HM20 Virtual

The expansion of the field of pediatric hospital medicine in the past 30 years has resulted in improved health care outcomes for hospitalized children^1,2 and has been accompanied by a robust increase in the amount of scholarly work related to the field.³ We performed a review of the literature published in 2019 to identify the 10 articles that had the most impact on pediatric hospital medicine, and presented the findings at HM20 Virtual, the 2020 annual conference of the Society of Hospital Medicine. Five of the selected articles are highlighted here.

STUDY 1

Wechsler ME et al. Step-up therapy in black children and adults with poorly controlled asthma. N Engl J Med. 2019 Sep 26;381(13):1227-39.

Background

Current pediatric asthma guidelines suggest adding a long-acting beta-agonist (LABA) to inhaled corticosteroid (ICS) therapy, rather than increasing the ICS dose, for children with poorly controlled asthma. However, these data are based on trials with disproportionately few Black subjects. This study aimed to determine the best step-up therapy for Black patients whose asthma was poorly controlled on ICS monotherapy.
 

Study overview and results

The authors reported two parallel double-blind, randomized, controlled trials, one in children and one in adolescents and adults. The study of children included 280 subjects ranging in age from 5 to 11, with at least one Black grandparent, and with poorly controlled asthma on low-dose ICS therapy. It used a four-way crossover design in which each subject was treated with four different 14-week treatment regimens: either double (medium-dose) or quintuple (high-dose) their baseline ICS dose, with or without the addition of a LABA. A superior response was defined by the composite outcome of at least one fewer asthma exacerbation, more asthma-control days, or a 5–percentage point difference in predicted FEV₁. Forty-six percent of children had improved asthma outcomes when the ICS dose was increased rather than with the addition of a LABA. In contrast, Black adolescents and Black adults had superior responses to the addition of a LABA. There was no significant interaction between the percentage of African ancestry as determined by DNA genotyping and the primary composite outcome. High-dose ICS was associated with a decrease in the ratio of urinary cortisol to creatinine in children younger than 8 years.
 

Limitations

Approximately 25% of children dropped out of the study, with disproportionately more children dropping out while on a high-dose ICS regimen. Additionally, the difference in the composite outcome was primarily driven by differences in FEV₁, with few subjects demonstrating a difference in asthma exacerbations or asthma-control days. Although a decrease in urinary cortisol to creatinine ratio was noted in children under 8 on high-dose ICS, the study period was not long enough to determine the clinical implications of this finding.
 

Important findings and implications

While studies with a majority of white children have suggested a superior response from adding a LABA compared to increasing the dose of an ICS, almost half of Black children showed a superior response when the dose of an ICS was increased rather than adding a LABA. It is important to note that current guidelines are based on studies with a disproportionate majority of white subjects and may not accurately reflect optimal care for patients in other racial groups. This study underscores the need to include a diverse patient population in research studies.
 

STUDY 2

Chang PW, Newman TB. A simpler prediction rule for rebound hyperbilirubinemia. Pediatrics. 2019 Jul;144(1):e20183712.

Background

Hyperbilirubinemia (jaundice) is estimated to affect 50%-60% of all newborns. Rebound hyperbilirubinemia – a rise in bilirubin after cessation of phototherapy – is common and can lead to recently discharged infants being readmitted for additional therapy. Lack of clear guidelines regarding when to discharge infants with hyperbilirubinemia has likely contributed to practice variation and some trepidation regarding whether a bilirubin level is “low enough” to discontinue therapy.
 

Study overview and results

The authors had previously proposed a three-factor hyperbilirubinemia risk model and sought to simplify their rule further.⁴ They examined a retrospective cohort of 7,048 infants greater than or equal to 35 weeks’ gestation using a random split sample. The authors derived a two-factor model using the same methods and compared its performance to the three-factor model. The two-factor formula was shown to be a good fit as a logistic regression model (Hosmer-Lemeshow test 9.21; P = .33), and the AUROC (area under the receiver operating characteristic) curves for the derivation and validation cohorts were similar between the two-factor (0.877 and 0.876, respectively) and three-factor risk models (0.887 and 0.881, respectively).
 

Limitations

These data are limited to infants receiving their first treatment of phototherapy and have not been externally validated. An important variable, serum bilirubin at phototherapy termination, was estimated in most subjects, which may have affected the accuracy of the prediction rule. Whether infants received home phototherapy was based only on equipment orders, and some infants may have received phototherapy unbeknownst to investigators. Last, infants with rebound hyperbilirubinemia at less than 72 hours after phototherapy discontinuation may have been missed.
 

Important findings and implications

This prediction model provides evidence-based, concrete data that can be used in making joint decisions with families regarding discharge timing of infants with hyperbilirubinemia. It also could be beneficial when deciding appropriate follow-up time after discharge.

STUDY 3

Ramgopal S et al. Risk of serious bacterial infection in infants aged ≤60 days presenting to emergency departments with a history of fever only. J Pediatr. 2019 Jan;204:191-195. doi: 10.1016/j.jpeds.2018.08.043.

Background

Febrile infants aged 60 days and younger are at risk for serious bacterial infections (SBI) including urinary tract infections (UTI), bacteremia, and meningitis. As physical exam is a poor discriminator of SBI in this age group, providers frequently rely on laboratory values and risk factors to guide management. Infants presenting with documented fevers by caregivers but found to have no fever in the emergency department are a challenge, and there are limited data regarding SBI frequency in this population.
 

Study overview and results

The authors performed a secondary analysis of a prospectively gathered cohort of infants aged 60 days and younger within the Pediatric Emergency Care Applied Research Network (PECARN) who had blood, urine, and CSF data available. Notable exclusions included infants who were premature, had a focal infection, were clinically ill, had recent antibiotic use, did not have blood, urine, and CSF data available, or were lost to telephone follow-up at 7 days to ensure wellness. The study cohort included 6,014 infants, 1,233 (32%) who were febrile by history alone. Rates of overall SBI were lower in the afebrile group (8.8% vs. 12.8%). For infants 0-28 days, rates of UTI were lower for the afebrile group (9.5% vs. 14.5%), but there was no difference in the rates of bacteremia or meningitis. For infants 29-60 days, rates of UTI (6.6% vs. 9.3%) and bacteremia (.5% vs. 1.7%) were lower in the afebrile group.
 

Limitations

Neither the use of home antipyretics nor the method of temperature taking at home were studied. Also, as this was a secondary analysis, it is possible that not all infants who presented with history of fever only were captured, as work-up was dictated by individual treating providers who may have chosen not to work up certain afebrile infants.
 

Important findings and implications

Nearly one-third of infants presenting for fever evaluation are afebrile on arrival. Although overall rates of SBI were lower in the group with fever by history only, this difference is largely accounted for by differing rates of UTI. Rates of bacteremia and meningitis remained substantial between groups, particularly for infants aged 0-28 days. Because of the significant morbidity associated with these infections, it is reasonable to suggest that absence of fever on presentation alone should not alter clinical or laboratory work-up, particularly in infants 0-28 days.
 

