By now almost everyone has heard about the social network site MySpace. More than 50 million people—mostly between ages 14 and 24—post and view online profiles connected by links to friends in the system. It’s one of the most heavily trafficked sites on the Internet.

MySpace is remarkable not only for consistent, double-digit growth rate, but also because visitors average two hours on the site modifying their profiles, and checking out friends’ profiles and commenting on them. MySpace has become ubiquitous to a generation using this public space to create and modify their identity on a daily basis—with technology that only recently has become available.

While recognizing that it may be a long time before www.hospitalmedicine.org becomes a household destination, the SHM Research Committee aims to generate similar excitement among our peers for connecting with each other over hospital medicine research on the Web.

Chapter Summary

Las Vegas

The SHM Las Vegas Chapter held its quarterly administrative meeting June 26 at Roy’s in Las Vegas. Gary Skankey, MD, infectious disease specialist and associate clinical professor at the University of Nevada School of Medicine, presented “Treating Complicated Skin and Skin Infections in an Era of Increasing Resistance.” The chapter will host a CME Program on surviving sepsis Sept. 28-29. Visit the chapter page for further program details.

Nashville

The SHM Nashville Chapter meeting June 6 at Stoney River restaurant was sponsored by Ortho McNeil and HCA Physician Recruitment. Eric Siegal, MD, with the University of Wisconsin Hospital in Madison, was the featured presenter and led an interactive session during “Malpractice for the Hospitalists: Identifying and Mitigating Risks.” The next meeting is scheduled for this month. Details will be posted at a later date.

At the SHM Research Committee meeting in Dallas in May, the conversation covered many topics, including the need for research mentorship, training, and career development. Plans for short- and medium-term measures to support SHM members in these areas are in the works, with a focus on Internet-based resources.

Over the long term, the committee would like to see its efforts result in national, high-impact hospital medicine studies and well-trained researchers. Whether driven by a curiosity in a particular area and/or the desire to provide better care by incorporating the best research, the universal challenge is to free enough time to pursue the answers and for appropriate recognition systems to be in place—be they promotion, funding to support further work, or recognition that leads to new connections.

The 249 abstracts published in a supplement to the Journal of Hospital Medicine only hinted at the depth and enthusiasm behind SHM members’ work. Anyone who walked through the exhibit hall during the poster session at the SHM Annual Meeting and talked with the people behind the research was impressed with their dedication and relative youth. They are the future of hospital medicine and are looking for ways to collaborate and continue to learn. The SHM Research Committee is dedicated to finding ways to support their efforts.

It seems as if many SHM members either engage in research, think about a research project, or wish they could evaluate their everyday practice in a way that can help others. However, it is difficult to discern how best to support individual hospitalists working in diverse settings across the country.

Because clinical responsibilities will not slow down anytime soon, we will have to work within the current, hectic environment and use technology as an equalizer to enable communication. In the spectrum of professional medical societies, SHM could be considered similar to the age 14-24 demographic attracted to the fluidity, instant communication/information and innovation that fuels MySpace.

Our long-term research goals could be powerfully advanced by a peer-catalyzed hospitalist research network.

The term “research network” can refer to many types of collaboration. One type that has been successful is the collection, analysis, and reporting of data in a registry or repository. In this example, medical care can be measured through the collection, analysis, and reporting of data. The National Cardiovascular Data Registry (established in 1998 by the American College of Cardiology Foundation) is a well-known example, but there are many others that have been organized for the purposes of improving quality and providing educational and research activities.

A second type of research network is the developing partnership between the American Medical Association (AMA) and Sermo, an online community where physicians exchange medical opinions. The partnership attempts to use technology to harness innovation, support physicians, and improve the capability of a peer network to influence the care patients receive by letting them share information with each other regarding patient care, pertinent scientific research, and advocacy issues. This is a looser network—without the constraints of data dictionaries—that relies on technology to make the connection between physician peers. While its start-up costs may be lower, its impact will be more difficult to measure.

A third example is the Gotham Prize for Cancer Research, which requires investigators to qualify by logging onto a Web site (www.gothamprize.org), posting a short proposal, and answering questions. If accepted by the expert panel of cancer researchers into this active forum, the new member will not only be eligible to receive the annual prize for the best idea, these individuals and their ideas will be matched to funding agencies and other scientists who may be able to support, assist, and/or collaborate. This limited-access network requires more facilitation than the previous AMA example, and the incentives and outcomes are more clearly defined.

The SHM Research Committee sees potential in exploring a network for hospital medicine researchers, through which members can access resources, collaborate, and innovate. Internet technology has the potential to level the playing field and erase the barriers of time differences and geography. By organizing around areas of interest designed to attract a critical mass of interested hospitalists, the goal of this network is to position SHM to lead hospital medicine research and ensure long-term success and sustainability by enabling powerful, high-impact studies in hospital medicine and supporting well-trained hospitalist researchers. Although this discussion is in the early stages of development, the SHM Research Committee plans to consider the following questions:

click for large version

How would a network help hospital medicine and hospitalists? During the meeting in May in Dallas, the SHM Research Committee articulated the need for research mentorship, training, and career development. Any proposed network must further these aims. Hospital medicine investigators and SHM members would be involved in refining these goals at the earliest stages. Opportunities for training a new generation of hospital medicine investigators and strengthening the existing ones through such a network will be explored, including options for training in outcomes research and opportunities to link participants with mentors.

 What questions should a network focus on? Hospitalists are well positioned to lead or collaborate on a range of key questions—questions that, in the short term, likely will focus on effectiveness and implementation research (related to quality improvement). Over the longer term, hospitalists should position themselves to be involved in all facets of clinical translational research, including T1 (bench-to-bedside research) and T2 (effectiveness research, such as larger randomized studies, and health services research). As hospital medicine grows, the potential areas where hospitalists might focus their scientific interests will expand. As hospitalists assume greater roles in caring for patients outside general medicine (e.g., surgical, cardiovascular, neurology, and oncology patients), the breadth of scientific inquiry will expand. In many of these cases, research networks exist; SHM will have to facilitate collaboration whenever possible.

How will the network engage a broad swath of hospitalists? By selecting research questions important to public health and anticipating a changing clinical environment, we hope to enhance the interest and relevance of an SHM research network. The SHM Research Committee will focus on how best to design a research network that is practical and useful for hospital medicine researchers and enable straightforward studies. A main goal will be promoting visibility for investigators and coordinators through opportunities for authorship and presentation of results at national meetings.

Healthcare reform has become a hot political issue again—more than a year before the presidential election. All three leading Democratic candidates (Hillary Clinton, Barack Obama, and John Edwards) have proposed some sort of a central institute to assess treatment options and disseminate research and information to providers. Hospitalists (as generalists and team leaders in an arena where approximately 30% of the healthcare dollar is spent) are a key part of any national solution.

Whether this research requires a catalyst such as a hospitalist network—and what that network would look like—remains to be seen. The SHM Research Committee is considering mechanisms to provide research mentorship, training, and career development, and weighing the best use of resources. We count on your input. Contact Carolyn Brennan, director of research program development for SHM, at cbrennan@hospitalmedicine.org for more information or to get involved. TH

SHM Behind the Scenes

PRIS updates in Salt Lake City

By Todd Von Deak

Each year, one of the premier events in pediatric hospital medicine is a summer conference presented by the American Academy of Pediatrics (AAP), the Ambulatory Pediatric Association (APA), and SHM. This year’s conference, held last month in Salt Lake City under the lead sponsorship of the AAP, was no exception.

More than 300 pediatric hospitalists, medical directors, residents, nurse practitioners, and physician assistants came together for four days to network, get answers, and learn from colleagues at 30 sessions. Charlie Homer, CEO of the National Institute for Children’s HealthCare Quality in Cambridge, Mass., was the keynote speaker. Dr. Homer highlighted the roles hospitalists can and must play to improve children’s health, and challenged all present to create a dashboard that includes quality indicators for care that is efficient, equitable, evidence-based, safe, and family-centered.

Leaders from the AAP, APA, and SHM opened the morning sessions the next day with brief presentations that highlighted the role of pediatric hospitalists in each organization, and the potential to work together to continue to develop pediatric hospital medicine and advance the care of hospitalized children. Participants were then free to choose from more than 16 sessions ranging from clinical issues such as the management of apparent life-threatening events and appropriate maintenance IV fluids, to practice management (Coding 101 and 201), quality improvement, and resident teaching and research.

Capping the schedule of events was a luncheon presentation from Christopher P. Landrigan, MD, director of the Pediatric Research in Inpatient Settings network. He presented “PRIS Update: The Need for Collaborative Hospitalist Research in 2007.” PRIS is an independent collaborative entity established by the same organizations that sponsor the Salt Lake City conference and is designed to allow for collaborative study of key questions in inpatient pediatrics.

Linda Snelling, MD, inpatient director and chief of pediatric critical care at Hasbro Children’s Hospital in Providence, R.I., followed with a talk on how pediatric hospitalists can effectively negotiate for themselves and the field. Her key insights included, “ ‘No.’ is a complete sentence.”

According to Jack Percelay, MD, past chair of SHM’s Pediatric Committee and a practicing pediatric hospitalist in New York and New Jersey, the conference exceeded its goals. “The energy at the conference was tremendous,” he said. “Sessions were filled with attendees learning of and debating cutting-edge issues for pediatric hospitalists. The buzz in the hotel was so intoxicating we were worried that we were violating Salt Lake City liquor laws. The AAP put on a spectacular meeting. SHM is looking forward to following this tradition of excellence as we take the lead for putting on an even larger meeting in Denver July 24-27, 2008.”

Given that the 2008 meeting sold out six weeks in advance, pediatric hospitalists will do well to stay tuned to The Hospitalist and visit SHM’s Web site, www.hospitalmedicine.org, for more details as the 2008 conference approaches. TH

By now almost everyone has heard about the social network site MySpace. More than 50 million people—mostly between ages 14 and 24—post and view online profiles connected by links to friends in the system. It’s one of the most heavily trafficked sites on the Internet.

MySpace is remarkable not only for consistent, double-digit growth rate, but also because visitors average two hours on the site modifying their profiles, and checking out friends’ profiles and commenting on them. MySpace has become ubiquitous to a generation using this public space to create and modify their identity on a daily basis—with technology that only recently has become available.

While recognizing that it may be a long time before www.hospitalmedicine.org becomes a household destination, the SHM Research Committee aims to generate similar excitement among our peers for connecting with each other over hospital medicine research on the Web.

Chapter Summary

Las Vegas

The SHM Las Vegas Chapter held its quarterly administrative meeting June 26 at Roy’s in Las Vegas. Gary Skankey, MD, infectious disease specialist and associate clinical professor at the University of Nevada School of Medicine, presented “Treating Complicated Skin and Skin Infections in an Era of Increasing Resistance.” The chapter will host a CME Program on surviving sepsis Sept. 28-29. Visit the chapter page for further program details.

Nashville

The SHM Nashville Chapter meeting June 6 at Stoney River restaurant was sponsored by Ortho McNeil and HCA Physician Recruitment. Eric Siegal, MD, with the University of Wisconsin Hospital in Madison, was the featured presenter and led an interactive session during “Malpractice for the Hospitalists: Identifying and Mitigating Risks.” The next meeting is scheduled for this month. Details will be posted at a later date.

At the SHM Research Committee meeting in Dallas in May, the conversation covered many topics, including the need for research mentorship, training, and career development. Plans for short- and medium-term measures to support SHM members in these areas are in the works, with a focus on Internet-based resources.

Over the long term, the committee would like to see its efforts result in national, high-impact hospital medicine studies and well-trained researchers. Whether driven by a curiosity in a particular area and/or the desire to provide better care by incorporating the best research, the universal challenge is to free enough time to pursue the answers and for appropriate recognition systems to be in place—be they promotion, funding to support further work, or recognition that leads to new connections.

