolerate about half an hour of physical or occupational therapy each day.
The space was set up so that patients could interact with each other as well as staff, and this ability to share their experiences of trauma and recovery “led to an improved sense of psychological well-being and to healing,” according to Dr. Singh. Group therapy and meditation were also held several times a week.
“All this together, we thought we were really meeting the need for a lot of these patients from medical to psychosocial,” he said.
New York Presbyterian––Lower Manhattan Hospital also established a program called ICU Outreach to give hospitalists a “bird’s eye view” of the ICU in order to help move patients from unit to unit for optimized care. One hospitalist acted as a bridge between the ICU, the floors, and the emergency room.
The hospitalist on duty touched based with the ICU each day at 10 a.m., assessed the available beds, compiled a list of patients being discharged, met with all of the hospitalists and individual teams in inpatient and emergency services, and compiled a list of “watchers” – the sickest patients who needed help being managed.
The broad perspective was important, Dr. Singh said.
“We quickly found that each individual team or provider only knew the patients they were caring for, and the ICU Outreach person knew the whole big picture and could put the pieces together,” he said. “They could answer who was next in line for a bed, who benefited from a goals of care discussion, who could be managed on the floor with assistance. And this bridge, having this person fill this role, allowed the intensivists to focus on the patients they had in the unit.”
Palliative care and patient flow
Dr. Singh also described how hospitalists played an important role in palliative care for COVID patients. The hospital medicine team offered hospitalist palliative care services, which included COVIDtalk, a course on communicating about end of life, which helped to expand the pool of palliative care providers. Those trained were taught that these difficult conversations had to be honest and clear, with the goals of care addressed very early in the admission, should a patient decompensate soon after arrival.
A palliative “rapid response team” included a virtual hospitalist, a palliative care nurse practitioner, and a virtual psychiatrist – a team available 24 hours a day to have longer conversations so that clinicians could better tend to their patients when the in-person palliative care service was stretched thin, or at off hours like the middle of the night.
These innovations not only helped serve patients and families better, but also gave hospitalists training and experience in palliative care.
At Roper Hospital, Dr. Stein explained how hospitalists helped improve management of COVID patient flow. Depending on the time of day and the staffing on duty, there could be considerable confusion about where patients should go after the ED, or the COVID progressive unit, or the floor.
Hospitalists helped develop hospitalwide algorithms for escalating and deescalating acuity, Dr. Stein said, providing a “shared mental model for where a patient should go.”
“There are many ways hospitalists can and did rise to meet the unique demands of COVID,” Dr. Singh said, “whether it was innovating a new unit or service or work flow or leading a multidisciplinary team to extend or support other services that may have been strained.”
With intensive care units stretched to their limits – and beyond – during the COVID-19 pandemic, hospitalists became more central than ever in orchestrating the response.
At SHM Converge, the annual conference of the Society of Hospital Medicine, two hospitalists shared how their teams helped to develop new critical care units and strategies for best managing and allocating care to COVID patients in the ICU.
“The pandemic has been a selective pressure on us as a specialty,” said Jason Stein, MD, SFHM, a full-time clinical hospitalist at Roper Hospital, a 332-bed facility in Charleston, S.C.
Dr. Stein explained how hospitalists at Roper helped create the Progressive Care Unit – a negative-pressure unit with 12 high-flow oxygen beds overseen by a hospital medicine team, with the help of a respiratory therapist, pharmacist, and nurses. Patients in this unit had escalating acuity – quickly increasing oxygen needs – or deescalating acuity, such as ICU transfers, Dr. Stein said. Cardiac catheterization space was converted for the unit, which was intended to preserve beds in the hospital ICU for patients needing mechanical ventilation or vasoactive medication.
Interdisciplinary rounds – to assess oxygen and inflammatory marker trends, and run through a COVID care checklist – took place every day at 10 a.m.
“Consistency was the key,” Dr. Stein said.
At Weill Cornell Medical Center in New York, hospitalists helped build the COVID Recovery Unit, which was dedicated to the care of patients coming out of the ICU, said Vishwas Anand Singh, MD, MS, FHM, cochief of hospital medicine at New York Presbyterian–Lower Manhattan Hospital.
“The pandemic created an unprecedented need for critical care, and post-ICU care,” Dr. Singh said. “After extubation, patients remain very complicated and they have unique needs.”