STUDY 4

Humphrey-Murto S et al. The influence of prior performance information on ratings of current performance and implications for learner handover: A scoping review. Acad Med. 2019 Jul;94(7):1050-7.

Background

Learner Handover (LH) or “forward feeding” occurs when information about trainees is shared between faculty supervisors. Although this can be helpful to tailor educational experiences and build upon previous assessments, it risks stigmatizing trainees and adding bias to future feedback and assessments as the trainee never really has a “clean slate.” In this study, the authors sought to uncover the key concepts of how prior performance information (PPI) influences assessments and any implications for medical education.
 

Study overview and results

The authors performed a cross-disciplinary scoping review looking at over 17,000 articles published between 1980 and 2017 across the domains of psychology, sports, business, and education. Seven themes were identified with the following notable findings. Raters exposed to positive PPI scored a learner’s performance higher, and vice versa. There was a dose-response relationship with more positive and more negative PPI resulting in higher and lower assessments, respectively. General standards, such as a direction to complete all work in a timely manner, caused an assimilation effect, while specific standards, such as a direction to complete a certain task by a certain day, did not. More motivated and more experienced raters are less affected by PPI, and those who believe that people can change (incremental theorists) are less affected by PPI while those who believe personal attributes are fixed (entity theorists) are more affected.
 

Limitations

The heterogeneity of the studies and the fact that they were largely conducted in experimental settings may limit generalizability to medical education. Slightly less than half of the studies included a control arm. Last, most of the studies looked at the ratings of only one target performance, not multiple performances over time.
 

Important findings and implications

Ratings of current performance displace toward PPI direction, with negative PPI more influential than positive PPI. In a formative setting, PPI may help the assessor focus on areas of possible weakness. In contrast, for a summative assessment, PPI may be prejudicial and have an impact on the rating given to the student. Clinicians should be mindful of the information they share with future raters about learners and the potential bias on future assessments that can manifest as a result.
 

STUDY 5

McCann ME et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): An international, multicentre, randomised, controlled equivalence trial. The Lancet. 2019 Feb;393:664-77.

Background

Animal models and observational studies have suggested a link between early anesthesia exposure and adverse neurocognitive outcomes; however, findings have been mixed and studies are prone to confounding. This study is the first randomized controlled trial to compare neurocognitive outcomes for infants exposed to general anesthesia versus awake-regional anesthesia.

Study overview and results

In this international, multicenter, assessor-masked trial, 722 infants undergoing inguinal hernia repair were randomized to awake-regional anesthesia or single-agent sevoflurane-based general anesthesia. Infants born at greater than 26 weeks’ gestational age were eligible, while those with prior anesthesia exposure or risks for neurocognitive delay were excluded. The primary outcome was full-scale intelligence quotient (FSIQ) testing at 5 years of age on the Wechsler Preschool and Primary Scale of Intelligence, third edition (WPPSI-III). Seven additional neurodevelopmental assessments and parental questionnaires regarding behavior were administered as secondary outcomes. Average anesthesia exposure was 54 minutes and no infant had exposure greater than 120 minutes. There was no significant difference in mean scores on WPPSI-III FSIQ testing, and no difference in the additional neurocognitive assessments or parent-reported outcomes used as secondary outcomes.
 

Limitations

This study was limited to single, short periods of single-agent anesthesia exposure in children with no additional neurologic risk factors, so caution should be used in extrapolating these data to children with medical complexity and children undergoing multiple procedures, longer surgeries, or multidrug anesthetic regimens. The study population was majority male because of the surgical pathology selected and included only children in the narrow range of postmenstrual age 60 weeks or less. While this population represents a suspected a period of high cerebral vulnerability based on animal models, the implications of anesthesia exposure at other ages are unclear.
 

Important findings and implications

An estimated 10% of children from developed countries are exposed to general anesthesia during the first 3 years of life. While hospitalists do not typically select the route of anesthesia, they frequently care for patients undergoing procedures and must address parental concerns regarding the safety of anesthesia exposure. Given the rigorous study methods and long-term follow up in the current study, these data should provide reassurance that, for healthy infants undergoing short, single-agent anesthetic exposure, there is no evidence of future adverse neurologic outcomes.
 

Dr. Russo is director of pediatrics, medical director for quality and innovation, at WellSpan Health, York, Pa. Dr. Money is a pediatric hospitalist at Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City. Dr. Steed is instructor of hospital medicine, Northwestern Memorial Hospital and Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University School of Medicine, Chicago. The authors would like to thank Dr. Klint M. Schwenk and the Society for Hospital Medicine Pediatric Special Interest Group Executive Council.

References

1. Roberts KB, Fisher ER, and Rauch DA. The history of pediatric hospital medicine in the United States, 1996-2019. J Hosp Med. 2020 Jul;15(7):424-7.

2. Mussman GM and Conway PH. Pediatric hospitalist systems versus traditional models of care: Effect on quality and cost outcomes. J Hosp Med. 2012 Apr;7(4):350-7.

3. Wang ME, Shaughnessy EE, and Leyenaar JK. The future of pediatric hospital medicine: Challenges and opportunities. J Hosp Med. 2020 Jul;15(7):428-30.

4. Chang PW et al. A clinical prediction rule for rebound hyperbilirubinemia following inpatient phototherapy. Pediatrics. 2017;139 Mar;139(3):e20162896.

The expansion of the field of pediatric hospital medicine in the past 30 years has resulted in improved health care outcomes for hospitalized children^1,2 and has been accompanied by a robust increase in the amount of scholarly work related to the field.³ We performed a review of the literature published in 2019 to identify the 10 articles that had the most impact on pediatric hospital medicine, and presented the findings at HM20 Virtual, the 2020 annual conference of the Society of Hospital Medicine. Five of the selected articles are highlighted here.

STUDY 1

Wechsler ME et al. Step-up therapy in black children and adults with poorly controlled asthma. N Engl J Med. 2019 Sep 26;381(13):1227-39.

Background

Current pediatric asthma guidelines suggest adding a long-acting beta-agonist (LABA) to inhaled corticosteroid (ICS) therapy, rather than increasing the ICS dose, for children with poorly controlled asthma. However, these data are based on trials with disproportionately few Black subjects. This study aimed to determine the best step-up therapy for Black patients whose asthma was poorly controlled on ICS monotherapy.
 

Study overview and results

The authors reported two parallel double-blind, randomized, controlled trials, one in children and one in adolescents and adults. The study of children included 280 subjects ranging in age from 5 to 11, with at least one Black grandparent, and with poorly controlled asthma on low-dose ICS therapy. It used a four-way crossover design in which each subject was treated with four different 14-week treatment regimens: either double (medium-dose) or quintuple (high-dose) their baseline ICS dose, with or without the addition of a LABA. A superior response was defined by the composite outcome of at least one fewer asthma exacerbation, more asthma-control days, or a 5–percentage point difference in predicted FEV₁. Forty-six percent of children had improved asthma outcomes when the ICS dose was increased rather than with the addition of a LABA. In contrast, Black adolescents and Black adults had superior responses to the addition of a LABA. There was no significant interaction between the percentage of African ancestry as determined by DNA genotyping and the primary composite outcome. High-dose ICS was associated with a decrease in the ratio of urinary cortisol to creatinine in children younger than 8 years.
 