The 249 abstracts published in a supplement to the Journal of Hospital Medicine only hinted at the depth and enthusiasm behind SHM members’ work. Anyone who walked through the exhibit hall during the poster session at the SHM Annual Meeting and talked with the people behind the research was impressed with their dedication and relative youth. They are the future of hospital medicine and are looking for ways to collaborate and continue to learn. The SHM Research Committee is dedicated to finding ways to support their efforts.

It seems as if many SHM members either engage in research, think about a research project, or wish they could evaluate their everyday practice in a way that can help others. However, it is difficult to discern how best to support individual hospitalists working in diverse settings across the country.

Because clinical responsibilities will not slow down anytime soon, we will have to work within the current, hectic environment and use technology as an equalizer to enable communication. In the spectrum of professional medical societies, SHM could be considered similar to the age 14-24 demographic attracted to the fluidity, instant communication/information and innovation that fuels MySpace.

Our long-term research goals could be powerfully advanced by a peer-catalyzed hospitalist research network.

The term “research network” can refer to many types of collaboration. One type that has been successful is the collection, analysis, and reporting of data in a registry or repository. In this example, medical care can be measured through the collection, analysis, and reporting of data. The National Cardiovascular Data Registry (established in 1998 by the American College of Cardiology Foundation) is a well-known example, but there are many others that have been organized for the purposes of improving quality and providing educational and research activities.

A second type of research network is the developing partnership between the American Medical Association (AMA) and Sermo, an online community where physicians exchange medical opinions. The partnership attempts to use technology to harness innovation, support physicians, and improve the capability of a peer network to influence the care patients receive by letting them share information with each other regarding patient care, pertinent scientific research, and advocacy issues. This is a looser network—without the constraints of data dictionaries—that relies on technology to make the connection between physician peers. While its start-up costs may be lower, its impact will be more difficult to measure.

A third example is the Gotham Prize for Cancer Research, which requires investigators to qualify by logging onto a Web site (www.gothamprize.org), posting a short proposal, and answering questions. If accepted by the expert panel of cancer researchers into this active forum, the new member will not only be eligible to receive the annual prize for the best idea, these individuals and their ideas will be matched to funding agencies and other scientists who may be able to support, assist, and/or collaborate. This limited-access network requires more facilitation than the previous AMA example, and the incentives and outcomes are more clearly defined.

The SHM Research Committee sees potential in exploring a network for hospital medicine researchers, through which members can access resources, collaborate, and innovate. Internet technology has the potential to level the playing field and erase the barriers of time differences and geography. By organizing around areas of interest designed to attract a critical mass of interested hospitalists, the goal of this network is to position SHM to lead hospital medicine research and ensure long-term success and sustainability by enabling powerful, high-impact studies in hospital medicine and supporting well-trained hospitalist researchers. Although this discussion is in the early stages of development, the SHM Research Committee plans to consider the following questions:

click for large version

How would a network help hospital medicine and hospitalists? During the meeting in May in Dallas, the SHM Research Committee articulated the need for research mentorship, training, and career development. Any proposed network must further these aims. Hospital medicine investigators and SHM members would be involved in refining these goals at the earliest stages. Opportunities for training a new generation of hospital medicine investigators and strengthening the existing ones through such a network will be explored, including options for training in outcomes research and opportunities to link participants with mentors.

 What questions should a network focus on? Hospitalists are well positioned to lead or collaborate on a range of key questions—questions that, in the short term, likely will focus on effectiveness and implementation research (related to quality improvement). Over the longer term, hospitalists should position themselves to be involved in all facets of clinical translational research, including T1 (bench-to-bedside research) and T2 (effectiveness research, such as larger randomized studies, and health services research). As hospital medicine grows, the potential areas where hospitalists might focus their scientific interests will expand. As hospitalists assume greater roles in caring for patients outside general medicine (e.g., surgical, cardiovascular, neurology, and oncology patients), the breadth of scientific inquiry will expand. In many of these cases, research networks exist; SHM will have to facilitate collaboration whenever possible.

How will the network engage a broad swath of hospitalists? By selecting research questions important to public health and anticipating a changing clinical environment, we hope to enhance the interest and relevance of an SHM research network. The SHM Research Committee will focus on how best to design a research network that is practical and useful for hospital medicine researchers and enable straightforward studies. A main goal will be promoting visibility for investigators and coordinators through opportunities for authorship and presentation of results at national meetings.

Healthcare reform has become a hot political issue again—more than a year before the presidential election. All three leading Democratic candidates (Hillary Clinton, Barack Obama, and John Edwards) have proposed some sort of a central institute to assess treatment options and disseminate research and information to providers. Hospitalists (as generalists and team leaders in an arena where approximately 30% of the healthcare dollar is spent) are a key part of any national solution.

Whether this research requires a catalyst such as a hospitalist network—and what that network would look like—remains to be seen. The SHM Research Committee is considering mechanisms to provide research mentorship, training, and career development, and weighing the best use of resources. We count on your input. Contact Carolyn Brennan, director of research program development for SHM, at cbrennan@hospitalmedicine.org for more information or to get involved. TH

SHM Behind the Scenes

PRIS updates in Salt Lake City

By Todd Von Deak

Each year, one of the premier events in pediatric hospital medicine is a summer conference presented by the American Academy of Pediatrics (AAP), the Ambulatory Pediatric Association (APA), and SHM. This year’s conference, held last month in Salt Lake City under the lead sponsorship of the AAP, was no exception.

More than 300 pediatric hospitalists, medical directors, residents, nurse practitioners, and physician assistants came together for four days to network, get answers, and learn from colleagues at 30 sessions. Charlie Homer, CEO of the National Institute for Children’s HealthCare Quality in Cambridge, Mass., was the keynote speaker. Dr. Homer highlighted the roles hospitalists can and must play to improve children’s health, and challenged all present to create a dashboard that includes quality indicators for care that is efficient, equitable, evidence-based, safe, and family-centered.

Leaders from the AAP, APA, and SHM opened the morning sessions the next day with brief presentations that highlighted the role of pediatric hospitalists in each organization, and the potential to work together to continue to develop pediatric hospital medicine and advance the care of hospitalized children. Participants were then free to choose from more than 16 sessions ranging from clinical issues such as the management of apparent life-threatening events and appropriate maintenance IV fluids, to practice management (Coding 101 and 201), quality improvement, and resident teaching and research.

Capping the schedule of events was a luncheon presentation from Christopher P. Landrigan, MD, director of the Pediatric Research in Inpatient Settings network. He presented “PRIS Update: The Need for Collaborative Hospitalist Research in 2007.” PRIS is an independent collaborative entity established by the same organizations that sponsor the Salt Lake City conference and is designed to allow for collaborative study of key questions in inpatient pediatrics.

Linda Snelling, MD, inpatient director and chief of pediatric critical care at Hasbro Children’s Hospital in Providence, R.I., followed with a talk on how pediatric hospitalists can effectively negotiate for themselves and the field. Her key insights included, “ ‘No.’ is a complete sentence.”

According to Jack Percelay, MD, past chair of SHM’s Pediatric Committee and a practicing pediatric hospitalist in New York and New Jersey, the conference exceeded its goals. “The energy at the conference was tremendous,” he said. “Sessions were filled with attendees learning of and debating cutting-edge issues for pediatric hospitalists. The buzz in the hotel was so intoxicating we were worried that we were violating Salt Lake City liquor laws. The AAP put on a spectacular meeting. SHM is looking forward to following this tradition of excellence as we take the lead for putting on an even larger meeting in Denver July 24-27, 2008.”

Given that the 2008 meeting sold out six weeks in advance, pediatric hospitalists will do well to stay tuned to The Hospitalist and visit SHM’s Web site, www.hospitalmedicine.org, for more details as the 2008 conference approaches. TH

By now almost everyone has heard about the social network site MySpace. More than 50 million people—mostly between ages 14 and 24—post and view online profiles connected by links to friends in the system. It’s one of the most heavily trafficked sites on the Internet.

MySpace is remarkable not only for consistent, double-digit growth rate, but also because visitors average two hours on the site modifying their profiles, and checking out friends’ profiles and commenting on them. MySpace has become ubiquitous to a generation using this public space to create and modify their identity on a daily basis—with technology that only recently has become available.

While recognizing that it may be a long time before www.hospitalmedicine.org becomes a household destination, the SHM Research Committee aims to generate similar excitement among our peers for connecting with each other over hospital medicine research on the Web.

Chapter Summary

Las Vegas

The SHM Las Vegas Chapter held its quarterly administrative meeting June 26 at Roy’s in Las Vegas. Gary Skankey, MD, infectious disease specialist and associate clinical professor at the University of Nevada School of Medicine, presented “Treating Complicated Skin and Skin Infections in an Era of Increasing Resistance.” The chapter will host a CME Program on surviving sepsis Sept. 28-29. Visit the chapter page for further program details.

Nashville

The SHM Nashville Chapter meeting June 6 at Stoney River restaurant was sponsored by Ortho McNeil and HCA Physician Recruitment. Eric Siegal, MD, with the University of Wisconsin Hospital in Madison, was the featured presenter and led an interactive session during “Malpractice for the Hospitalists: Identifying and Mitigating Risks.” The next meeting is scheduled for this month. Details will be posted at a later date.

At the SHM Research Committee meeting in Dallas in May, the conversation covered many topics, including the need for research mentorship, training, and career development. Plans for short- and medium-term measures to support SHM members in these areas are in the works, with a focus on Internet-based resources.

Over the long term, the committee would like to see its efforts result in national, high-impact hospital medicine studies and well-trained researchers. Whether driven by a curiosity in a particular area and/or the desire to provide better care by incorporating the best research, the universal challenge is to free enough time to pursue the answers and for appropriate recognition systems to be in place—be they promotion, funding to support further work, or recognition that leads to new connections.

The 249 abstracts published in a supplement to the Journal of Hospital Medicine only hinted at the depth and enthusiasm behind SHM members’ work. Anyone who walked through the exhibit hall during the poster session at the SHM Annual Meeting and talked with the people behind the research was impressed with their dedication and relative youth. They are the future of hospital medicine and are looking for ways to collaborate and continue to learn. The SHM Research Committee is dedicated to finding ways to support their efforts.

It seems as if many SHM members either engage in research, think about a research project, or wish they could evaluate their everyday practice in a way that can help others. However, it is difficult to discern how best to support individual hospitalists working in diverse settings across the country.

Because clinical responsibilities will not slow down anytime soon, we will have to work within the current, hectic environment and use technology as an equalizer to enable communication. In the spectrum of professional medical societies, SHM could be considered similar to the age 14-24 demographic attracted to the fluidity, instant communication/information and innovation that fuels MySpace.

Our long-term research goals could be powerfully advanced by a peer-catalyzed hospitalist research network.

The term “research network” can refer to many types of collaboration. One type that has been successful is the collection, analysis, and reporting of data in a registry or repository. In this example, medical care can be measured through the collection, analysis, and reporting of data. The National Cardiovascular Data Registry (established in 1998 by the American College of Cardiology Foundation) is a well-known example, but there are many others that have been organized for the purposes of improving quality and providing educational and research activities.

A second type of research network is the developing partnership between the American Medical Association (AMA) and Sermo, an online community where physicians exchange medical opinions. The partnership attempts to use technology to harness innovation, support physicians, and improve the capability of a peer network to influence the care patients receive by letting them share information with each other regarding patient care, pertinent scientific research, and advocacy issues. This is a looser network—without the constraints of data dictionaries—that relies on technology to make the connection between physician peers. While its start-up costs may be lower, its impact will be more difficult to measure.

A third example is the Gotham Prize for Cancer Research, which requires investigators to qualify by logging onto a Web site (www.gothamprize.org), posting a short proposal, and answering questions. If accepted by the expert panel of cancer researchers into this active forum, the new member will not only be eligible to receive the annual prize for the best idea, these individuals and their ideas will be matched to funding agencies and other scientists who may be able to support, assist, and/or collaborate. This limited-access network requires more facilitation than the previous AMA example, and the incentives and outcomes are more clearly defined.