The 30-bed COVID Recovery Unit – converted from a behavioral health unit – was designed to meet those needs. It was staffed by one lead hospitalist, 3 hospitalist physicians, 3 advanced practitioners, about 12 nurses and a neurologist, psychiatrist, and neuropsychologist.
The idea was to integrate medical care with careful attention to rehab and neuropsychological needs, Dr. Singh said. To be in the unit, patients had to be medically stable but with ongoing medical and rehabilitation needs and able to tolerate about half an hour of physical or occupational therapy each day.
The space was set up so that patients could interact with each other as well as staff, and this ability to share their experiences of trauma and recovery “led to an improved sense of psychological well-being and to healing,” according to Dr. Singh. Group therapy and meditation were also held several times a week.
“All this together, we thought we were really meeting the need for a lot of these patients from medical to psychosocial,” he said.
New York Presbyterian––Lower Manhattan Hospital also established a program called ICU Outreach to give hospitalists a “bird’s eye view” of the ICU in order to help move patients from unit to unit for optimized care. One hospitalist acted as a bridge between the ICU, the floors, and the emergency room.
The hospitalist on duty touched based with the ICU each day at 10 a.m., assessed the available beds, compiled a list of patients being discharged, met with all of the hospitalists and individual teams in inpatient and emergency services, and compiled a list of “watchers” – the sickest patients who needed help being managed.
The broad perspective was important, Dr. Singh said.
“We quickly found that each individual team or provider only knew the patients they were caring for, and the ICU Outreach person knew the whole big picture and could put the pieces together,” he said. “They could answer who was next in line for a bed, who benefited from a goals of care discussion, who could be managed on the floor with assistance. And this bridge, having this person fill this role, allowed the intensivists to focus on the patients they had in the unit.”
Palliative care and patient flow
Dr. Singh also described how hospitalists played an important role in palliative care for COVID patients. The hospital medicine team offered hospitalist palliative care services, which included COVIDtalk, a course on communicating about end of life, which helped to expand the pool of palliative care providers. Those trained were taught that these difficult conversations had to be honest and clear, with the goals of care addressed very early in the admission, should a patient decompensate soon after arrival.
A palliative “rapid response team” included a virtual hospitalist, a palliative care nurse practitioner, and a virtual psychiatrist – a team available 24 hours a day to have longer conversations so that clinicians could better tend to their patients when the in-person palliative care service was stretched thin, or at off hours like the middle of the night.
These innovations not only helped serve patients and families better, but also gave hospitalists training and experience in palliative care.
At Roper Hospital, Dr. Stein explained how hospitalists helped improve management of COVID patient flow. Depending on the time of day and the staffing on duty, there could be considerable confusion about where patients should go after the ED, or the COVID progressive unit, or the floor.
Hospitalists helped develop hospitalwide algorithms for escalating and deescalating acuity, Dr. Stein said, providing a “shared mental model for where a patient should go.”
“There are many ways hospitalists can and did rise to meet the unique demands of COVID,” Dr. Singh said, “whether it was innovating a new unit or service or work flow or leading a multidisciplinary team to extend or support other services that may have been strained.”
FROM SHM CONVERGE 2021
Pandemic experience taught lessons about clinician wellness
As a member of the Society of Hospital Medicine Wellbeing Task Force, Mark Rudolph, MD, SFHM, thought he understood a thing or two about resilience, but nothing could prepare him for the vulnerability he felt when his parents became infected with COVID-19 following a visit to New York City in March 2020 – which soon became an epicenter of disease outbreak.
“They were both quite ill but fortunately they recovered,” Dr. Rudolph, chief experience officer for Sound Physicians said during SHM Converge, the annual conference of the Society of Hospital Medicine. He had completed his residency training in New York, where he cared for patients following the 9/11 terrorist attacks, “so I had a lot of PTSD related to all that stuff,” he recalled. Then he started to worry about the clinicians who work for Sound Physicians, a multispecialty group with roots in hospital medicine. “I found it difficult knowing there was someone in the hospital somewhere taking care of our patients all day long, all night long,” he said. “I felt fearful for them.”