Limitations

Approximately 25% of children dropped out of the study, with disproportionately more children dropping out while on a high-dose ICS regimen. Additionally, the difference in the composite outcome was primarily driven by differences in FEV₁, with few subjects demonstrating a difference in asthma exacerbations or asthma-control days. Although a decrease in urinary cortisol to creatinine ratio was noted in children under 8 on high-dose ICS, the study period was not long enough to determine the clinical implications of this finding.
 

Important findings and implications

While studies with a majority of white children have suggested a superior response from adding a LABA compared to increasing the dose of an ICS, almost half of Black children showed a superior response when the dose of an ICS was increased rather than adding a LABA. It is important to note that current guidelines are based on studies with a disproportionate majority of white subjects and may not accurately reflect optimal care for patients in other racial groups. This study underscores the need to include a diverse patient population in research studies.
 

STUDY 2

Chang PW, Newman TB. A simpler prediction rule for rebound hyperbilirubinemia. Pediatrics. 2019 Jul;144(1):e20183712.

Background

Hyperbilirubinemia (jaundice) is estimated to affect 50%-60% of all newborns. Rebound hyperbilirubinemia – a rise in bilirubin after cessation of phototherapy – is common and can lead to recently discharged infants being readmitted for additional therapy. Lack of clear guidelines regarding when to discharge infants with hyperbilirubinemia has likely contributed to practice variation and some trepidation regarding whether a bilirubin level is “low enough” to discontinue therapy.
 

Study overview and results

The authors had previously proposed a three-factor hyperbilirubinemia risk model and sought to simplify their rule further.⁴ They examined a retrospective cohort of 7,048 infants greater than or equal to 35 weeks’ gestation using a random split sample. The authors derived a two-factor model using the same methods and compared its performance to the three-factor model. The two-factor formula was shown to be a good fit as a logistic regression model (Hosmer-Lemeshow test 9.21; P = .33), and the AUROC (area under the receiver operating characteristic) curves for the derivation and validation cohorts were similar between the two-factor (0.877 and 0.876, respectively) and three-factor risk models (0.887 and 0.881, respectively).
 

Limitations

These data are limited to infants receiving their first treatment of phototherapy and have not been externally validated. An important variable, serum bilirubin at phototherapy termination, was estimated in most subjects, which may have affected the accuracy of the prediction rule. Whether infants received home phototherapy was based only on equipment orders, and some infants may have received phototherapy unbeknownst to investigators. Last, infants with rebound hyperbilirubinemia at less than 72 hours after phototherapy discontinuation may have been missed.
 

Important findings and implications

This prediction model provides evidence-based, concrete data that can be used in making joint decisions with families regarding discharge timing of infants with hyperbilirubinemia. It also could be beneficial when deciding appropriate follow-up time after discharge.

STUDY 3

Ramgopal S et al. Risk of serious bacterial infection in infants aged ≤60 days presenting to emergency departments with a history of fever only. J Pediatr. 2019 Jan;204:191-195. doi: 10.1016/j.jpeds.2018.08.043.

Background

Febrile infants aged 60 days and younger are at risk for serious bacterial infections (SBI) including urinary tract infections (UTI), bacteremia, and meningitis. As physical exam is a poor discriminator of SBI in this age group, providers frequently rely on laboratory values and risk factors to guide management. Infants presenting with documented fevers by caregivers but found to have no fever in the emergency department are a challenge, and there are limited data regarding SBI frequency in this population.
 

Study overview and results

The authors performed a secondary analysis of a prospectively gathered cohort of infants aged 60 days and younger within the Pediatric Emergency Care Applied Research Network (PECARN) who had blood, urine, and CSF data available. Notable exclusions included infants who were premature, had a focal infection, were clinically ill, had recent antibiotic use, did not have blood, urine, and CSF data available, or were lost to telephone follow-up at 7 days to ensure wellness. The study cohort included 6,014 infants, 1,233 (32%) who were febrile by history alone. Rates of overall SBI were lower in the afebrile group (8.8% vs. 12.8%). For infants 0-28 days, rates of UTI were lower for the afebrile group (9.5% vs. 14.5%), but there was no difference in the rates of bacteremia or meningitis. For infants 29-60 days, rates of UTI (6.6% vs. 9.3%) and bacteremia (.5% vs. 1.7%) were lower in the afebrile group.
 

Limitations

Neither the use of home antipyretics nor the method of temperature taking at home were studied. Also, as this was a secondary analysis, it is possible that not all infants who presented with history of fever only were captured, as work-up was dictated by individual treating providers who may have chosen not to work up certain afebrile infants.
 

Important findings and implications

Nearly one-third of infants presenting for fever evaluation are afebrile on arrival. Although overall rates of SBI were lower in the group with fever by history only, this difference is largely accounted for by differing rates of UTI. Rates of bacteremia and meningitis remained substantial between groups, particularly for infants aged 0-28 days. Because of the significant morbidity associated with these infections, it is reasonable to suggest that absence of fever on presentation alone should not alter clinical or laboratory work-up, particularly in infants 0-28 days.
 

STUDY 4

Humphrey-Murto S et al. The influence of prior performance information on ratings of current performance and implications for learner handover: A scoping review. Acad Med. 2019 Jul;94(7):1050-7.

Background

Learner Handover (LH) or “forward feeding” occurs when information about trainees is shared between faculty supervisors. Although this can be helpful to tailor educational experiences and build upon previous assessments, it risks stigmatizing trainees and adding bias to future feedback and assessments as the trainee never really has a “clean slate.” In this study, the authors sought to uncover the key concepts of how prior performance information (PPI) influences assessments and any implications for medical education.
 

Study overview and results

The authors performed a cross-disciplinary scoping review looking at over 17,000 articles published between 1980 and 2017 across the domains of psychology, sports, business, and education. Seven themes were identified with the following notable findings. Raters exposed to positive PPI scored a learner’s performance higher, and vice versa. There was a dose-response relationship with more positive and more negative PPI resulting in higher and lower assessments, respectively. General standards, such as a direction to complete all work in a timely manner, caused an assimilation effect, while specific standards, such as a direction to complete a certain task by a certain day, did not. More motivated and more experienced raters are less affected by PPI, and those who believe that people can change (incremental theorists) are less affected by PPI while those who believe personal attributes are fixed (entity theorists) are more affected.
 

Limitations

The heterogeneity of the studies and the fact that they were largely conducted in experimental settings may limit generalizability to medical education. Slightly less than half of the studies included a control arm. Last, most of the studies looked at the ratings of only one target performance, not multiple performances over time.
 

Important findings and implications

Ratings of current performance displace toward PPI direction, with negative PPI more influential than positive PPI. In a formative setting, PPI may help the assessor focus on areas of possible weakness. In contrast, for a summative assessment, PPI may be prejudicial and have an impact on the rating given to the student. Clinicians should be mindful of the information they share with future raters about learners and the potential bias on future assessments that can manifest as a result.
 