The SHM Research Committee sees potential in exploring a network for hospital medicine researchers, through which members can access resources, collaborate, and innovate. Internet technology has the potential to level the playing field and erase the barriers of time differences and geography. By organizing around areas of interest designed to attract a critical mass of interested hospitalists, the goal of this network is to position SHM to lead hospital medicine research and ensure long-term success and sustainability by enabling powerful, high-impact studies in hospital medicine and supporting well-trained hospitalist researchers. Although this discussion is in the early stages of development, the SHM Research Committee plans to consider the following questions:

click for large version

How would a network help hospital medicine and hospitalists? During the meeting in May in Dallas, the SHM Research Committee articulated the need for research mentorship, training, and career development. Any proposed network must further these aims. Hospital medicine investigators and SHM members would be involved in refining these goals at the earliest stages. Opportunities for training a new generation of hospital medicine investigators and strengthening the existing ones through such a network will be explored, including options for training in outcomes research and opportunities to link participants with mentors.

 What questions should a network focus on? Hospitalists are well positioned to lead or collaborate on a range of key questions—questions that, in the short term, likely will focus on effectiveness and implementation research (related to quality improvement). Over the longer term, hospitalists should position themselves to be involved in all facets of clinical translational research, including T1 (bench-to-bedside research) and T2 (effectiveness research, such as larger randomized studies, and health services research). As hospital medicine grows, the potential areas where hospitalists might focus their scientific interests will expand. As hospitalists assume greater roles in caring for patients outside general medicine (e.g., surgical, cardiovascular, neurology, and oncology patients), the breadth of scientific inquiry will expand. In many of these cases, research networks exist; SHM will have to facilitate collaboration whenever possible.

How will the network engage a broad swath of hospitalists? By selecting research questions important to public health and anticipating a changing clinical environment, we hope to enhance the interest and relevance of an SHM research network. The SHM Research Committee will focus on how best to design a research network that is practical and useful for hospital medicine researchers and enable straightforward studies. A main goal will be promoting visibility for investigators and coordinators through opportunities for authorship and presentation of results at national meetings.

Healthcare reform has become a hot political issue again—more than a year before the presidential election. All three leading Democratic candidates (Hillary Clinton, Barack Obama, and John Edwards) have proposed some sort of a central institute to assess treatment options and disseminate research and information to providers. Hospitalists (as generalists and team leaders in an arena where approximately 30% of the healthcare dollar is spent) are a key part of any national solution.

Whether this research requires a catalyst such as a hospitalist network—and what that network would look like—remains to be seen. The SHM Research Committee is considering mechanisms to provide research mentorship, training, and career development, and weighing the best use of resources. We count on your input. Contact Carolyn Brennan, director of research program development for SHM, at cbrennan@hospitalmedicine.org for more information or to get involved. TH

SHM Behind the Scenes

PRIS updates in Salt Lake City

By Todd Von Deak

Each year, one of the premier events in pediatric hospital medicine is a summer conference presented by the American Academy of Pediatrics (AAP), the Ambulatory Pediatric Association (APA), and SHM. This year’s conference, held last month in Salt Lake City under the lead sponsorship of the AAP, was no exception.

More than 300 pediatric hospitalists, medical directors, residents, nurse practitioners, and physician assistants came together for four days to network, get answers, and learn from colleagues at 30 sessions. Charlie Homer, CEO of the National Institute for Children’s HealthCare Quality in Cambridge, Mass., was the keynote speaker. Dr. Homer highlighted the roles hospitalists can and must play to improve children’s health, and challenged all present to create a dashboard that includes quality indicators for care that is efficient, equitable, evidence-based, safe, and family-centered.

Leaders from the AAP, APA, and SHM opened the morning sessions the next day with brief presentations that highlighted the role of pediatric hospitalists in each organization, and the potential to work together to continue to develop pediatric hospital medicine and advance the care of hospitalized children. Participants were then free to choose from more than 16 sessions ranging from clinical issues such as the management of apparent life-threatening events and appropriate maintenance IV fluids, to practice management (Coding 101 and 201), quality improvement, and resident teaching and research.

Capping the schedule of events was a luncheon presentation from Christopher P. Landrigan, MD, director of the Pediatric Research in Inpatient Settings network. He presented “PRIS Update: The Need for Collaborative Hospitalist Research in 2007.” PRIS is an independent collaborative entity established by the same organizations that sponsor the Salt Lake City conference and is designed to allow for collaborative study of key questions in inpatient pediatrics.

Linda Snelling, MD, inpatient director and chief of pediatric critical care at Hasbro Children’s Hospital in Providence, R.I., followed with a talk on how pediatric hospitalists can effectively negotiate for themselves and the field. Her key insights included, “ ‘No.’ is a complete sentence.”

According to Jack Percelay, MD, past chair of SHM’s Pediatric Committee and a practicing pediatric hospitalist in New York and New Jersey, the conference exceeded its goals. “The energy at the conference was tremendous,” he said. “Sessions were filled with attendees learning of and debating cutting-edge issues for pediatric hospitalists. The buzz in the hotel was so intoxicating we were worried that we were violating Salt Lake City liquor laws. The AAP put on a spectacular meeting. SHM is looking forward to following this tradition of excellence as we take the lead for putting on an even larger meeting in Denver July 24-27, 2008.”

Given that the 2008 meeting sold out six weeks in advance, pediatric hospitalists will do well to stay tuned to The Hospitalist and visit SHM’s Web site, www.hospitalmedicine.org, for more details as the 2008 conference approaches. TH

Isn’t it ironic that just as America is waking up to the importance of primary care medicine, our own representative organizations are selling us down the river?

The training of primary care physicians has for decades allowed us to branch out and follow our patients in multiple sites of care. We are the masters of managing care across this continuum.

Government and big business are finally recognizing that they need to bolster primary care to manage patients in the new chronic care medical home models. They are finally recognizing the need to better supply, equip, and finance primary care physicians.

The American College of Physicians (ACP), the American Academy of Family Practice (AAFP), and the American Medical Association all appear to support this concept. So where is the irony?

The American Board of Internal Medicine (ABIM), along with the aforementioned groups and others, continues to carve medicine into ever increasing sub areas, based on sites of care and interests. Hospitalists (who already have three branches—general hospitalists, proceduralists, and nocturnists) are seeking special certification recognition through ABIM. Palliative care is a new certification. These branches of medicine deserve recognition, but do we need all these fractured certifications?

Soon, no primary care physicians will be certified as capable of practicing in multiple sites of care without multiple certifications for each separate site and individual function. Soon there will be no “general” primary care physicians. Can hospitalists equally manage the whole continuum of care, or will they need to become generalists again to do the job?

Medicine teaches us to care for the whole person—body, mind, and spirit—not just individual parts. I urge the ABIM, the ACP, the AAFP, the AMA, SHM, and others to stop this fracturing of primary care. Now is the time to promote the generalists. Now is the time to lift all primary care-related areas of medicine together, leaving no one behind.

John M. Colombo, MD

HAN/Colombo

Crozer Keystone Health Network

Isn’t it ironic that just as America is waking up to the importance of primary care medicine, our own representative organizations are selling us down the river?

The training of primary care physicians has for decades allowed us to branch out and follow our patients in multiple sites of care. We are the masters of managing care across this continuum.

Government and big business are finally recognizing that they need to bolster primary care to manage patients in the new chronic care medical home models. They are finally recognizing the need to better supply, equip, and finance primary care physicians.

The American College of Physicians (ACP), the American Academy of Family Practice (AAFP), and the American Medical Association all appear to support this concept. So where is the irony?

The American Board of Internal Medicine (ABIM), along with the aforementioned groups and others, continues to carve medicine into ever increasing sub areas, based on sites of care and interests. Hospitalists (who already have three branches—general hospitalists, proceduralists, and nocturnists) are seeking special certification recognition through ABIM. Palliative care is a new certification. These branches of medicine deserve recognition, but do we need all these fractured certifications?

Soon, no primary care physicians will be certified as capable of practicing in multiple sites of care without multiple certifications for each separate site and individual function. Soon there will be no “general” primary care physicians. Can hospitalists equally manage the whole continuum of care, or will they need to become generalists again to do the job?

Medicine teaches us to care for the whole person—body, mind, and spirit—not just individual parts. I urge the ABIM, the ACP, the AAFP, the AMA, SHM, and others to stop this fracturing of primary care. Now is the time to promote the generalists. Now is the time to lift all primary care-related areas of medicine together, leaving no one behind.

John M. Colombo, MD

HAN/Colombo

Crozer Keystone Health Network

Isn’t it ironic that just as America is waking up to the importance of primary care medicine, our own representative organizations are selling us down the river?

The training of primary care physicians has for decades allowed us to branch out and follow our patients in multiple sites of care. We are the masters of managing care across this continuum.

Government and big business are finally recognizing that they need to bolster primary care to manage patients in the new chronic care medical home models. They are finally recognizing the need to better supply, equip, and finance primary care physicians.

The American College of Physicians (ACP), the American Academy of Family Practice (AAFP), and the American Medical Association all appear to support this concept. So where is the irony?

The American Board of Internal Medicine (ABIM), along with the aforementioned groups and others, continues to carve medicine into ever increasing sub areas, based on sites of care and interests. Hospitalists (who already have three branches—general hospitalists, proceduralists, and nocturnists) are seeking special certification recognition through ABIM. Palliative care is a new certification. These branches of medicine deserve recognition, but do we need all these fractured certifications?

Soon, no primary care physicians will be certified as capable of practicing in multiple sites of care without multiple certifications for each separate site and individual function. Soon there will be no “general” primary care physicians. Can hospitalists equally manage the whole continuum of care, or will they need to become generalists again to do the job?

Medicine teaches us to care for the whole person—body, mind, and spirit—not just individual parts. I urge the ABIM, the ACP, the AAFP, the AMA, SHM, and others to stop this fracturing of primary care. Now is the time to promote the generalists. Now is the time to lift all primary care-related areas of medicine together, leaving no one behind.

John M. Colombo, MD

HAN/Colombo

Crozer Keystone Health Network

Dr. Wachter

Anyone who has attended the closing session of an SHM Annual Meeting or read one of his editorial pieces in The Hospitalist or other publications knows that Bob Wachter, MD, sees the world in a unique and uniquely informed way.

This fall, Dr. Wachter—professor and associate chairman of the Department of Medicine at the University of California, San Francisco (UCSF), co-founder of SHM, and the man who coined the term “hospitalist” (along with Lee Goldman, MD)—will regularly share his one-of-a-kind perspective via a Weblog, or blog. Tentatively titled “Wachter’s World,” the hospital medicine blog will debut at www.the-hospitalist.org in time for the “Management of the Hospitalized Patient” session Oct. 4-6 at UCSF. The in-depth course serves as the West Coast regional meeting of SHM.

“Even an old guy like me realizes that blogs are incredibly hot,” says Dr. Wachter. “And as I read more of them and began relying on them more for information and insights, I started looking for one in our field that was lively, engaging and informative, one I’d like to read. I couldn’t find anything, so I thought I should start one.”

When Dr. Wachter approached SHM about hosting his blog, the organization’s leadership was quite interested—especially because SHM was already considering starting its own blog.

“SHM’s audience is perfect for the growing blog medium,” says Larry Wellikson, MD, the CEO of SHM. “We saw this with the enormous response to the SHM blogs at the May 2007 Annual Meeting.”

So “Wachter’s World” will be found on The Hospitalist’s Web site, where Dr. Wachter will post regular updates—he estimates typically three or four times a week.

“SHM’s partnership with Bob Wachter to launch an innovative blog, housed on the Web site for the most widely read publication in hospital medicine, SHM’s The Hospitalist, just makes sense as hospitalists need to hear new ideas and meet the challenge to be the change agents for the hospital of the future,” Dr. Wellikson says. “Wachter has proven himself a nationally sought-after thought leader who has something to say about hospital medicine, patient safety, improving quality, and the future of medicine.”