Other members of the SHM Wellbeing Task Force shared challenges they faced during the pandemic’s early stages, as well as lessons learned. Task force chair Sarah Richards, MD, said the COVID-19 pandemic brought on feelings of guilt after hearing from fellow hospitalists about the surge of cases they were caring for, or that their best friend or colleague died by suicide. “I felt a sense of guilt because I didn’t have a loved one get COVID or die from COVID,” said Dr. Richards, a hospitalist at the University of Nebraska Medical Center in Omaha. “I felt like the world was crumbling around me and I was still okay. That guilt was almost like a helplessness. I didn’t know how make it better. I didn’t know how to help people because the problem was so big, especially during the height of the pandemic. That was tough for me because I’m a helper. I think we go into this field wanting to help and I feel like we didn’t know how to help make things better.”
Sonia George, MD, recalled first hearing about COVID-19 as she was preparing to attend the 2020 SHM annual conference in San Diego, which was planned for April but was canceled amid the escalating health concerns. “That was difficult for me, because I wanted to travel more in 2020,” said Dr. George, a hospitalist at Long Island Jewish Medical Center in New Hyde Park, N.Y. “Traveling is something that I’ve been wanting to do ever since I finished residency, after all that training. I wanted to reward myself. What I have learned about myself is that I’ve learned to be more patient, to take every day as it is, to find some small moments of joy within each day and try to take that forward with me, and try to remember what I do have, and celebrate that a bit more every day.”
Over the past 14 months or so, Dr. Rudolph said that he grew to appreciate the importance of connecting with colleagues, “however short [the time] may be, where we can talk with one another, commiserate, discuss situations and experiences – whether virtually or in person. Those have been critical. If you add those all up, that’s what’s keeping us all going. At least it’s keeping me going.”
Dr. Richards echoed that sentiment. “The lesson I learned is that people really do want to share and to talk,” she said. “I can’t tell you how many times I told people about my [sense of] guilt and they would say things like, ‘Me, too!’ Knowing ‘it’s not just me’ made me feel so much better.”
During the course of the pandemic, the SHM Wellbeing Task Force created a one-page resource for clinicians known as the “Hospital Medicine COVID-19 Check-in Guide for Self & Peers,” which can be accessed here:. The three main recommended steps are to identify (“self-assess” to see if you are experiencing physical, emotional, cognitive, or behavioral stress); initiate (“reach out to your colleagues one-one-one or in small informal groups”); and intervene (“take action to make change or get help.”)
“Wellness and thriving are a team sport,” observed task force member Patrick Kneeland, MD, vice president of medical affairs at DispatchHealth, which provides hospital to home services. “It’s not an individual task to achieve. The team sport thing is complicated by gowns and masks and the lack of in-person meetings. You can’t even grab a cup of coffee with colleagues. That part has impacted most of us.” However, he said, he learned that clinicians can “double down on those small practices that form human connection” by using virtual communication platforms like Zoom. “For me, it’s been a great reminder [of] why presence with others matters, even if it’s in an unusual format, and how sharing our humanity across [communication] channels or through several layers of PPE is so critical.” Dr. Kneeland said.
None of the presenters reported having financial disclosures.
As a member of the Society of Hospital Medicine Wellbeing Task Force, Mark Rudolph, MD, SFHM, thought he understood a thing or two about resilience, but nothing could prepare him for the vulnerability he felt when his parents became infected with COVID-19 following a visit to New York City in March 2020 – which soon became an epicenter of disease outbreak.
“They were both quite ill but fortunately they recovered,” Dr. Rudolph, chief experience officer for Sound Physicians said during SHM Converge, the annual conference of the Society of Hospital Medicine. He had completed his residency training in New York, where he cared for patients following the 9/11 terrorist attacks, “so I had a lot of PTSD related to all that stuff,” he recalled. Then he started to worry about the clinicians who work for Sound Physicians, a multispecialty group with roots in hospital medicine. “I found it difficult knowing there was someone in the hospital somewhere taking care of our patients all day long, all night long,” he said. “I felt fearful for them.”
Other members of the SHM Wellbeing Task Force shared challenges they faced during the pandemic’s early stages, as well as lessons learned. Task force chair Sarah Richards, MD, said the COVID-19 pandemic brought on feelings of guilt after hearing from fellow hospitalists about the surge of cases they were caring for, or that their best friend or colleague died by suicide. “I felt a sense of guilt because I didn’t have a loved one get COVID or die from COVID,” said Dr. Richards, a hospitalist at the University of Nebraska Medical Center in Omaha. “I felt like the world was crumbling around me and I was still okay. That guilt was almost like a helplessness. I didn’t know how make it better. I didn’t know how to help people because the problem was so big, especially during the height of the pandemic. That was tough for me because I’m a helper. I think we go into this field wanting to help and I feel like we didn’t know how to help make things better.”