STUDY 5

McCann ME et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): An international, multicentre, randomised, controlled equivalence trial. The Lancet. 2019 Feb;393:664-77.

Background

Animal models and observational studies have suggested a link between early anesthesia exposure and adverse neurocognitive outcomes; however, findings have been mixed and studies are prone to confounding. This study is the first randomized controlled trial to compare neurocognitive outcomes for infants exposed to general anesthesia versus awake-regional anesthesia.

Study overview and results

In this international, multicenter, assessor-masked trial, 722 infants undergoing inguinal hernia repair were randomized to awake-regional anesthesia or single-agent sevoflurane-based general anesthesia. Infants born at greater than 26 weeks’ gestational age were eligible, while those with prior anesthesia exposure or risks for neurocognitive delay were excluded. The primary outcome was full-scale intelligence quotient (FSIQ) testing at 5 years of age on the Wechsler Preschool and Primary Scale of Intelligence, third edition (WPPSI-III). Seven additional neurodevelopmental assessments and parental questionnaires regarding behavior were administered as secondary outcomes. Average anesthesia exposure was 54 minutes and no infant had exposure greater than 120 minutes. There was no significant difference in mean scores on WPPSI-III FSIQ testing, and no difference in the additional neurocognitive assessments or parent-reported outcomes used as secondary outcomes.
 

Limitations

This study was limited to single, short periods of single-agent anesthesia exposure in children with no additional neurologic risk factors, so caution should be used in extrapolating these data to children with medical complexity and children undergoing multiple procedures, longer surgeries, or multidrug anesthetic regimens. The study population was majority male because of the surgical pathology selected and included only children in the narrow range of postmenstrual age 60 weeks or less. While this population represents a suspected a period of high cerebral vulnerability based on animal models, the implications of anesthesia exposure at other ages are unclear.
 

Important findings and implications

An estimated 10% of children from developed countries are exposed to general anesthesia during the first 3 years of life. While hospitalists do not typically select the route of anesthesia, they frequently care for patients undergoing procedures and must address parental concerns regarding the safety of anesthesia exposure. Given the rigorous study methods and long-term follow up in the current study, these data should provide reassurance that, for healthy infants undergoing short, single-agent anesthetic exposure, there is no evidence of future adverse neurologic outcomes.
 

Dr. Russo is director of pediatrics, medical director for quality and innovation, at WellSpan Health, York, Pa. Dr. Money is a pediatric hospitalist at Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City. Dr. Steed is instructor of hospital medicine, Northwestern Memorial Hospital and Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University School of Medicine, Chicago. The authors would like to thank Dr. Klint M. Schwenk and the Society for Hospital Medicine Pediatric Special Interest Group Executive Council.

References

1. Roberts KB, Fisher ER, and Rauch DA. The history of pediatric hospital medicine in the United States, 1996-2019. J Hosp Med. 2020 Jul;15(7):424-7.

2. Mussman GM and Conway PH. Pediatric hospitalist systems versus traditional models of care: Effect on quality and cost outcomes. J Hosp Med. 2012 Apr;7(4):350-7.

3. Wang ME, Shaughnessy EE, and Leyenaar JK. The future of pediatric hospital medicine: Challenges and opportunities. J Hosp Med. 2020 Jul;15(7):428-30.

4. Chang PW et al. A clinical prediction rule for rebound hyperbilirubinemia following inpatient phototherapy. Pediatrics. 2017;139 Mar;139(3):e20162896.

The expansion of the field of pediatric hospital medicine in the past 30 years has resulted in improved health care outcomes for hospitalized children^1,2 and has been accompanied by a robust increase in the amount of scholarly work related to the field.³ We performed a review of the literature published in 2019 to identify the 10 articles that had the most impact on pediatric hospital medicine, and presented the findings at HM20 Virtual, the 2020 annual conference of the Society of Hospital Medicine. Five of the selected articles are highlighted here.

STUDY 1

Wechsler ME et al. Step-up therapy in black children and adults with poorly controlled asthma. N Engl J Med. 2019 Sep 26;381(13):1227-39.

Background

Current pediatric asthma guidelines suggest adding a long-acting beta-agonist (LABA) to inhaled corticosteroid (ICS) therapy, rather than increasing the ICS dose, for children with poorly controlled asthma. However, these data are based on trials with disproportionately few Black subjects. This study aimed to determine the best step-up therapy for Black patients whose asthma was poorly controlled on ICS monotherapy.
 

Study overview and results

The authors reported two parallel double-blind, randomized, controlled trials, one in children and one in adolescents and adults. The study of children included 280 subjects ranging in age from 5 to 11, with at least one Black grandparent, and with poorly controlled asthma on low-dose ICS therapy. It used a four-way crossover design in which each subject was treated with four different 14-week treatment regimens: either double (medium-dose) or quintuple (high-dose) their baseline ICS dose, with or without the addition of a LABA. A superior response was defined by the composite outcome of at least one fewer asthma exacerbation, more asthma-control days, or a 5–percentage point difference in predicted FEV₁. Forty-six percent of children had improved asthma outcomes when the ICS dose was increased rather than with the addition of a LABA. In contrast, Black adolescents and Black adults had superior responses to the addition of a LABA. There was no significant interaction between the percentage of African ancestry as determined by DNA genotyping and the primary composite outcome. High-dose ICS was associated with a decrease in the ratio of urinary cortisol to creatinine in children younger than 8 years.
 

Limitations

Approximately 25% of children dropped out of the study, with disproportionately more children dropping out while on a high-dose ICS regimen. Additionally, the difference in the composite outcome was primarily driven by differences in FEV₁, with few subjects demonstrating a difference in asthma exacerbations or asthma-control days. Although a decrease in urinary cortisol to creatinine ratio was noted in children under 8 on high-dose ICS, the study period was not long enough to determine the clinical implications of this finding.
 

Important findings and implications

While studies with a majority of white children have suggested a superior response from adding a LABA compared to increasing the dose of an ICS, almost half of Black children showed a superior response when the dose of an ICS was increased rather than adding a LABA. It is important to note that current guidelines are based on studies with a disproportionate majority of white subjects and may not accurately reflect optimal care for patients in other racial groups. This study underscores the need to include a diverse patient population in research studies.
 

STUDY 2

Chang PW, Newman TB. A simpler prediction rule for rebound hyperbilirubinemia. Pediatrics. 2019 Jul;144(1):e20183712.

Background

Hyperbilirubinemia (jaundice) is estimated to affect 50%-60% of all newborns. Rebound hyperbilirubinemia – a rise in bilirubin after cessation of phototherapy – is common and can lead to recently discharged infants being readmitted for additional therapy. Lack of clear guidelines regarding when to discharge infants with hyperbilirubinemia has likely contributed to practice variation and some trepidation regarding whether a bilirubin level is “low enough” to discontinue therapy.
 