Dr. Wachter has a unique perspective on, well, everything. His years of experience working in hospital medicine as well as his high-level involvement in shaping the field—such as his position as chair of the American Board of Internal Medicine (ABIM) Committee on Hospital Medicine Focused Recognition—allows him ground-level and big-picture views of issues and trends that affect hospitalists’ work.

He often makes unique connections and forms original opinions on those issues—whether addressing road bumps a hospitalist runs into on the job or policy points that may change that job—and he plans to share those connections and opinions in his blog.

“I want to comment on the confluence of real stuff we all see day to day and the things that influence our field,” Dr. Wachter says. And he certainly has plenty of subjects to cover.

“There are so many issues that cross my retina every day that I think are of interest to hospitalists,” he says. “I see things in context—how they develop and how they all fit together, including trends as they develop. This blog will show my point of view—not on the differences in healthcare policy between Clinton’s camp and Obama’s camp—but closer to the ground. I’ll cover what relates to all of us.” TH

Dr. Wachter

Anyone who has attended the closing session of an SHM Annual Meeting or read one of his editorial pieces in The Hospitalist or other publications knows that Bob Wachter, MD, sees the world in a unique and uniquely informed way.

This fall, Dr. Wachter—professor and associate chairman of the Department of Medicine at the University of California, San Francisco (UCSF), co-founder of SHM, and the man who coined the term “hospitalist” (along with Lee Goldman, MD)—will regularly share his one-of-a-kind perspective via a Weblog, or blog. Tentatively titled “Wachter’s World,” the hospital medicine blog will debut at www.the-hospitalist.org in time for the “Management of the Hospitalized Patient” session Oct. 4-6 at UCSF. The in-depth course serves as the West Coast regional meeting of SHM.

“Even an old guy like me realizes that blogs are incredibly hot,” says Dr. Wachter. “And as I read more of them and began relying on them more for information and insights, I started looking for one in our field that was lively, engaging and informative, one I’d like to read. I couldn’t find anything, so I thought I should start one.”

When Dr. Wachter approached SHM about hosting his blog, the organization’s leadership was quite interested—especially because SHM was already considering starting its own blog.

“SHM’s audience is perfect for the growing blog medium,” says Larry Wellikson, MD, the CEO of SHM. “We saw this with the enormous response to the SHM blogs at the May 2007 Annual Meeting.”

So “Wachter’s World” will be found on The Hospitalist’s Web site, where Dr. Wachter will post regular updates—he estimates typically three or four times a week.

“SHM’s partnership with Bob Wachter to launch an innovative blog, housed on the Web site for the most widely read publication in hospital medicine, SHM’s The Hospitalist, just makes sense as hospitalists need to hear new ideas and meet the challenge to be the change agents for the hospital of the future,” Dr. Wellikson says. “Wachter has proven himself a nationally sought-after thought leader who has something to say about hospital medicine, patient safety, improving quality, and the future of medicine.”

Dr. Wachter has a unique perspective on, well, everything. His years of experience working in hospital medicine as well as his high-level involvement in shaping the field—such as his position as chair of the American Board of Internal Medicine (ABIM) Committee on Hospital Medicine Focused Recognition—allows him ground-level and big-picture views of issues and trends that affect hospitalists’ work.

He often makes unique connections and forms original opinions on those issues—whether addressing road bumps a hospitalist runs into on the job or policy points that may change that job—and he plans to share those connections and opinions in his blog.

“I want to comment on the confluence of real stuff we all see day to day and the things that influence our field,” Dr. Wachter says. And he certainly has plenty of subjects to cover.

“There are so many issues that cross my retina every day that I think are of interest to hospitalists,” he says. “I see things in context—how they develop and how they all fit together, including trends as they develop. This blog will show my point of view—not on the differences in healthcare policy between Clinton’s camp and Obama’s camp—but closer to the ground. I’ll cover what relates to all of us.” TH

Dr. Wachter

Anyone who has attended the closing session of an SHM Annual Meeting or read one of his editorial pieces in The Hospitalist or other publications knows that Bob Wachter, MD, sees the world in a unique and uniquely informed way.

This fall, Dr. Wachter—professor and associate chairman of the Department of Medicine at the University of California, San Francisco (UCSF), co-founder of SHM, and the man who coined the term “hospitalist” (along with Lee Goldman, MD)—will regularly share his one-of-a-kind perspective via a Weblog, or blog. Tentatively titled “Wachter’s World,” the hospital medicine blog will debut at www.the-hospitalist.org in time for the “Management of the Hospitalized Patient” session Oct. 4-6 at UCSF. The in-depth course serves as the West Coast regional meeting of SHM.

“Even an old guy like me realizes that blogs are incredibly hot,” says Dr. Wachter. “And as I read more of them and began relying on them more for information and insights, I started looking for one in our field that was lively, engaging and informative, one I’d like to read. I couldn’t find anything, so I thought I should start one.”

When Dr. Wachter approached SHM about hosting his blog, the organization’s leadership was quite interested—especially because SHM was already considering starting its own blog.

“SHM’s audience is perfect for the growing blog medium,” says Larry Wellikson, MD, the CEO of SHM. “We saw this with the enormous response to the SHM blogs at the May 2007 Annual Meeting.”

So “Wachter’s World” will be found on The Hospitalist’s Web site, where Dr. Wachter will post regular updates—he estimates typically three or four times a week.

“SHM’s partnership with Bob Wachter to launch an innovative blog, housed on the Web site for the most widely read publication in hospital medicine, SHM’s The Hospitalist, just makes sense as hospitalists need to hear new ideas and meet the challenge to be the change agents for the hospital of the future,” Dr. Wellikson says. “Wachter has proven himself a nationally sought-after thought leader who has something to say about hospital medicine, patient safety, improving quality, and the future of medicine.”

Dr. Wachter has a unique perspective on, well, everything. His years of experience working in hospital medicine as well as his high-level involvement in shaping the field—such as his position as chair of the American Board of Internal Medicine (ABIM) Committee on Hospital Medicine Focused Recognition—allows him ground-level and big-picture views of issues and trends that affect hospitalists’ work.

He often makes unique connections and forms original opinions on those issues—whether addressing road bumps a hospitalist runs into on the job or policy points that may change that job—and he plans to share those connections and opinions in his blog.

“I want to comment on the confluence of real stuff we all see day to day and the things that influence our field,” Dr. Wachter says. And he certainly has plenty of subjects to cover.

“There are so many issues that cross my retina every day that I think are of interest to hospitalists,” he says. “I see things in context—how they develop and how they all fit together, including trends as they develop. This blog will show my point of view—not on the differences in healthcare policy between Clinton’s camp and Obama’s camp—but closer to the ground. I’ll cover what relates to all of us.” TH

Patient-controlled analgesia (PCA), well accepted and widely used to quickly ease post-operative and acute pain, is safe and effective—in skilled hands. But there are complications, caveats, and safety concerns hospitalists should consider to incorporate this tool into their pain management routines and hospital protocols.

Studies show patients prefer the PCA compared with other analgesic routes.1-2 Less clear is whether it is more effective or leads to lower opioid use.

Some hospitalists use the PCA for their patients with pain—others defer to anesthesiologists, pain services, or palliative care consultants to manage the PCA and its multifaceted dosing requirements.

“There are a lot of misconceptions about the PCA,” says Deb Gordon, RN, MS, FAAN, senior clinical nurse specialist and pain consultant at the University of Wisconsin (UW) Medical Center in Madison. “There is a misunderstanding that the PCA is a magic black box for pain relief,” which can lead to its overuse. As a general rule of pain management, patients prefer the oral route of analgesic administration, Gordon says, unless that is a problem or rapid titration is needed.

“I don’t think [the PCA is] rocket science—it’s just a tool to deliver analgesics conveniently,” Gordon says. “I think every hospitalist should learn how to use the PCA, but there are always nuances of how to titrate opioids by any route.” UW has implemented PCA protocols, which staff can use for ballpark dosing recommendations.

How Hospitalists Use the PCA

The PCA delivers pain medication intravenously via a computerized pump with a button the patient can press when needed—without waiting for busy nurses to answer a call button and then confirm, prepare, and administer an analgesic treatment.

Hospitalists at UW, including Rob Hoffman, MD, often order the PCA. “It’s very well-liked by patients, who are not dependent on a busy nurse to get their analgesics administered,” Dr. Hoffman says. “The biggest concern, involving overdosing patients who are opioid-naïve, may be somewhat overblown. I haven’t experienced problems with my patients being over narcotized, but I start with a low dose and monitor them frequently.”

PCA technology can tabulate how much analgesic the patient has received during the previous 24 hours, Dr. Hoffman notes. “You know that’s a safe dose for the patient, and you can use it to make the transition to oral medications,” he says.

“Most of the patients I have on PCAs are palliative care patients,” says Rachelle Bernacki, MD, MS, a hospitalist, palliative care physician, and geriatrician at the University of California-San Francisco Medical Center. “I use it somewhat differently for the patients in my hospitalist practice—for example, for those who are experiencing intermittent, unpredictable episodes of abdominal pain. It’s also useful for patients with a need to feel in control of their situation. For constant, predictable pain, it’s better to use an around-the-clock schedule. I also send certain patients home on PCAs, especially if they are going to hospice care.”

Dr. Bernacki notes that some of her patients kiss the PCA button as if it were a long-lost friend, including one she recalls who had a bowel obstruction and had not found relief prior to starting on the PCA. But she also recalls a patient for whom the PCA was not a solution. “He was Cantonese-speaking,” she says. “Despite the presence of an interpreter and several attempts at education, he was never able to understand the connection between the PCA button and relief for his pain. We just couldn’t cross the cultural and language barriers.”

Hospitalists probably underuse the PCA, says Mahmood Shahlapour, MD, hospitalist and palliative care consultant at Chandler Regional Hospital in Chandler, Ariz. “Some hospitalists may feel uncomfortable with it,” he says. “I think it’s important for hospitalists to try to get more experience and comfort to be able to use it for the right patient and the right setting.”

What Is the PCA?

PCA technology as we know it today was pioneered in the early 1970s. Now it’s routine for post-surgical pain management. It is used for patients who have trouble taking oral medications or who need rapid response to acute pain crises. Increasingly, it is also used for patients with moderate to severe chronic pain related to cancer or who are being followed by hospice or palliative care services.

PCA refers both to the process of patient self-administration of parenteral analgesics and to the computerized infusion pump that makes this control possible. Recent advances in pain management also include patient-controlled epidural and transdermal analgesia systems—and other new pain modalities continue to be developed.3 Patients unable to operate the equipment themselves—for example, neonates or infants—may receive nurse-controlled analgesia, but experts say this should only be done within carefully defined parameters.

With the more typical intravenous PCA, the computerized pump allows for a number of variables, including:

• An initial bolus or loading dose to bring the pain under immediate control—an important but sometimes overlooked consideration in the successful use of PCAs;
• The patient-initiated or demand dose, available to the patient at the press of a button;
• The delay interval or lockout, typically between six and 15 minutes, allowing the analgesic to achieve its peak effect before another dose can be administered. The number of unsuccessful demands by patients during lockout periods is important for the physician to know;
• A continuous infusion or basal rate to provide continuous pain relief, although this may be contraindicated for opioid-naïve patients starting on PCAs.4 For those receiving opioids for chronic pain, the basal rate could be their current analgesic dose converted to the intravenous equivalent. Alternatively, the patient could receive this dose in a long-acting oral analgesic, with the PCA used for incidental or breakthrough pain. A basal rate also helps patients sleep, their pain controlled without having to wake up to press for a dose;
• A maximum volume of drug to be administered within a defined period of one, four, eight, or 24 hours, calculated to prevent an opioid overdose—regardless of how many times the PCA button gets pushed; and
• Monitoring devices such as pulse oximeter or end-tidal carbon dioxide monitor may be part of the PCA system to help warn of emerging respiratory depression.

The fundamental challenge for physicians lies in balancing the loading, basal, and patient-initiated doses with an appropriate maximum to make sure the patient gets adequate pain relief but doesn’t overdose. This is a more complex, multifaceted mathematical formula than ordering opioids to be administered two, three, or four times a day.