Sonia George, MD, recalled first hearing about COVID-19 as she was preparing to attend the 2020 SHM annual conference in San Diego, which was planned for April but was canceled amid the escalating health concerns. “That was difficult for me, because I wanted to travel more in 2020,” said Dr. George, a hospitalist at Long Island Jewish Medical Center in New Hyde Park, N.Y. “Traveling is something that I’ve been wanting to do ever since I finished residency, after all that training. I wanted to reward myself. What I have learned about myself is that I’ve learned to be more patient, to take every day as it is, to find some small moments of joy within each day and try to take that forward with me, and try to remember what I do have, and celebrate that a bit more every day.”
Over the past 14 months or so, Dr. Rudolph said that he grew to appreciate the importance of connecting with colleagues, “however short [the time] may be, where we can talk with one another, commiserate, discuss situations and experiences – whether virtually or in person. Those have been critical. If you add those all up, that’s what’s keeping us all going. At least it’s keeping me going.”
Dr. Richards echoed that sentiment. “The lesson I learned is that people really do want to share and to talk,” she said. “I can’t tell you how many times I told people about my [sense of] guilt and they would say things like, ‘Me, too!’ Knowing ‘it’s not just me’ made me feel so much better.”
During the course of the pandemic, the SHM Wellbeing Task Force created a one-page resource for clinicians known as the “Hospital Medicine COVID-19 Check-in Guide for Self & Peers,” which can be accessed here:. The three main recommended steps are to identify (“self-assess” to see if you are experiencing physical, emotional, cognitive, or behavioral stress); initiate (“reach out to your colleagues one-one-one or in small informal groups”); and intervene (“take action to make change or get help.”)
“Wellness and thriving are a team sport,” observed task force member Patrick Kneeland, MD, vice president of medical affairs at DispatchHealth, which provides hospital to home services. “It’s not an individual task to achieve. The team sport thing is complicated by gowns and masks and the lack of in-person meetings. You can’t even grab a cup of coffee with colleagues. That part has impacted most of us.” However, he said, he learned that clinicians can “double down on those small practices that form human connection” by using virtual communication platforms like Zoom. “For me, it’s been a great reminder [of] why presence with others matters, even if it’s in an unusual format, and how sharing our humanity across [communication] channels or through several layers of PPE is so critical.” Dr. Kneeland said.
None of the presenters reported having financial disclosures.
As a member of the Society of Hospital Medicine Wellbeing Task Force, Mark Rudolph, MD, SFHM, thought he understood a thing or two about resilience, but nothing could prepare him for the vulnerability he felt when his parents became infected with COVID-19 following a visit to New York City in March 2020 – which soon became an epicenter of disease outbreak.
“They were both quite ill but fortunately they recovered,” Dr. Rudolph, chief experience officer for Sound Physicians said during SHM Converge, the annual conference of the Society of Hospital Medicine. He had completed his residency training in New York, where he cared for patients following the 9/11 terrorist attacks, “so I had a lot of PTSD related to all that stuff,” he recalled. Then he started to worry about the clinicians who work for Sound Physicians, a multispecialty group with roots in hospital medicine. “I found it difficult knowing there was someone in the hospital somewhere taking care of our patients all day long, all night long,” he said. “I felt fearful for them.”
Other members of the SHM Wellbeing Task Force shared challenges they faced during the pandemic’s early stages, as well as lessons learned. Task force chair Sarah Richards, MD, said the COVID-19 pandemic brought on feelings of guilt after hearing from fellow hospitalists about the surge of cases they were caring for, or that their best friend or colleague died by suicide. “I felt a sense of guilt because I didn’t have a loved one get COVID or die from COVID,” said Dr. Richards, a hospitalist at the University of Nebraska Medical Center in Omaha. “I felt like the world was crumbling around me and I was still okay. That guilt was almost like a helplessness. I didn’t know how make it better. I didn’t know how to help people because the problem was so big, especially during the height of the pandemic. That was tough for me because I’m a helper. I think we go into this field wanting to help and I feel like we didn’t know how to help make things better.”