Study overview and results

The authors had previously proposed a three-factor hyperbilirubinemia risk model and sought to simplify their rule further.⁴ They examined a retrospective cohort of 7,048 infants greater than or equal to 35 weeks’ gestation using a random split sample. The authors derived a two-factor model using the same methods and compared its performance to the three-factor model. The two-factor formula was shown to be a good fit as a logistic regression model (Hosmer-Lemeshow test 9.21; P = .33), and the AUROC (area under the receiver operating characteristic) curves for the derivation and validation cohorts were similar between the two-factor (0.877 and 0.876, respectively) and three-factor risk models (0.887 and 0.881, respectively).
 

Limitations

These data are limited to infants receiving their first treatment of phototherapy and have not been externally validated. An important variable, serum bilirubin at phototherapy termination, was estimated in most subjects, which may have affected the accuracy of the prediction rule. Whether infants received home phototherapy was based only on equipment orders, and some infants may have received phototherapy unbeknownst to investigators. Last, infants with rebound hyperbilirubinemia at less than 72 hours after phototherapy discontinuation may have been missed.
 

Important findings and implications

This prediction model provides evidence-based, concrete data that can be used in making joint decisions with families regarding discharge timing of infants with hyperbilirubinemia. It also could be beneficial when deciding appropriate follow-up time after discharge.

STUDY 3

Ramgopal S et al. Risk of serious bacterial infection in infants aged ≤60 days presenting to emergency departments with a history of fever only. J Pediatr. 2019 Jan;204:191-195. doi: 10.1016/j.jpeds.2018.08.043.

Background

Febrile infants aged 60 days and younger are at risk for serious bacterial infections (SBI) including urinary tract infections (UTI), bacteremia, and meningitis. As physical exam is a poor discriminator of SBI in this age group, providers frequently rely on laboratory values and risk factors to guide management. Infants presenting with documented fevers by caregivers but found to have no fever in the emergency department are a challenge, and there are limited data regarding SBI frequency in this population.
 

Study overview and results

The authors performed a secondary analysis of a prospectively gathered cohort of infants aged 60 days and younger within the Pediatric Emergency Care Applied Research Network (PECARN) who had blood, urine, and CSF data available. Notable exclusions included infants who were premature, had a focal infection, were clinically ill, had recent antibiotic use, did not have blood, urine, and CSF data available, or were lost to telephone follow-up at 7 days to ensure wellness. The study cohort included 6,014 infants, 1,233 (32%) who were febrile by history alone. Rates of overall SBI were lower in the afebrile group (8.8% vs. 12.8%). For infants 0-28 days, rates of UTI were lower for the afebrile group (9.5% vs. 14.5%), but there was no difference in the rates of bacteremia or meningitis. For infants 29-60 days, rates of UTI (6.6% vs. 9.3%) and bacteremia (.5% vs. 1.7%) were lower in the afebrile group.
 

Limitations

Neither the use of home antipyretics nor the method of temperature taking at home were studied. Also, as this was a secondary analysis, it is possible that not all infants who presented with history of fever only were captured, as work-up was dictated by individual treating providers who may have chosen not to work up certain afebrile infants.
 

Important findings and implications

Nearly one-third of infants presenting for fever evaluation are afebrile on arrival. Although overall rates of SBI were lower in the group with fever by history only, this difference is largely accounted for by differing rates of UTI. Rates of bacteremia and meningitis remained substantial between groups, particularly for infants aged 0-28 days. Because of the significant morbidity associated with these infections, it is reasonable to suggest that absence of fever on presentation alone should not alter clinical or laboratory work-up, particularly in infants 0-28 days.
 

STUDY 4

Humphrey-Murto S et al. The influence of prior performance information on ratings of current performance and implications for learner handover: A scoping review. Acad Med. 2019 Jul;94(7):1050-7.

Background

Learner Handover (LH) or “forward feeding” occurs when information about trainees is shared between faculty supervisors. Although this can be helpful to tailor educational experiences and build upon previous assessments, it risks stigmatizing trainees and adding bias to future feedback and assessments as the trainee never really has a “clean slate.” In this study, the authors sought to uncover the key concepts of how prior performance information (PPI) influences assessments and any implications for medical education.
 

Study overview and results

The authors performed a cross-disciplinary scoping review looking at over 17,000 articles published between 1980 and 2017 across the domains of psychology, sports, business, and education. Seven themes were identified with the following notable findings. Raters exposed to positive PPI scored a learner’s performance higher, and vice versa. There was a dose-response relationship with more positive and more negative PPI resulting in higher and lower assessments, respectively. General standards, such as a direction to complete all work in a timely manner, caused an assimilation effect, while specific standards, such as a direction to complete a certain task by a certain day, did not. More motivated and more experienced raters are less affected by PPI, and those who believe that people can change (incremental theorists) are less affected by PPI while those who believe personal attributes are fixed (entity theorists) are more affected.
 

Limitations

The heterogeneity of the studies and the fact that they were largely conducted in experimental settings may limit generalizability to medical education. Slightly less than half of the studies included a control arm. Last, most of the studies looked at the ratings of only one target performance, not multiple performances over time.
 

Important findings and implications

Ratings of current performance displace toward PPI direction, with negative PPI more influential than positive PPI. In a formative setting, PPI may help the assessor focus on areas of possible weakness. In contrast, for a summative assessment, PPI may be prejudicial and have an impact on the rating given to the student. Clinicians should be mindful of the information they share with future raters about learners and the potential bias on future assessments that can manifest as a result.
 

STUDY 5

McCann ME et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): An international, multicentre, randomised, controlled equivalence trial. The Lancet. 2019 Feb;393:664-77.

Background

Animal models and observational studies have suggested a link between early anesthesia exposure and adverse neurocognitive outcomes; however, findings have been mixed and studies are prone to confounding. This study is the first randomized controlled trial to compare neurocognitive outcomes for infants exposed to general anesthesia versus awake-regional anesthesia.

Study overview and results

In this international, multicenter, assessor-masked trial, 722 infants undergoing inguinal hernia repair were randomized to awake-regional anesthesia or single-agent sevoflurane-based general anesthesia. Infants born at greater than 26 weeks’ gestational age were eligible, while those with prior anesthesia exposure or risks for neurocognitive delay were excluded. The primary outcome was full-scale intelligence quotient (FSIQ) testing at 5 years of age on the Wechsler Preschool and Primary Scale of Intelligence, third edition (WPPSI-III). Seven additional neurodevelopmental assessments and parental questionnaires regarding behavior were administered as secondary outcomes. Average anesthesia exposure was 54 minutes and no infant had exposure greater than 120 minutes. There was no significant difference in mean scores on WPPSI-III FSIQ testing, and no difference in the additional neurocognitive assessments or parent-reported outcomes used as secondary outcomes.
 

Limitations

This study was limited to single, short periods of single-agent anesthesia exposure in children with no additional neurologic risk factors, so caution should be used in extrapolating these data to children with medical complexity and children undergoing multiple procedures, longer surgeries, or multidrug anesthetic regimens. The study population was majority male because of the surgical pathology selected and included only children in the narrow range of postmenstrual age 60 weeks or less. While this population represents a suspected a period of high cerebral vulnerability based on animal models, the implications of anesthesia exposure at other ages are unclear.
 