A basic safeguard of the PCA for preventing overdose is that when the opioid analgesic starts to make the patient drowsy, he or she is likely to stop pressing the button for another dose. However, for this to work, the PCA must be patient-controlled. If a nurse or family member pushes the button on the patient’s behalf out of a well-meaning desire to keep pain in check, this raises the risk of overdose.

In the past few years, several national quality and safety organizations have issued alerts about the danger of such patient-controlled analgesia by proxy. The Institute for Safe Medication Practices (ISMP) in Huntington Valley, Pa., issued two safety alerts in July 2003 discussing how potentially life-threatening errors can occur with PCAs and offering ways to prevent such errors.

U.S. Pharmacopeia’s summer 2004 USP Quality Review also offered safety recommendations based on analysis of medical errors directly resulting from PCA by proxy. The Joint Commission issued a Sentinel Alert on Dec. 20, 2004, noting that “serious adverse effects can occur when family members, caregivers or clinicians who are not authorized become involved in administering the analgesic for the patient by proxy.”5 Earlier this year the American Society for Pain Management Nursing issued clinical practice recommendations for how nurses can deal with the problem of PCA by proxy.6

Well-designed hospital PCA protocols will address this problem by including clear instructions to family members not to push the button for the patient, with an explanation of why this can be dangerous. Printed brochures and signs in the patient’s room are also helpful.

The Need for Training

“Physicians, as a rule, don’t receive adequate training in the PCA,” says Jean Youngwerth, MD, hospitalist, palliative care consultant and fellowship associate director at the University of Colorado Health Sciences Center in Denver. “Then you’re expected to know how to use it. There clearly is a need for this kind of training in the basics of the PCA, but a brief in-service should be sufficient.”

Dan Johnson, MD, regional department chief for palliative care for Kaiser-Permanente in Colorado, says the level of experience with the PCA is highly variable among physicians he works with. “Some know how to use the PCA and actually do it quite well. Many others are not adequately trained,” he says. “When I test residents with a few questions, they customarily do very poorly. Some of the answers I see make me nervous.”

Dr. Johnson offers a refresher on the PCA for hospitalists in the Denver area who attend an annual palliative care retreat. Those who come regularly seem to retain the information he offers. “If I were in a hospital that had not rolled out PCA standing orders, I’d make sure that there were educational units provided for hospitalists,” he says. “I’d also investigate how to develop standing orders for the hospital.” TH

Larry Beresford is a frequent contributor to The Hospitalist.

References

1. Hudcova J, McNicol E, Quah C, et al. Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database Syst Rev. 2006;4.
2. Ballantyne JC, Carr DB, Chalmers TC. Postoperative patient-controlled analgesia: Meta-analyses of initial randomized controlled trials. J Clin Anesth. 1993 May/June;5(3):182-193.
3. D’Arcy Y. New pain management options: Delivery systems and techniques. Nursing. 2007 February; 37(2):26-27.
4. Pasero C, McCaffery M. Safe use of a continuous infusion with IV PCA. J PeriAnesthesia Nursing. 2004 Feb;19(1):42-45.
5. Joint Commission. Patient-controlled analgesia by proxy. Available at www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_33.htm. Last accessed July 12, 2007.
6. Wuhrman E, Cooney MF, Dunwoody CJ, et al. Authorized and unauthorized (“PCA by Proxy”) dosing of analgesic infusion pumps: Position statement with clinical practice recommendations. Pain Manag Nurs. 2007 Mar;8(1):4-11.
7. Prommer E. Fast Fact and Concept #92, Patient controlled analgesia in palliative care. End-of-Life/ Palliative Education Resource Center, Medical College of Wisconsin, Milwaukee:www.eperc.mcw.edu/ff_index.htm.
8. Owen H, Plummer JL, Armstrong I, et al. Variables of patient-controlled analgesia. 1. Bolus size. Anaesthesia.1989 Jan.;44(1):7-10.
9. Vicente KJ, Kada-Bekhaled K, Hillel G, et al. Programming errors contribute to death from patient-controlled analgesia. Can J Anesth. 2003;50:328-332.

Patient-controlled analgesia (PCA), well accepted and widely used to quickly ease post-operative and acute pain, is safe and effective—in skilled hands. But there are complications, caveats, and safety concerns hospitalists should consider to incorporate this tool into their pain management routines and hospital protocols.

Studies show patients prefer the PCA compared with other analgesic routes.1-2 Less clear is whether it is more effective or leads to lower opioid use.

Some hospitalists use the PCA for their patients with pain—others defer to anesthesiologists, pain services, or palliative care consultants to manage the PCA and its multifaceted dosing requirements.

“There are a lot of misconceptions about the PCA,” says Deb Gordon, RN, MS, FAAN, senior clinical nurse specialist and pain consultant at the University of Wisconsin (UW) Medical Center in Madison. “There is a misunderstanding that the PCA is a magic black box for pain relief,” which can lead to its overuse. As a general rule of pain management, patients prefer the oral route of analgesic administration, Gordon says, unless that is a problem or rapid titration is needed.

“I don’t think [the PCA is] rocket science—it’s just a tool to deliver analgesics conveniently,” Gordon says. “I think every hospitalist should learn how to use the PCA, but there are always nuances of how to titrate opioids by any route.” UW has implemented PCA protocols, which staff can use for ballpark dosing recommendations.

How Hospitalists Use the PCA

The PCA delivers pain medication intravenously via a computerized pump with a button the patient can press when needed—without waiting for busy nurses to answer a call button and then confirm, prepare, and administer an analgesic treatment.

Hospitalists at UW, including Rob Hoffman, MD, often order the PCA. “It’s very well-liked by patients, who are not dependent on a busy nurse to get their analgesics administered,” Dr. Hoffman says. “The biggest concern, involving overdosing patients who are opioid-naïve, may be somewhat overblown. I haven’t experienced problems with my patients being over narcotized, but I start with a low dose and monitor them frequently.”

PCA technology can tabulate how much analgesic the patient has received during the previous 24 hours, Dr. Hoffman notes. “You know that’s a safe dose for the patient, and you can use it to make the transition to oral medications,” he says.

“Most of the patients I have on PCAs are palliative care patients,” says Rachelle Bernacki, MD, MS, a hospitalist, palliative care physician, and geriatrician at the University of California-San Francisco Medical Center. “I use it somewhat differently for the patients in my hospitalist practice—for example, for those who are experiencing intermittent, unpredictable episodes of abdominal pain. It’s also useful for patients with a need to feel in control of their situation. For constant, predictable pain, it’s better to use an around-the-clock schedule. I also send certain patients home on PCAs, especially if they are going to hospice care.”

Dr. Bernacki notes that some of her patients kiss the PCA button as if it were a long-lost friend, including one she recalls who had a bowel obstruction and had not found relief prior to starting on the PCA. But she also recalls a patient for whom the PCA was not a solution. “He was Cantonese-speaking,” she says. “Despite the presence of an interpreter and several attempts at education, he was never able to understand the connection between the PCA button and relief for his pain. We just couldn’t cross the cultural and language barriers.”

Hospitalists probably underuse the PCA, says Mahmood Shahlapour, MD, hospitalist and palliative care consultant at Chandler Regional Hospital in Chandler, Ariz. “Some hospitalists may feel uncomfortable with it,” he says. “I think it’s important for hospitalists to try to get more experience and comfort to be able to use it for the right patient and the right setting.”

What Is the PCA?

PCA technology as we know it today was pioneered in the early 1970s. Now it’s routine for post-surgical pain management. It is used for patients who have trouble taking oral medications or who need rapid response to acute pain crises. Increasingly, it is also used for patients with moderate to severe chronic pain related to cancer or who are being followed by hospice or palliative care services.

PCA refers both to the process of patient self-administration of parenteral analgesics and to the computerized infusion pump that makes this control possible. Recent advances in pain management also include patient-controlled epidural and transdermal analgesia systems—and other new pain modalities continue to be developed.3 Patients unable to operate the equipment themselves—for example, neonates or infants—may receive nurse-controlled analgesia, but experts say this should only be done within carefully defined parameters.

With the more typical intravenous PCA, the computerized pump allows for a number of variables, including:

• An initial bolus or loading dose to bring the pain under immediate control—an important but sometimes overlooked consideration in the successful use of PCAs;
• The patient-initiated or demand dose, available to the patient at the press of a button;
• The delay interval or lockout, typically between six and 15 minutes, allowing the analgesic to achieve its peak effect before another dose can be administered. The number of unsuccessful demands by patients during lockout periods is important for the physician to know;
• A continuous infusion or basal rate to provide continuous pain relief, although this may be contraindicated for opioid-naïve patients starting on PCAs.4 For those receiving opioids for chronic pain, the basal rate could be their current analgesic dose converted to the intravenous equivalent. Alternatively, the patient could receive this dose in a long-acting oral analgesic, with the PCA used for incidental or breakthrough pain. A basal rate also helps patients sleep, their pain controlled without having to wake up to press for a dose;
• A maximum volume of drug to be administered within a defined period of one, four, eight, or 24 hours, calculated to prevent an opioid overdose—regardless of how many times the PCA button gets pushed; and
• Monitoring devices such as pulse oximeter or end-tidal carbon dioxide monitor may be part of the PCA system to help warn of emerging respiratory depression.

The fundamental challenge for physicians lies in balancing the loading, basal, and patient-initiated doses with an appropriate maximum to make sure the patient gets adequate pain relief but doesn’t overdose. This is a more complex, multifaceted mathematical formula than ordering opioids to be administered two, three, or four times a day.

A basic safeguard of the PCA for preventing overdose is that when the opioid analgesic starts to make the patient drowsy, he or she is likely to stop pressing the button for another dose. However, for this to work, the PCA must be patient-controlled. If a nurse or family member pushes the button on the patient’s behalf out of a well-meaning desire to keep pain in check, this raises the risk of overdose.

In the past few years, several national quality and safety organizations have issued alerts about the danger of such patient-controlled analgesia by proxy. The Institute for Safe Medication Practices (ISMP) in Huntington Valley, Pa., issued two safety alerts in July 2003 discussing how potentially life-threatening errors can occur with PCAs and offering ways to prevent such errors.

U.S. Pharmacopeia’s summer 2004 USP Quality Review also offered safety recommendations based on analysis of medical errors directly resulting from PCA by proxy. The Joint Commission issued a Sentinel Alert on Dec. 20, 2004, noting that “serious adverse effects can occur when family members, caregivers or clinicians who are not authorized become involved in administering the analgesic for the patient by proxy.”5 Earlier this year the American Society for Pain Management Nursing issued clinical practice recommendations for how nurses can deal with the problem of PCA by proxy.6

Well-designed hospital PCA protocols will address this problem by including clear instructions to family members not to push the button for the patient, with an explanation of why this can be dangerous. Printed brochures and signs in the patient’s room are also helpful.

The Need for Training

“Physicians, as a rule, don’t receive adequate training in the PCA,” says Jean Youngwerth, MD, hospitalist, palliative care consultant and fellowship associate director at the University of Colorado Health Sciences Center in Denver. “Then you’re expected to know how to use it. There clearly is a need for this kind of training in the basics of the PCA, but a brief in-service should be sufficient.”

Dan Johnson, MD, regional department chief for palliative care for Kaiser-Permanente in Colorado, says the level of experience with the PCA is highly variable among physicians he works with. “Some know how to use the PCA and actually do it quite well. Many others are not adequately trained,” he says. “When I test residents with a few questions, they customarily do very poorly. Some of the answers I see make me nervous.”

Dr. Johnson offers a refresher on the PCA for hospitalists in the Denver area who attend an annual palliative care retreat. Those who come regularly seem to retain the information he offers. “If I were in a hospital that had not rolled out PCA standing orders, I’d make sure that there were educational units provided for hospitalists,” he says. “I’d also investigate how to develop standing orders for the hospital.” TH

Larry Beresford is a frequent contributor to The Hospitalist.