Sonia George, MD, recalled first hearing about COVID-19 as she was preparing to attend the 2020 SHM annual conference in San Diego, which was planned for April but was canceled amid the escalating health concerns. “That was difficult for me, because I wanted to travel more in 2020,” said Dr. George, a hospitalist at Long Island Jewish Medical Center in New Hyde Park, N.Y. “Traveling is something that I’ve been wanting to do ever since I finished residency, after all that training. I wanted to reward myself. What I have learned about myself is that I’ve learned to be more patient, to take every day as it is, to find some small moments of joy within each day and try to take that forward with me, and try to remember what I do have, and celebrate that a bit more every day.”
Over the past 14 months or so, Dr. Rudolph said that he grew to appreciate the importance of connecting with colleagues, “however short [the time] may be, where we can talk with one another, commiserate, discuss situations and experiences – whether virtually or in person. Those have been critical. If you add those all up, that’s what’s keeping us all going. At least it’s keeping me going.”
Dr. Richards echoed that sentiment. “The lesson I learned is that people really do want to share and to talk,” she said. “I can’t tell you how many times I told people about my [sense of] guilt and they would say things like, ‘Me, too!’ Knowing ‘it’s not just me’ made me feel so much better.”
During the course of the pandemic, the SHM Wellbeing Task Force created a one-page resource for clinicians known as the “Hospital Medicine COVID-19 Check-in Guide for Self & Peers,” which can be accessed here:. The three main recommended steps are to identify (“self-assess” to see if you are experiencing physical, emotional, cognitive, or behavioral stress); initiate (“reach out to your colleagues one-one-one or in small informal groups”); and intervene (“take action to make change or get help.”)
“Wellness and thriving are a team sport,” observed task force member Patrick Kneeland, MD, vice president of medical affairs at DispatchHealth, which provides hospital to home services. “It’s not an individual task to achieve. The team sport thing is complicated by gowns and masks and the lack of in-person meetings. You can’t even grab a cup of coffee with colleagues. That part has impacted most of us.” However, he said, he learned that clinicians can “double down on those small practices that form human connection” by using virtual communication platforms like Zoom. “For me, it’s been a great reminder [of] why presence with others matters, even if it’s in an unusual format, and how sharing our humanity across [communication] channels or through several layers of PPE is so critical.” Dr. Kneeland said.
None of the presenters reported having financial disclosures.
FROM SHM CONVERGE 2021
Making sense of LAMA discharges
Converge 2021 session
LAMA’s DRAMA: Left AMA – Documentation and Rules of AMA
Presenter
Venkatrao Medarametla, MD, SFHM
Session summary
Most hospitalists equate LAMA (left against medical advice) patients with noncompliance and stop at that. During the recent SHM Converge conference session on LAMA, Dr. Venkatrao Medarametla, medical director for hospital medicine at Baystate Medical Center, Springfield, Mass., delved into the etiology and pathophysiology of LAMA discharges.
According to Dr. Medarametla, LAMA accounts for 1.4% of all discharges amounting to more than 500,000 discharges per year nationwide. LAMA discharges are at high risk for readmissions (20%-40% higher), have longer length of stay on readmission, higher morbidity and mortality (10% higher), and result in higher costs of care (56% higher).
The reasons for LAMA discharges could be broadly divided into patient and provider factors. Patient factors include refusal to wait for administrative delays, extenuating domestic and social concerns, conflicts with care providers, disagreement with providers’ judgment of health status, mistrust of the health system, substance dependence with inadequate treatment for withdrawal, patient’s perception of respect, stereotyping or stigma, and even ambiance and diet at the hospital.
Provider factors include conflict with the patient, concerns of legal and ethical responsibilities, formally distancing from nonstandard plan, and deflecting blame for worse outcomes.
Faced with a LAMA discharge, the important role of a hospitalist is to assess capacity. Help may be sought from other specialists such as psychiatrists and geriatricians. Some of the best practices also include a clear discussion of risks of outpatient treatment, exploration of safe alternative care plans, patient-centered care, shared decision-making (e.g., needle exchange), and harm reduction.
Dr. Medarametla advised hospitalists not to rely on the AMA forms the patients are asked to sign for liability protection. The forms may not stand up to legal scrutiny. Excellent documentation regarding the details of discussions with the patient, and determination of capacity encompassing the patients’ understanding, reasoning, and insight should be made. Hospitalists can also assess the barriers and mitigate them. Appropriate outpatient and alternative treatment plans should be explored. Postdischarge care and follow ups also should be facilitated.