Important findings and implications

An estimated 10% of children from developed countries are exposed to general anesthesia during the first 3 years of life. While hospitalists do not typically select the route of anesthesia, they frequently care for patients undergoing procedures and must address parental concerns regarding the safety of anesthesia exposure. Given the rigorous study methods and long-term follow up in the current study, these data should provide reassurance that, for healthy infants undergoing short, single-agent anesthetic exposure, there is no evidence of future adverse neurologic outcomes.
 

Dr. Russo is director of pediatrics, medical director for quality and innovation, at WellSpan Health, York, Pa. Dr. Money is a pediatric hospitalist at Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City. Dr. Steed is instructor of hospital medicine, Northwestern Memorial Hospital and Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University School of Medicine, Chicago. The authors would like to thank Dr. Klint M. Schwenk and the Society for Hospital Medicine Pediatric Special Interest Group Executive Council.

References

1. Roberts KB, Fisher ER, and Rauch DA. The history of pediatric hospital medicine in the United States, 1996-2019. J Hosp Med. 2020 Jul;15(7):424-7.

2. Mussman GM and Conway PH. Pediatric hospitalist systems versus traditional models of care: Effect on quality and cost outcomes. J Hosp Med. 2012 Apr;7(4):350-7.

3. Wang ME, Shaughnessy EE, and Leyenaar JK. The future of pediatric hospital medicine: Challenges and opportunities. J Hosp Med. 2020 Jul;15(7):428-30.

4. Chang PW et al. A clinical prediction rule for rebound hyperbilirubinemia following inpatient phototherapy. Pediatrics. 2017;139 Mar;139(3):e20162896.

The HM20 Virtual conference in August was filled with excellent content that can be applied by all hospitalists. This article summarizes key concepts and takeaways for the pediatric hospitalist.

Racism and bias in medicine

HM20 Virtual session: Structural Racism and Bias in Hospital Medicine During Two Pandemics

Presenters: Nathan Chomilo, MD, FAAP, and Benji K. Mathews, MD, SFHM

Dr. Nathan Chomilo, of HealthPartners in Minneapolis, opened the session sharing how racial disparities were a symptom of racism. The presenters explained how structural racism has been propagated in medicine with the Hospital Survey and Construction Act of 1964 that allowed segregated hospitals, as well as the racism that exists within the “hidden curriculum.”

Dr. Chomilo discussed how personal experiences of racism can lead to worse health outcomes, including depression, obesity, and overall poor health. Dr. Mathews, also of HealthPartners, discussed how implicit biases can be addressed at the individual level, the organizational level, and simultaneously at both levels to create an antiracist culture. He presented strategies to mitigate individual biases; recognizing when biases may be triggered, checking biases at the door, connecting with others from different backgrounds as equals, and practicing antiracism by being an active bystander. Dr. Chomilo concluded the session by sharing that we can all grow by addressing racism at “our houses” (health care systems, medical schools, payer systems) with the goal to create an antiracist system.
 

Key takeaways

• Racial disparities are a symptom of structural racism that has been propagated in medicine for centuries.
• Addressing implicit biases at the individual level, organization level, and simultaneously at both levels can help leaders model and promote an antiracism culture.

HM20 Virtual session: When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics

Presenter: Kimberly Manning, MD, FACP, FAAP

Dr. Kimberly Manning, of Emory University in Atlanta, discussed the dual pandemics of COVID-19 and the racism that we are currently experiencing and tried to describe the unique perspective of Black Americans. Though it is easy to see that COVID-19 is a pandemic, racism is not always seen in this way. Dr. Manning demonstrated that, when a pandemic is defined as “that which occurs over a wide geographic area and affects a high proportion of the population,” racism is absolutely a pandemic. Black Americans have been disproportionately affected by COVID-19. Dr. Manning said we often hear that we are in unprecedented times but as far as racism is concerned, there is nothing new about this. She shared stories of personal milestones and how each of these instances, though marked by something beautiful, was also marked by something truly awful. Each time she had a reason to smile, there was something awful going on in the country that showed how racism was still present. Dr. Manning described that, though these were her stories, all Black Americans can recount the same stories, emotions, and feelings of grief.

Dr. Manning concluded by sharing how we can “Do The Work” to combat the pandemic of racism: broaden our funds of knowledge, remember that people are grieving, explore our implicit biases, be brave bystanders, and avoid performative allyship
 

Key takeaways

• Though the COVID19 pandemic is unprecedented, the pandemic of racism is not.
• We must “Do The Work” to combat everyday racism and to be cognizant of what our Black colleagues are going through every day.

Immigrant hospitalist challenges

HM20 Virtual session: The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19

Presenters: Manpreet S. Malik, MD, FHM, and Benji K. Mathews, MD, SFHM

Dr. Malik of Emory University in Atlanta, and Dr. Mathews of HealthPartners, opened this session by sharing their personal stories as immigrant physicians in the United States. Dr. Malik noted that physicians born outside the United States make up 29% of U.S. physicians, and 32% of hospitalists are international medical graduates.

The presenters revealed the structural hurdles immigrant physicians face, including lack of empowerment until achieving permanent residency status; limited leadership, administrative, and academic roles; concerns for job security and financial stability; and experiencing micro- and macroaggressions at work. The presenters shared a framework for a developmental orientation inclined toward cultural competency beginning with denial, followed by polarization, progressing to minimization, advancing to acceptance, and culminating in adaptation.

They concluded the session by stressing the importance of advocacy for immigrant physicians and encouraged colleagues to become engaged in efforts within their professional organizations.
 

Key takeaway

• Immigrant physicians experience structural challenges to their professional advancement because of their residency status.

Learner supervision

HM20 Virtual session: Call Me Maybe: Balancing Resident Autonomy With Sensible Supervision

Presenter: Daniel Steinberg, MD, SFHM, FACP

Dr. Steinberg, based at Mount Sinai in New York, explained that resident supervision is driven by three factors: what residents need, what residents want, and what the supervisor can provide. Although data is mixed as to whether supervision improves patient outcomes, supervision is essential for patient care and resident education. Dr. Steinberg showcased several relevant medical education studies related to supervision and focused on a key question: Do you trust the resident? The review of medical education literature discussed the meaning and development of trust, oral case presentations to determine trust, and the influence of supervisor experience.

Key takeaways

• Resident supervision is driven by what residents need, what residents want, and what the supervisor can provide.
• Trust can be determined from direct supervision, oral presentations, and remote access of electronic medical records, but is also influenced by attending experience and style.

Balancing personal and professional life

HM20 Virtual session: Being a Hospitalist and a Parent: Balancing Roles With Grace

Presenters: Heather E. Nye, MD, PhD, SFHM, and David Alfandre, MD, MSPH

Dr. Nye of the University of California, San Francisco, and Dr. Alfandre of New York University shared their challenges as hospitalists, parents, and partners before and during the COVID-19 pandemic. They described their feelings of guilt during the pandemic related to increasing their families’ infection risks, as well as the gratitude they felt for having stable jobs during the crisis. They shared solutions that worked for their families, including cooperating with their partners, expressing their scheduling needs, and negotiating to meet those needs with their employers.