References

1. Hudcova J, McNicol E, Quah C, et al. Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database Syst Rev. 2006;4.
2. Ballantyne JC, Carr DB, Chalmers TC. Postoperative patient-controlled analgesia: Meta-analyses of initial randomized controlled trials. J Clin Anesth. 1993 May/June;5(3):182-193.
3. D’Arcy Y. New pain management options: Delivery systems and techniques. Nursing. 2007 February; 37(2):26-27.
4. Pasero C, McCaffery M. Safe use of a continuous infusion with IV PCA. J PeriAnesthesia Nursing. 2004 Feb;19(1):42-45.
5. Joint Commission. Patient-controlled analgesia by proxy. Available at www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_33.htm. Last accessed July 12, 2007.
6. Wuhrman E, Cooney MF, Dunwoody CJ, et al. Authorized and unauthorized (“PCA by Proxy”) dosing of analgesic infusion pumps: Position statement with clinical practice recommendations. Pain Manag Nurs. 2007 Mar;8(1):4-11.
7. Prommer E. Fast Fact and Concept #92, Patient controlled analgesia in palliative care. End-of-Life/ Palliative Education Resource Center, Medical College of Wisconsin, Milwaukee:www.eperc.mcw.edu/ff_index.htm.
8. Owen H, Plummer JL, Armstrong I, et al. Variables of patient-controlled analgesia. 1. Bolus size. Anaesthesia.1989 Jan.;44(1):7-10.
9. Vicente KJ, Kada-Bekhaled K, Hillel G, et al. Programming errors contribute to death from patient-controlled analgesia. Can J Anesth. 2003;50:328-332.

Patient-controlled analgesia (PCA), well accepted and widely used to quickly ease post-operative and acute pain, is safe and effective—in skilled hands. But there are complications, caveats, and safety concerns hospitalists should consider to incorporate this tool into their pain management routines and hospital protocols.

Studies show patients prefer the PCA compared with other analgesic routes.1-2 Less clear is whether it is more effective or leads to lower opioid use.

Some hospitalists use the PCA for their patients with pain—others defer to anesthesiologists, pain services, or palliative care consultants to manage the PCA and its multifaceted dosing requirements.

“There are a lot of misconceptions about the PCA,” says Deb Gordon, RN, MS, FAAN, senior clinical nurse specialist and pain consultant at the University of Wisconsin (UW) Medical Center in Madison. “There is a misunderstanding that the PCA is a magic black box for pain relief,” which can lead to its overuse. As a general rule of pain management, patients prefer the oral route of analgesic administration, Gordon says, unless that is a problem or rapid titration is needed.

“I don’t think [the PCA is] rocket science—it’s just a tool to deliver analgesics conveniently,” Gordon says. “I think every hospitalist should learn how to use the PCA, but there are always nuances of how to titrate opioids by any route.” UW has implemented PCA protocols, which staff can use for ballpark dosing recommendations.

How Hospitalists Use the PCA

The PCA delivers pain medication intravenously via a computerized pump with a button the patient can press when needed—without waiting for busy nurses to answer a call button and then confirm, prepare, and administer an analgesic treatment.

Hospitalists at UW, including Rob Hoffman, MD, often order the PCA. “It’s very well-liked by patients, who are not dependent on a busy nurse to get their analgesics administered,” Dr. Hoffman says. “The biggest concern, involving overdosing patients who are opioid-naïve, may be somewhat overblown. I haven’t experienced problems with my patients being over narcotized, but I start with a low dose and monitor them frequently.”

PCA technology can tabulate how much analgesic the patient has received during the previous 24 hours, Dr. Hoffman notes. “You know that’s a safe dose for the patient, and you can use it to make the transition to oral medications,” he says.

“Most of the patients I have on PCAs are palliative care patients,” says Rachelle Bernacki, MD, MS, a hospitalist, palliative care physician, and geriatrician at the University of California-San Francisco Medical Center. “I use it somewhat differently for the patients in my hospitalist practice—for example, for those who are experiencing intermittent, unpredictable episodes of abdominal pain. It’s also useful for patients with a need to feel in control of their situation. For constant, predictable pain, it’s better to use an around-the-clock schedule. I also send certain patients home on PCAs, especially if they are going to hospice care.”

Dr. Bernacki notes that some of her patients kiss the PCA button as if it were a long-lost friend, including one she recalls who had a bowel obstruction and had not found relief prior to starting on the PCA. But she also recalls a patient for whom the PCA was not a solution. “He was Cantonese-speaking,” she says. “Despite the presence of an interpreter and several attempts at education, he was never able to understand the connection between the PCA button and relief for his pain. We just couldn’t cross the cultural and language barriers.”

Hospitalists probably underuse the PCA, says Mahmood Shahlapour, MD, hospitalist and palliative care consultant at Chandler Regional Hospital in Chandler, Ariz. “Some hospitalists may feel uncomfortable with it,” he says. “I think it’s important for hospitalists to try to get more experience and comfort to be able to use it for the right patient and the right setting.”

What Is the PCA?

PCA technology as we know it today was pioneered in the early 1970s. Now it’s routine for post-surgical pain management. It is used for patients who have trouble taking oral medications or who need rapid response to acute pain crises. Increasingly, it is also used for patients with moderate to severe chronic pain related to cancer or who are being followed by hospice or palliative care services.

PCA refers both to the process of patient self-administration of parenteral analgesics and to the computerized infusion pump that makes this control possible. Recent advances in pain management also include patient-controlled epidural and transdermal analgesia systems—and other new pain modalities continue to be developed.3 Patients unable to operate the equipment themselves—for example, neonates or infants—may receive nurse-controlled analgesia, but experts say this should only be done within carefully defined parameters.

With the more typical intravenous PCA, the computerized pump allows for a number of variables, including:

• An initial bolus or loading dose to bring the pain under immediate control—an important but sometimes overlooked consideration in the successful use of PCAs;
• The patient-initiated or demand dose, available to the patient at the press of a button;
• The delay interval or lockout, typically between six and 15 minutes, allowing the analgesic to achieve its peak effect before another dose can be administered. The number of unsuccessful demands by patients during lockout periods is important for the physician to know;
• A continuous infusion or basal rate to provide continuous pain relief, although this may be contraindicated for opioid-naïve patients starting on PCAs.4 For those receiving opioids for chronic pain, the basal rate could be their current analgesic dose converted to the intravenous equivalent. Alternatively, the patient could receive this dose in a long-acting oral analgesic, with the PCA used for incidental or breakthrough pain. A basal rate also helps patients sleep, their pain controlled without having to wake up to press for a dose;
• A maximum volume of drug to be administered within a defined period of one, four, eight, or 24 hours, calculated to prevent an opioid overdose—regardless of how many times the PCA button gets pushed; and
• Monitoring devices such as pulse oximeter or end-tidal carbon dioxide monitor may be part of the PCA system to help warn of emerging respiratory depression.

The fundamental challenge for physicians lies in balancing the loading, basal, and patient-initiated doses with an appropriate maximum to make sure the patient gets adequate pain relief but doesn’t overdose. This is a more complex, multifaceted mathematical formula than ordering opioids to be administered two, three, or four times a day.

A basic safeguard of the PCA for preventing overdose is that when the opioid analgesic starts to make the patient drowsy, he or she is likely to stop pressing the button for another dose. However, for this to work, the PCA must be patient-controlled. If a nurse or family member pushes the button on the patient’s behalf out of a well-meaning desire to keep pain in check, this raises the risk of overdose.

In the past few years, several national quality and safety organizations have issued alerts about the danger of such patient-controlled analgesia by proxy. The Institute for Safe Medication Practices (ISMP) in Huntington Valley, Pa., issued two safety alerts in July 2003 discussing how potentially life-threatening errors can occur with PCAs and offering ways to prevent such errors.

U.S. Pharmacopeia’s summer 2004 USP Quality Review also offered safety recommendations based on analysis of medical errors directly resulting from PCA by proxy. The Joint Commission issued a Sentinel Alert on Dec. 20, 2004, noting that “serious adverse effects can occur when family members, caregivers or clinicians who are not authorized become involved in administering the analgesic for the patient by proxy.”5 Earlier this year the American Society for Pain Management Nursing issued clinical practice recommendations for how nurses can deal with the problem of PCA by proxy.6

Well-designed hospital PCA protocols will address this problem by including clear instructions to family members not to push the button for the patient, with an explanation of why this can be dangerous. Printed brochures and signs in the patient’s room are also helpful.

The Need for Training

“Physicians, as a rule, don’t receive adequate training in the PCA,” says Jean Youngwerth, MD, hospitalist, palliative care consultant and fellowship associate director at the University of Colorado Health Sciences Center in Denver. “Then you’re expected to know how to use it. There clearly is a need for this kind of training in the basics of the PCA, but a brief in-service should be sufficient.”

Dan Johnson, MD, regional department chief for palliative care for Kaiser-Permanente in Colorado, says the level of experience with the PCA is highly variable among physicians he works with. “Some know how to use the PCA and actually do it quite well. Many others are not adequately trained,” he says. “When I test residents with a few questions, they customarily do very poorly. Some of the answers I see make me nervous.”

Dr. Johnson offers a refresher on the PCA for hospitalists in the Denver area who attend an annual palliative care retreat. Those who come regularly seem to retain the information he offers. “If I were in a hospital that had not rolled out PCA standing orders, I’d make sure that there were educational units provided for hospitalists,” he says. “I’d also investigate how to develop standing orders for the hospital.” TH

Larry Beresford is a frequent contributor to The Hospitalist.

References

1. Hudcova J, McNicol E, Quah C, et al. Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database Syst Rev. 2006;4.
2. Ballantyne JC, Carr DB, Chalmers TC. Postoperative patient-controlled analgesia: Meta-analyses of initial randomized controlled trials. J Clin Anesth. 1993 May/June;5(3):182-193.
3. D’Arcy Y. New pain management options: Delivery systems and techniques. Nursing. 2007 February; 37(2):26-27.
4. Pasero C, McCaffery M. Safe use of a continuous infusion with IV PCA. J PeriAnesthesia Nursing. 2004 Feb;19(1):42-45.
5. Joint Commission. Patient-controlled analgesia by proxy. Available at www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_33.htm. Last accessed July 12, 2007.
6. Wuhrman E, Cooney MF, Dunwoody CJ, et al. Authorized and unauthorized (“PCA by Proxy”) dosing of analgesic infusion pumps: Position statement with clinical practice recommendations. Pain Manag Nurs. 2007 Mar;8(1):4-11.
7. Prommer E. Fast Fact and Concept #92, Patient controlled analgesia in palliative care. End-of-Life/ Palliative Education Resource Center, Medical College of Wisconsin, Milwaukee:www.eperc.mcw.edu/ff_index.htm.
8. Owen H, Plummer JL, Armstrong I, et al. Variables of patient-controlled analgesia. 1. Bolus size. Anaesthesia.1989 Jan.;44(1):7-10.
9. Vicente KJ, Kada-Bekhaled K, Hillel G, et al. Programming errors contribute to death from patient-controlled analgesia. Can J Anesth. 2003;50:328-332.