According to Dr. Medarametla, another myth about AMA discharge is that insurance will not pay for it. About 57% of a survey sample of attendings and residents believed the same, and 66% heard other providers telling patients that insurance would not cover the AMA discharges. In a multicentric study of 526 patients, payment was refused only in 4.1% of AMA cases, mostly for administrative reasons.
Another prevalent myth is that patients who leave AMA will lose their right to follow up. Prescriptions also could be given to LAMA patients provided hospitalists adhere to detailed and relevant documentation. Overall, the session was very interesting and informative.
Key takeaways
- There are patient and provider factors leading to LAMA.
- Patients signing an AMA form does not provide legal protection for providers, but a stream-lined discharge process and a detailed documentation are likely to.
- There is no evidence that insurance companies will not pay for LAMA discharges.
- LAMA patients could be given prescriptions and follow up as long as they are well documented.
References
Schaefer G et al. Financial responsibility of hospitalized patients who left against medical advice: Medical urban legend? J Gen Intern Med. 2012 Jul;27(7):825-30. doi: 10.1007/s11606-012-1984-x.
Wigder H et al. Insurance companies refusing payment for patients who leave the emergency department against medical advice is a myth. Ann Emerg Med. 2010 Apr;55(4):393. doi: 10.1016/j.annemergmed.2009.11.024.
Dr. Kumar is a hospitalist in Port Huron, Mich. He is a member of the editorial advisory board for the Hospitalist.
Converge 2021 session
LAMA’s DRAMA: Left AMA – Documentation and Rules of AMA
Presenter
Venkatrao Medarametla, MD, SFHM
Session summary
Most hospitalists equate LAMA (left against medical advice) patients with noncompliance and stop at that. During the recent SHM Converge conference session on LAMA, Dr. Venkatrao Medarametla, medical director for hospital medicine at Baystate Medical Center, Springfield, Mass., delved into the etiology and pathophysiology of LAMA discharges.
According to Dr. Medarametla, LAMA accounts for 1.4% of all discharges amounting to more than 500,000 discharges per year nationwide. LAMA discharges are at high risk for readmissions (20%-40% higher), have longer length of stay on readmission, higher morbidity and mortality (10% higher), and result in higher costs of care (56% higher).
The reasons for LAMA discharges could be broadly divided into patient and provider factors. Patient factors include refusal to wait for administrative delays, extenuating domestic and social concerns, conflicts with care providers, disagreement with providers’ judgment of health status, mistrust of the health system, substance dependence with inadequate treatment for withdrawal, patient’s perception of respect, stereotyping or stigma, and even ambiance and diet at the hospital.
Provider factors include conflict with the patient, concerns of legal and ethical responsibilities, formally distancing from nonstandard plan, and deflecting blame for worse outcomes.
Faced with a LAMA discharge, the important role of a hospitalist is to assess capacity. Help may be sought from other specialists such as psychiatrists and geriatricians. Some of the best practices also include a clear discussion of risks of outpatient treatment, exploration of safe alternative care plans, patient-centered care, shared decision-making (e.g., needle exchange), and harm reduction.
Dr. Medarametla advised hospitalists not to rely on the AMA forms the patients are asked to sign for liability protection. The forms may not stand up to legal scrutiny. Excellent documentation regarding the details of discussions with the patient, and determination of capacity encompassing the patients’ understanding, reasoning, and insight should be made. Hospitalists can also assess the barriers and mitigate them. Appropriate outpatient and alternative treatment plans should be explored. Postdischarge care and follow ups also should be facilitated.
According to Dr. Medarametla, another myth about AMA discharge is that insurance will not pay for it. About 57% of a survey sample of attendings and residents believed the same, and 66% heard other providers telling patients that insurance would not cover the AMA discharges. In a multicentric study of 526 patients, payment was refused only in 4.1% of AMA cases, mostly for administrative reasons.
Another prevalent myth is that patients who leave AMA will lose their right to follow up. Prescriptions also could be given to LAMA patients provided hospitalists adhere to detailed and relevant documentation. Overall, the session was very interesting and informative.
Key takeaways
- There are patient and provider factors leading to LAMA.
- Patients signing an AMA form does not provide legal protection for providers, but a stream-lined discharge process and a detailed documentation are likely to.