Dr. Nye and Dr. Alfandre recommended staying connected with others for help, including partners, institutions, neighbors, and colleagues. They also recommended supporting, sharing, collaborating, and connecting with their partners and colleagues to maintain a balanced professional and personal life.
 

Key takeaway:

• Stay connected and support, collaborate, and share with your colleagues and partner at home.

Dr. Kumar is the pediatric editor of The Hospitalist. She is clinical assistant professor of pediatrics at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University and a pediatric hospitalist at Cleveland Clinic Children’s. Dr. Doraiswamy is an assistant professor of medicine and pediatrics and a med-peds hospitalist at The Ohio State University and Nationwide Children’s Hospital, both in Columbus. Dr. Tantoco is an academic med-peds hospitalist practicing in Northwestern Memorial Hospital, Chicago, and Ann & Robert H. Lurie Children’s Hospital of Chicago.

The HM20 Virtual conference in August was filled with excellent content that can be applied by all hospitalists. This article summarizes key concepts and takeaways for the pediatric hospitalist.

Racism and bias in medicine

HM20 Virtual session: Structural Racism and Bias in Hospital Medicine During Two Pandemics

Presenters: Nathan Chomilo, MD, FAAP, and Benji K. Mathews, MD, SFHM

Dr. Nathan Chomilo, of HealthPartners in Minneapolis, opened the session sharing how racial disparities were a symptom of racism. The presenters explained how structural racism has been propagated in medicine with the Hospital Survey and Construction Act of 1964 that allowed segregated hospitals, as well as the racism that exists within the “hidden curriculum.”

Dr. Chomilo discussed how personal experiences of racism can lead to worse health outcomes, including depression, obesity, and overall poor health. Dr. Mathews, also of HealthPartners, discussed how implicit biases can be addressed at the individual level, the organizational level, and simultaneously at both levels to create an antiracist culture. He presented strategies to mitigate individual biases; recognizing when biases may be triggered, checking biases at the door, connecting with others from different backgrounds as equals, and practicing antiracism by being an active bystander. Dr. Chomilo concluded the session by sharing that we can all grow by addressing racism at “our houses” (health care systems, medical schools, payer systems) with the goal to create an antiracist system.
 

Key takeaways

• Racial disparities are a symptom of structural racism that has been propagated in medicine for centuries.
• Addressing implicit biases at the individual level, organization level, and simultaneously at both levels can help leaders model and promote an antiracism culture.

HM20 Virtual session: When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics

Presenter: Kimberly Manning, MD, FACP, FAAP

Dr. Kimberly Manning, of Emory University in Atlanta, discussed the dual pandemics of COVID-19 and the racism that we are currently experiencing and tried to describe the unique perspective of Black Americans. Though it is easy to see that COVID-19 is a pandemic, racism is not always seen in this way. Dr. Manning demonstrated that, when a pandemic is defined as “that which occurs over a wide geographic area and affects a high proportion of the population,” racism is absolutely a pandemic. Black Americans have been disproportionately affected by COVID-19. Dr. Manning said we often hear that we are in unprecedented times but as far as racism is concerned, there is nothing new about this. She shared stories of personal milestones and how each of these instances, though marked by something beautiful, was also marked by something truly awful. Each time she had a reason to smile, there was something awful going on in the country that showed how racism was still present. Dr. Manning described that, though these were her stories, all Black Americans can recount the same stories, emotions, and feelings of grief.

Dr. Manning concluded by sharing how we can “Do The Work” to combat the pandemic of racism: broaden our funds of knowledge, remember that people are grieving, explore our implicit biases, be brave bystanders, and avoid performative allyship
 

Key takeaways

• Though the COVID19 pandemic is unprecedented, the pandemic of racism is not.
• We must “Do The Work” to combat everyday racism and to be cognizant of what our Black colleagues are going through every day.

Immigrant hospitalist challenges

HM20 Virtual session: The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19

Presenters: Manpreet S. Malik, MD, FHM, and Benji K. Mathews, MD, SFHM

Dr. Malik of Emory University in Atlanta, and Dr. Mathews of HealthPartners, opened this session by sharing their personal stories as immigrant physicians in the United States. Dr. Malik noted that physicians born outside the United States make up 29% of U.S. physicians, and 32% of hospitalists are international medical graduates.

The presenters revealed the structural hurdles immigrant physicians face, including lack of empowerment until achieving permanent residency status; limited leadership, administrative, and academic roles; concerns for job security and financial stability; and experiencing micro- and macroaggressions at work. The presenters shared a framework for a developmental orientation inclined toward cultural competency beginning with denial, followed by polarization, progressing to minimization, advancing to acceptance, and culminating in adaptation.

They concluded the session by stressing the importance of advocacy for immigrant physicians and encouraged colleagues to become engaged in efforts within their professional organizations.
 

Key takeaway

• Immigrant physicians experience structural challenges to their professional advancement because of their residency status.

Learner supervision

HM20 Virtual session: Call Me Maybe: Balancing Resident Autonomy With Sensible Supervision

Presenter: Daniel Steinberg, MD, SFHM, FACP

Dr. Steinberg, based at Mount Sinai in New York, explained that resident supervision is driven by three factors: what residents need, what residents want, and what the supervisor can provide. Although data is mixed as to whether supervision improves patient outcomes, supervision is essential for patient care and resident education. Dr. Steinberg showcased several relevant medical education studies related to supervision and focused on a key question: Do you trust the resident? The review of medical education literature discussed the meaning and development of trust, oral case presentations to determine trust, and the influence of supervisor experience.

Key takeaways

• Resident supervision is driven by what residents need, what residents want, and what the supervisor can provide.
• Trust can be determined from direct supervision, oral presentations, and remote access of electronic medical records, but is also influenced by attending experience and style.

Balancing personal and professional life

HM20 Virtual session: Being a Hospitalist and a Parent: Balancing Roles With Grace

Presenters: Heather E. Nye, MD, PhD, SFHM, and David Alfandre, MD, MSPH

Dr. Nye of the University of California, San Francisco, and Dr. Alfandre of New York University shared their challenges as hospitalists, parents, and partners before and during the COVID-19 pandemic. They described their feelings of guilt during the pandemic related to increasing their families’ infection risks, as well as the gratitude they felt for having stable jobs during the crisis. They shared solutions that worked for their families, including cooperating with their partners, expressing their scheduling needs, and negotiating to meet those needs with their employers.

Dr. Nye and Dr. Alfandre recommended staying connected with others for help, including partners, institutions, neighbors, and colleagues. They also recommended supporting, sharing, collaborating, and connecting with their partners and colleagues to maintain a balanced professional and personal life.
 

Key takeaway:

• Stay connected and support, collaborate, and share with your colleagues and partner at home.