Supplement Co-Editors and Supplement Co-Directors:
Amir K. Jaffer, MD, and Franklin A. Michota, Jr., MD

Summit Co-Directors:
Angela M. Bader, MD, MPH, and Raymond Borkowski, MD

Contents

Forword: New topics, returning features, tools for enduring challenges
Amir K. Jaffer, MD, and Franklin A. Michota, Jr., MD

Summit Faculty

Summit Program

IMPACT Consults

Are routine preoperative chest radiographs necessary in asymptomatic patients undergoing noncardiothoracic surgery?
Anitha Rajamanickam, MD, Preethi Patel, MD, and Ali Usmani, MD

Do preoperative nutritional interventions improve outcomes in malnourished patients undergoing elective surgery?
Ramnath Hebbar, MD, and Brian Harte, MD

Do all patients undergoing bariatric surgery need polysomnography to evaluate for obstructive sleep apnea?
Roop Kaw, MD, Vesselin Dimov, MD, and Charles Bae, MD

Can brain natriuretic peptide identify noncardiac surgery patients at high risk for cardiac events?
Ali Usmani, MD, Priyanka Sharma, MD, and Ashish Aneja, MD

What is the significance of an isolated elevated activated partial thromboplastin time in the preoperative setting?
William H. Morris, MD, and Ajay Kumar, MD

Does unrecognized diabetes in the preoperative period worsen postoperative outcomes?
Krista Andersen-Harris, DO, and Christopher Whinney, MD

Should an asymptomatic patient with an abnormal urinalysis (bacteriuria or pyuria) be treated with antibiotics prior to major joint replacement surgery?
Anitha Rajamanickam, MD, Saira Noor, MD, and Ali Usmani, MD

Does a carotid bruit predict cerebrovascular complications following noncardiac surgery in asymptomatic patients?
Robert Mayock, MD

What risks does a history of pulmonary hypertension present for patients undergoing noncardiac surgery?
Roop Kaw, MD, Priyanka Sharma, MD, and Omar A. Minai, MD

Does a systolic murmur heard in the aortic area need to be further evaluated prior to elective surgery?
Thadeo Catacutan, MD, Ali Usmani, MD, and Ashish Aneja, MD

Abstracts

Oral Abstracts
Preoperative electrocardiograms: Patient factors predictive of abnormalities
Darin Correll, David Hepner, Lawrence Tsen, Candace Chang, Angela Bader

Impact of combination medical therapy on mortality in vascular surgery patients
Thomas Barrett, Motomi Mori, Caroline Koudelka

Do large electronic medical record databases permit collection of reliable and valid data for quality improvement purposes?
Ashish Aneja, Eric Hixson, Brian Harte, Vesselin Dimov, Amir Jaffer

Poster Abstracts
Innovations in Perioperative Medicine
Abstract 1: PONV: 'An ounce of prevention is worth a pound of cure'
Catherine Capitula, Shari Duguay

Abstract 2: Optimization of perioperative processes through innovation and technology for the orthopaedic operating room of the future
J.H. James Choi, Jennifer Blueter, Barbara Fahey, James Leonard, Ted Omilanowski, Vincent Riley, Mark Schauer, Timothy Sullivan, Viktor Krebs, Jonathan Schaffer

Abstract 3: A systematic approach to interpreting electrocardiograms by using two mnemonics
Vesselin Dimov, Kalina Uzunova-Dimova, Ajay Kumar, Ashish Aneja

Abstract 4: Improving and standardizing medicine consultation
Benny Gavi, Lisa Shieh, Keith Posley, Shahram Sepehri, Phil Pang

Abstract 5: Medical students' assessment of a required rotation in perioperative medicine and pain
Amir Jaffer, Samuel Irefin, John Tetzlaff, J. Harry Isaacson

Abstract 6: Improving safety for adult surgical patients with obstructive sleep apnea
Karen Watkins

Abstract 7: A multidisciplinary approach to improving the safety of high-risk spine surgery: The complex spine protocol
Peter Kallas, Anjali Desai, Andrew Naidech, Tyler Koski, Steve Ondra, Mary Lou Green

Abstract 8: The nurse practitioner role in evidence-based medication strategies
Patricia Kidik, Kathleen Holbrook

Abstract 9: Use of the motivator/hygiene theory of motivation to guide quality efforts
Ronald Kratz

Abstract 10: A novel care model coordinating inpatient and outpatient perioperative care, utilizing a computerized patient tracking system
Diane Levitan, Dominic Reilly, Christopher Wong, Kara Mitchell, Philip Vedovatti, Nason Hamlin

Abstract 11: The development of an admitting team
Kathleen McGrath, Janet Piatek, Jeanne Lanchester

Abstract 12: Improve communication among caregivers: Eliminating unauthorized abbreviations on hospital medical records
Magdalena G. Smith, Maura Walsh, Laurie Walsh, Marjorie Guglin, Dio Sumaygaysay, Evangelina Sapalasan, Frances Haug, Olivia Voellmicke, Mahin Sanjari, Nancy Cimitile, Mariya Chernyatskaya

Abstract 13: Improve preadmission testing process
Magdalena G. Smith, Tak Tam, Rita Medrozo, Maura Walsh, Laurie Walsh, Marjorie Guglin

Perioperative Clinical Vignettes
Abstract 14: Chronic renal insufficiency: An oft-forgotten component of the revised cardiac risk index
Vesselin Dimov, Ashish Aneja, Kalina Uzunova-Dimova

Abstract 15: When is a stress test indicated in patients with chronic kidney disease evaluated for noncardiac surgery?
Vesselin Dimov, Kalina Uzunova-Dimova, Mitko Badov, Saira Noor

Abstract 16: When to correct hyperkalemia in patients with chronic kidney disease prior to noncardiac surgery?
Vesselin Dimov, Kalina Uzunova-Dimova, Ajay Kumar, Anitha Rajamanickam, Mitko Badov

Abstract 17: What is the optimal time frame for performing hemodialysis in patients with end-stage renal disease prior to surgery?
Vesselin Dimov, Kalina Uzunova-Dimova, Mitko Badov, Ajay Kumar

Abstract 18: A recent vascular graft in a patient with end-stage renal disease on hemodialysis and the need for preoperative antibiotic prophylaxis
Vesselin Dimov, Kalina Uzunova-Dimova, Mitko Badov, Ajay Kumar

Abstract 19: Postoperative risk of acute kidney injury in patients with chronic kidney disease
Vesselin Dimov, Kalina Uzunova-Dimova, Ali Usmani, Ajay Kumar

Abstract 20: Preoperative hypoglycemia in a patient on detemir insulin
Ronad P. Olson, M. Angelyn Bethel, Lillian F. Lien

Abstract 21: Evaluation of Mobitz I atrioventricular block in a preoperative patient
Margaret Pothier

Abstract 22: Perioperative cardiac arrest in a patient with aortic stenosis: Is it preventable?
Zdravka Zafirova, Bobbie Sweitzer

Abstract 23: Antiplatelet therapy interruption and perioperative stent thrombosis: Too much, too early
Zdravka Zafirova, Bobbie Sweitzer

Research in Perioperative Medicine
Abstract 24: Use of an at-home internet-based patient evaluation tool for preoperative assessment
Margaret Pothier, David Hepner, Darrin Correll, Thomas Ho, Alina Lazar, Angela Bader

Abstract 25: The utility of a preoperative clinic questionnaire to predict postoperative delirium risk
David Hepner, Darin Correll, Thomas Ho, Juergen Bludau, Jhoanna Santos, Angela Bader

Abstract 26: A drug by any other name: Preoperative insulin regimens
Carlee Clark, Vivek Moitra, Bobbie Jean Sweitzer

Abstract 27: Preoperative cardiovascular risk factor assessment in morbidly obese patients with an abnormal electrocardiogram
Girish Mood, Roomana Akhtar, Rajagopal Reddy Edula, Gunjana Bhandari, Vishal Gupta, Michael Koch

Abstract 28: Cardiac testing prior to nonvascular surgery: The results from a newly formed preoperative clinic
Sheela Pai, Giang Tran, Alvin Blaustein, Prasad Atluri, Salwa Shenaq

Abstract 29: Which is better—half-dose or no insulin on day of surgery?
Kirk Smith, Vivek Moitra, Melinda Drum, Bobbie Jean Sweitzer

Index of Authors

Supplement Co-Editors and Supplement Co-Directors:
Amir K. Jaffer, MD, and Franklin A. Michota, Jr., MD

Summit Co-Directors:
Angela M. Bader, MD, MPH, and Raymond Borkowski, MD

Contents

Forword: New topics, returning features, tools for enduring challenges
Amir K. Jaffer, MD, and Franklin A. Michota, Jr., MD

Summit Faculty

Summit Program

IMPACT Consults

Are routine preoperative chest radiographs necessary in asymptomatic patients undergoing noncardiothoracic surgery?
Anitha Rajamanickam, MD, Preethi Patel, MD, and Ali Usmani, MD

Do preoperative nutritional interventions improve outcomes in malnourished patients undergoing elective surgery?
Ramnath Hebbar, MD, and Brian Harte, MD

Do all patients undergoing bariatric surgery need polysomnography to evaluate for obstructive sleep apnea?
Roop Kaw, MD, Vesselin Dimov, MD, and Charles Bae, MD

Can brain natriuretic peptide identify noncardiac surgery patients at high risk for cardiac events?
Ali Usmani, MD, Priyanka Sharma, MD, and Ashish Aneja, MD

What is the significance of an isolated elevated activated partial thromboplastin time in the preoperative setting?
William H. Morris, MD, and Ajay Kumar, MD

Does unrecognized diabetes in the preoperative period worsen postoperative outcomes?
Krista Andersen-Harris, DO, and Christopher Whinney, MD

Should an asymptomatic patient with an abnormal urinalysis (bacteriuria or pyuria) be treated with antibiotics prior to major joint replacement surgery?
Anitha Rajamanickam, MD, Saira Noor, MD, and Ali Usmani, MD

Does a carotid bruit predict cerebrovascular complications following noncardiac surgery in asymptomatic patients?
Robert Mayock, MD

What risks does a history of pulmonary hypertension present for patients undergoing noncardiac surgery?
Roop Kaw, MD, Priyanka Sharma, MD, and Omar A. Minai, MD

Does a systolic murmur heard in the aortic area need to be further evaluated prior to elective surgery?
Thadeo Catacutan, MD, Ali Usmani, MD, and Ashish Aneja, MD

Abstracts

Oral Abstracts
Preoperative electrocardiograms: Patient factors predictive of abnormalities
Darin Correll, David Hepner, Lawrence Tsen, Candace Chang, Angela Bader

Impact of combination medical therapy on mortality in vascular surgery patients
Thomas Barrett, Motomi Mori, Caroline Koudelka

Do large electronic medical record databases permit collection of reliable and valid data for quality improvement purposes?
Ashish Aneja, Eric Hixson, Brian Harte, Vesselin Dimov, Amir Jaffer

Poster Abstracts
Innovations in Perioperative Medicine
Abstract 1: PONV: 'An ounce of prevention is worth a pound of cure'
Catherine Capitula, Shari Duguay

Abstract 2: Optimization of perioperative processes through innovation and technology for the orthopaedic operating room of the future
J.H. James Choi, Jennifer Blueter, Barbara Fahey, James Leonard, Ted Omilanowski, Vincent Riley, Mark Schauer, Timothy Sullivan, Viktor Krebs, Jonathan Schaffer

Abstract 3: A systematic approach to interpreting electrocardiograms by using two mnemonics
Vesselin Dimov, Kalina Uzunova-Dimova, Ajay Kumar, Ashish Aneja

Abstract 4: Improving and standardizing medicine consultation
Benny Gavi, Lisa Shieh, Keith Posley, Shahram Sepehri, Phil Pang

Abstract 5: Medical students' assessment of a required rotation in perioperative medicine and pain
Amir Jaffer, Samuel Irefin, John Tetzlaff, J. Harry Isaacson

Abstract 6: Improving safety for adult surgical patients with obstructive sleep apnea
Karen Watkins

Abstract 7: A multidisciplinary approach to improving the safety of high-risk spine surgery: The complex spine protocol
Peter Kallas, Anjali Desai, Andrew Naidech, Tyler Koski, Steve Ondra, Mary Lou Green

Abstract 8: The nurse practitioner role in evidence-based medication strategies
Patricia Kidik, Kathleen Holbrook

Abstract 9: Use of the motivator/hygiene theory of motivation to guide quality efforts
Ronald Kratz

Abstract 10: A novel care model coordinating inpatient and outpatient perioperative care, utilizing a computerized patient tracking system
Diane Levitan, Dominic Reilly, Christopher Wong, Kara Mitchell, Philip Vedovatti, Nason Hamlin

Abstract 11: The development of an admitting team
Kathleen McGrath, Janet Piatek, Jeanne Lanchester