- There is no evidence that insurance companies will not pay for LAMA discharges.
- LAMA patients could be given prescriptions and follow up as long as they are well documented.
References
Schaefer G et al. Financial responsibility of hospitalized patients who left against medical advice: Medical urban legend? J Gen Intern Med. 2012 Jul;27(7):825-30. doi: 10.1007/s11606-012-1984-x.
Wigder H et al. Insurance companies refusing payment for patients who leave the emergency department against medical advice is a myth. Ann Emerg Med. 2010 Apr;55(4):393. doi: 10.1016/j.annemergmed.2009.11.024.
Dr. Kumar is a hospitalist in Port Huron, Mich. He is a member of the editorial advisory board for the Hospitalist.
Converge 2021 session
LAMA’s DRAMA: Left AMA – Documentation and Rules of AMA
Presenter
Venkatrao Medarametla, MD, SFHM
Session summary
Most hospitalists equate LAMA (left against medical advice) patients with noncompliance and stop at that. During the recent SHM Converge conference session on LAMA, Dr. Venkatrao Medarametla, medical director for hospital medicine at Baystate Medical Center, Springfield, Mass., delved into the etiology and pathophysiology of LAMA discharges.
According to Dr. Medarametla, LAMA accounts for 1.4% of all discharges amounting to more than 500,000 discharges per year nationwide. LAMA discharges are at high risk for readmissions (20%-40% higher), have longer length of stay on readmission, higher morbidity and mortality (10% higher), and result in higher costs of care (56% higher).
The reasons for LAMA discharges could be broadly divided into patient and provider factors. Patient factors include refusal to wait for administrative delays, extenuating domestic and social concerns, conflicts with care providers, disagreement with providers’ judgment of health status, mistrust of the health system, substance dependence with inadequate treatment for withdrawal, patient’s perception of respect, stereotyping or stigma, and even ambiance and diet at the hospital.
Provider factors include conflict with the patient, concerns of legal and ethical responsibilities, formally distancing from nonstandard plan, and deflecting blame for worse outcomes.
Faced with a LAMA discharge, the important role of a hospitalist is to assess capacity. Help may be sought from other specialists such as psychiatrists and geriatricians. Some of the best practices also include a clear discussion of risks of outpatient treatment, exploration of safe alternative care plans, patient-centered care, shared decision-making (e.g., needle exchange), and harm reduction.
Dr. Medarametla advised hospitalists not to rely on the AMA forms the patients are asked to sign for liability protection. The forms may not stand up to legal scrutiny. Excellent documentation regarding the details of discussions with the patient, and determination of capacity encompassing the patients’ understanding, reasoning, and insight should be made. Hospitalists can also assess the barriers and mitigate them. Appropriate outpatient and alternative treatment plans should be explored. Postdischarge care and follow ups also should be facilitated.
According to Dr. Medarametla, another myth about AMA discharge is that insurance will not pay for it. About 57% of a survey sample of attendings and residents believed the same, and 66% heard other providers telling patients that insurance would not cover the AMA discharges. In a multicentric study of 526 patients, payment was refused only in 4.1% of AMA cases, mostly for administrative reasons.
Another prevalent myth is that patients who leave AMA will lose their right to follow up. Prescriptions also could be given to LAMA patients provided hospitalists adhere to detailed and relevant documentation. Overall, the session was very interesting and informative.
Key takeaways
- There are patient and provider factors leading to LAMA.
- Patients signing an AMA form does not provide legal protection for providers, but a stream-lined discharge process and a detailed documentation are likely to.
- There is no evidence that insurance companies will not pay for LAMA discharges.
- LAMA patients could be given prescriptions and follow up as long as they are well documented.
References
Schaefer G et al. Financial responsibility of hospitalized patients who left against medical advice: Medical urban legend? J Gen Intern Med. 2012 Jul;27(7):825-30. doi: 10.1007/s11606-012-1984-x.
Wigder H et al. Insurance companies refusing payment for patients who leave the emergency department against medical advice is a myth. Ann Emerg Med. 2010 Apr;55(4):393. doi: 10.1016/j.annemergmed.2009.11.024.
Dr. Kumar is a hospitalist in Port Huron, Mich. He is a member of the editorial advisory board for the Hospitalist.
FROM SHM CONVERGE 2021