Abstract 12: Improve communication among caregivers: Eliminating unauthorized abbreviations on hospital medical records
Magdalena G. Smith, Maura Walsh, Laurie Walsh, Marjorie Guglin, Dio Sumaygaysay, Evangelina Sapalasan, Frances Haug, Olivia Voellmicke, Mahin Sanjari, Nancy Cimitile, Mariya Chernyatskaya

Abstract 13: Improve preadmission testing process
Magdalena G. Smith, Tak Tam, Rita Medrozo, Maura Walsh, Laurie Walsh, Marjorie Guglin

Perioperative Clinical Vignettes
Abstract 14: Chronic renal insufficiency: An oft-forgotten component of the revised cardiac risk index
Vesselin Dimov, Ashish Aneja, Kalina Uzunova-Dimova

Abstract 15: When is a stress test indicated in patients with chronic kidney disease evaluated for noncardiac surgery?
Vesselin Dimov, Kalina Uzunova-Dimova, Mitko Badov, Saira Noor

Abstract 16: When to correct hyperkalemia in patients with chronic kidney disease prior to noncardiac surgery?
Vesselin Dimov, Kalina Uzunova-Dimova, Ajay Kumar, Anitha Rajamanickam, Mitko Badov

Abstract 17: What is the optimal time frame for performing hemodialysis in patients with end-stage renal disease prior to surgery?
Vesselin Dimov, Kalina Uzunova-Dimova, Mitko Badov, Ajay Kumar

Abstract 18: A recent vascular graft in a patient with end-stage renal disease on hemodialysis and the need for preoperative antibiotic prophylaxis
Vesselin Dimov, Kalina Uzunova-Dimova, Mitko Badov, Ajay Kumar

Abstract 19: Postoperative risk of acute kidney injury in patients with chronic kidney disease
Vesselin Dimov, Kalina Uzunova-Dimova, Ali Usmani, Ajay Kumar

Abstract 20: Preoperative hypoglycemia in a patient on detemir insulin
Ronad P. Olson, M. Angelyn Bethel, Lillian F. Lien

Abstract 21: Evaluation of Mobitz I atrioventricular block in a preoperative patient
Margaret Pothier

Abstract 22: Perioperative cardiac arrest in a patient with aortic stenosis: Is it preventable?
Zdravka Zafirova, Bobbie Sweitzer

Abstract 23: Antiplatelet therapy interruption and perioperative stent thrombosis: Too much, too early
Zdravka Zafirova, Bobbie Sweitzer

Research in Perioperative Medicine
Abstract 24: Use of an at-home internet-based patient evaluation tool for preoperative assessment
Margaret Pothier, David Hepner, Darrin Correll, Thomas Ho, Alina Lazar, Angela Bader

Abstract 25: The utility of a preoperative clinic questionnaire to predict postoperative delirium risk
David Hepner, Darin Correll, Thomas Ho, Juergen Bludau, Jhoanna Santos, Angela Bader

Abstract 26: A drug by any other name: Preoperative insulin regimens
Carlee Clark, Vivek Moitra, Bobbie Jean Sweitzer

Abstract 27: Preoperative cardiovascular risk factor assessment in morbidly obese patients with an abnormal electrocardiogram
Girish Mood, Roomana Akhtar, Rajagopal Reddy Edula, Gunjana Bhandari, Vishal Gupta, Michael Koch

Abstract 28: Cardiac testing prior to nonvascular surgery: The results from a newly formed preoperative clinic
Sheela Pai, Giang Tran, Alvin Blaustein, Prasad Atluri, Salwa Shenaq

Abstract 29: Which is better—half-dose or no insulin on day of surgery?
Kirk Smith, Vivek Moitra, Melinda Drum, Bobbie Jean Sweitzer

Index of Authors

Supplement Co-Editors and Supplement Co-Directors:
Amir K. Jaffer, MD, and Franklin A. Michota, Jr., MD

Summit Co-Directors:
Angela M. Bader, MD, MPH, and Raymond Borkowski, MD

Contents

Forword: New topics, returning features, tools for enduring challenges
Amir K. Jaffer, MD, and Franklin A. Michota, Jr., MD

Summit Faculty

Summit Program

IMPACT Consults

Are routine preoperative chest radiographs necessary in asymptomatic patients undergoing noncardiothoracic surgery?
Anitha Rajamanickam, MD, Preethi Patel, MD, and Ali Usmani, MD

Do preoperative nutritional interventions improve outcomes in malnourished patients undergoing elective surgery?
Ramnath Hebbar, MD, and Brian Harte, MD

Do all patients undergoing bariatric surgery need polysomnography to evaluate for obstructive sleep apnea?
Roop Kaw, MD, Vesselin Dimov, MD, and Charles Bae, MD

Can brain natriuretic peptide identify noncardiac surgery patients at high risk for cardiac events?
Ali Usmani, MD, Priyanka Sharma, MD, and Ashish Aneja, MD

What is the significance of an isolated elevated activated partial thromboplastin time in the preoperative setting?
William H. Morris, MD, and Ajay Kumar, MD

Does unrecognized diabetes in the preoperative period worsen postoperative outcomes?
Krista Andersen-Harris, DO, and Christopher Whinney, MD

Should an asymptomatic patient with an abnormal urinalysis (bacteriuria or pyuria) be treated with antibiotics prior to major joint replacement surgery?
Anitha Rajamanickam, MD, Saira Noor, MD, and Ali Usmani, MD

Does a carotid bruit predict cerebrovascular complications following noncardiac surgery in asymptomatic patients?
Robert Mayock, MD

What risks does a history of pulmonary hypertension present for patients undergoing noncardiac surgery?
Roop Kaw, MD, Priyanka Sharma, MD, and Omar A. Minai, MD

Does a systolic murmur heard in the aortic area need to be further evaluated prior to elective surgery?
Thadeo Catacutan, MD, Ali Usmani, MD, and Ashish Aneja, MD

Abstracts

Oral Abstracts
Preoperative electrocardiograms: Patient factors predictive of abnormalities
Darin Correll, David Hepner, Lawrence Tsen, Candace Chang, Angela Bader

Impact of combination medical therapy on mortality in vascular surgery patients
Thomas Barrett, Motomi Mori, Caroline Koudelka

Do large electronic medical record databases permit collection of reliable and valid data for quality improvement purposes?
Ashish Aneja, Eric Hixson, Brian Harte, Vesselin Dimov, Amir Jaffer

Poster Abstracts
Innovations in Perioperative Medicine
Abstract 1: PONV: 'An ounce of prevention is worth a pound of cure'
Catherine Capitula, Shari Duguay

Abstract 2: Optimization of perioperative processes through innovation and technology for the orthopaedic operating room of the future
J.H. James Choi, Jennifer Blueter, Barbara Fahey, James Leonard, Ted Omilanowski, Vincent Riley, Mark Schauer, Timothy Sullivan, Viktor Krebs, Jonathan Schaffer

Abstract 3: A systematic approach to interpreting electrocardiograms by using two mnemonics
Vesselin Dimov, Kalina Uzunova-Dimova, Ajay Kumar, Ashish Aneja

Abstract 4: Improving and standardizing medicine consultation
Benny Gavi, Lisa Shieh, Keith Posley, Shahram Sepehri, Phil Pang

Abstract 5: Medical students' assessment of a required rotation in perioperative medicine and pain
Amir Jaffer, Samuel Irefin, John Tetzlaff, J. Harry Isaacson

Abstract 6: Improving safety for adult surgical patients with obstructive sleep apnea
Karen Watkins

Abstract 7: A multidisciplinary approach to improving the safety of high-risk spine surgery: The complex spine protocol
Peter Kallas, Anjali Desai, Andrew Naidech, Tyler Koski, Steve Ondra, Mary Lou Green

Abstract 8: The nurse practitioner role in evidence-based medication strategies
Patricia Kidik, Kathleen Holbrook

Abstract 9: Use of the motivator/hygiene theory of motivation to guide quality efforts
Ronald Kratz

Abstract 10: A novel care model coordinating inpatient and outpatient perioperative care, utilizing a computerized patient tracking system
Diane Levitan, Dominic Reilly, Christopher Wong, Kara Mitchell, Philip Vedovatti, Nason Hamlin

Abstract 11: The development of an admitting team
Kathleen McGrath, Janet Piatek, Jeanne Lanchester

Abstract 12: Improve communication among caregivers: Eliminating unauthorized abbreviations on hospital medical records
Magdalena G. Smith, Maura Walsh, Laurie Walsh, Marjorie Guglin, Dio Sumaygaysay, Evangelina Sapalasan, Frances Haug, Olivia Voellmicke, Mahin Sanjari, Nancy Cimitile, Mariya Chernyatskaya

Abstract 13: Improve preadmission testing process
Magdalena G. Smith, Tak Tam, Rita Medrozo, Maura Walsh, Laurie Walsh, Marjorie Guglin

Perioperative Clinical Vignettes
Abstract 14: Chronic renal insufficiency: An oft-forgotten component of the revised cardiac risk index
Vesselin Dimov, Ashish Aneja, Kalina Uzunova-Dimova

Abstract 15: When is a stress test indicated in patients with chronic kidney disease evaluated for noncardiac surgery?
Vesselin Dimov, Kalina Uzunova-Dimova, Mitko Badov, Saira Noor

Abstract 16: When to correct hyperkalemia in patients with chronic kidney disease prior to noncardiac surgery?
Vesselin Dimov, Kalina Uzunova-Dimova, Ajay Kumar, Anitha Rajamanickam, Mitko Badov

Abstract 17: What is the optimal time frame for performing hemodialysis in patients with end-stage renal disease prior to surgery?
Vesselin Dimov, Kalina Uzunova-Dimova, Mitko Badov, Ajay Kumar

Abstract 18: A recent vascular graft in a patient with end-stage renal disease on hemodialysis and the need for preoperative antibiotic prophylaxis
Vesselin Dimov, Kalina Uzunova-Dimova, Mitko Badov, Ajay Kumar

Abstract 19: Postoperative risk of acute kidney injury in patients with chronic kidney disease
Vesselin Dimov, Kalina Uzunova-Dimova, Ali Usmani, Ajay Kumar

Abstract 20: Preoperative hypoglycemia in a patient on detemir insulin
Ronad P. Olson, M. Angelyn Bethel, Lillian F. Lien

Abstract 21: Evaluation of Mobitz I atrioventricular block in a preoperative patient
Margaret Pothier

Abstract 22: Perioperative cardiac arrest in a patient with aortic stenosis: Is it preventable?
Zdravka Zafirova, Bobbie Sweitzer

Abstract 23: Antiplatelet therapy interruption and perioperative stent thrombosis: Too much, too early
Zdravka Zafirova, Bobbie Sweitzer

Research in Perioperative Medicine
Abstract 24: Use of an at-home internet-based patient evaluation tool for preoperative assessment
Margaret Pothier, David Hepner, Darrin Correll, Thomas Ho, Alina Lazar, Angela Bader

Abstract 25: The utility of a preoperative clinic questionnaire to predict postoperative delirium risk
David Hepner, Darin Correll, Thomas Ho, Juergen Bludau, Jhoanna Santos, Angela Bader

Abstract 26: A drug by any other name: Preoperative insulin regimens
Carlee Clark, Vivek Moitra, Bobbie Jean Sweitzer

Abstract 27: Preoperative cardiovascular risk factor assessment in morbidly obese patients with an abnormal electrocardiogram
Girish Mood, Roomana Akhtar, Rajagopal Reddy Edula, Gunjana Bhandari, Vishal Gupta, Michael Koch

Abstract 28: Cardiac testing prior to nonvascular surgery: The results from a newly formed preoperative clinic
Sheela Pai, Giang Tran, Alvin Blaustein, Prasad Atluri, Salwa Shenaq

Abstract 29: Which is better—half-dose or no insulin on day of surgery?
Kirk Smith, Vivek Moitra, Melinda Drum, Bobbie Jean Sweitzer

Index of Authors