Dr. Kumar is the pediatric editor of The Hospitalist. She is clinical assistant professor of pediatrics at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University and a pediatric hospitalist at Cleveland Clinic Children’s. Dr. Doraiswamy is an assistant professor of medicine and pediatrics and a med-peds hospitalist at The Ohio State University and Nationwide Children’s Hospital, both in Columbus. Dr. Tantoco is an academic med-peds hospitalist practicing in Northwestern Memorial Hospital, Chicago, and Ann & Robert H. Lurie Children’s Hospital of Chicago.

The HM20 Virtual conference in August was filled with excellent content that can be applied by all hospitalists. This article summarizes key concepts and takeaways for the pediatric hospitalist.

Racism and bias in medicine

HM20 Virtual session: Structural Racism and Bias in Hospital Medicine During Two Pandemics

Presenters: Nathan Chomilo, MD, FAAP, and Benji K. Mathews, MD, SFHM

Dr. Nathan Chomilo, of HealthPartners in Minneapolis, opened the session sharing how racial disparities were a symptom of racism. The presenters explained how structural racism has been propagated in medicine with the Hospital Survey and Construction Act of 1964 that allowed segregated hospitals, as well as the racism that exists within the “hidden curriculum.”

Dr. Chomilo discussed how personal experiences of racism can lead to worse health outcomes, including depression, obesity, and overall poor health. Dr. Mathews, also of HealthPartners, discussed how implicit biases can be addressed at the individual level, the organizational level, and simultaneously at both levels to create an antiracist culture. He presented strategies to mitigate individual biases; recognizing when biases may be triggered, checking biases at the door, connecting with others from different backgrounds as equals, and practicing antiracism by being an active bystander. Dr. Chomilo concluded the session by sharing that we can all grow by addressing racism at “our houses” (health care systems, medical schools, payer systems) with the goal to create an antiracist system.
 

Key takeaways

• Racial disparities are a symptom of structural racism that has been propagated in medicine for centuries.
• Addressing implicit biases at the individual level, organization level, and simultaneously at both levels can help leaders model and promote an antiracism culture.

HM20 Virtual session: When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics

Presenter: Kimberly Manning, MD, FACP, FAAP

Dr. Kimberly Manning, of Emory University in Atlanta, discussed the dual pandemics of COVID-19 and the racism that we are currently experiencing and tried to describe the unique perspective of Black Americans. Though it is easy to see that COVID-19 is a pandemic, racism is not always seen in this way. Dr. Manning demonstrated that, when a pandemic is defined as “that which occurs over a wide geographic area and affects a high proportion of the population,” racism is absolutely a pandemic. Black Americans have been disproportionately affected by COVID-19. Dr. Manning said we often hear that we are in unprecedented times but as far as racism is concerned, there is nothing new about this. She shared stories of personal milestones and how each of these instances, though marked by something beautiful, was also marked by something truly awful. Each time she had a reason to smile, there was something awful going on in the country that showed how racism was still present. Dr. Manning described that, though these were her stories, all Black Americans can recount the same stories, emotions, and feelings of grief.

Dr. Manning concluded by sharing how we can “Do The Work” to combat the pandemic of racism: broaden our funds of knowledge, remember that people are grieving, explore our implicit biases, be brave bystanders, and avoid performative allyship
 

Key takeaways

• Though the COVID19 pandemic is unprecedented, the pandemic of racism is not.
• We must “Do The Work” to combat everyday racism and to be cognizant of what our Black colleagues are going through every day.

Immigrant hospitalist challenges

HM20 Virtual session: The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19

Presenters: Manpreet S. Malik, MD, FHM, and Benji K. Mathews, MD, SFHM

Dr. Malik of Emory University in Atlanta, and Dr. Mathews of HealthPartners, opened this session by sharing their personal stories as immigrant physicians in the United States. Dr. Malik noted that physicians born outside the United States make up 29% of U.S. physicians, and 32% of hospitalists are international medical graduates.

The presenters revealed the structural hurdles immigrant physicians face, including lack of empowerment until achieving permanent residency status; limited leadership, administrative, and academic roles; concerns for job security and financial stability; and experiencing micro- and macroaggressions at work. The presenters shared a framework for a developmental orientation inclined toward cultural competency beginning with denial, followed by polarization, progressing to minimization, advancing to acceptance, and culminating in adaptation.

They concluded the session by stressing the importance of advocacy for immigrant physicians and encouraged colleagues to become engaged in efforts within their professional organizations.
 

Key takeaway

• Immigrant physicians experience structural challenges to their professional advancement because of their residency status.

Learner supervision

HM20 Virtual session: Call Me Maybe: Balancing Resident Autonomy With Sensible Supervision

Presenter: Daniel Steinberg, MD, SFHM, FACP

Dr. Steinberg, based at Mount Sinai in New York, explained that resident supervision is driven by three factors: what residents need, what residents want, and what the supervisor can provide. Although data is mixed as to whether supervision improves patient outcomes, supervision is essential for patient care and resident education. Dr. Steinberg showcased several relevant medical education studies related to supervision and focused on a key question: Do you trust the resident? The review of medical education literature discussed the meaning and development of trust, oral case presentations to determine trust, and the influence of supervisor experience.

Key takeaways

• Resident supervision is driven by what residents need, what residents want, and what the supervisor can provide.
• Trust can be determined from direct supervision, oral presentations, and remote access of electronic medical records, but is also influenced by attending experience and style.

Balancing personal and professional life

HM20 Virtual session: Being a Hospitalist and a Parent: Balancing Roles With Grace

Presenters: Heather E. Nye, MD, PhD, SFHM, and David Alfandre, MD, MSPH

Dr. Nye of the University of California, San Francisco, and Dr. Alfandre of New York University shared their challenges as hospitalists, parents, and partners before and during the COVID-19 pandemic. They described their feelings of guilt during the pandemic related to increasing their families’ infection risks, as well as the gratitude they felt for having stable jobs during the crisis. They shared solutions that worked for their families, including cooperating with their partners, expressing their scheduling needs, and negotiating to meet those needs with their employers.

Dr. Nye and Dr. Alfandre recommended staying connected with others for help, including partners, institutions, neighbors, and colleagues. They also recommended supporting, sharing, collaborating, and connecting with their partners and colleagues to maintain a balanced professional and personal life.
 

Key takeaway:

• Stay connected and support, collaborate, and share with your colleagues and partner at home.

Dr. Kumar is the pediatric editor of The Hospitalist. She is clinical assistant professor of pediatrics at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University and a pediatric hospitalist at Cleveland Clinic Children’s. Dr. Doraiswamy is an assistant professor of medicine and pediatrics and a med-peds hospitalist at The Ohio State University and Nationwide Children’s Hospital, both in Columbus. Dr. Tantoco is an academic med-peds hospitalist practicing in Northwestern Memorial Hospital, Chicago, and Ann & Robert H. Lurie Children’s Hospital of Chicago.

HM20 Virtual session title

When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics
 

Presenter

Kimberly Manning, MD, FACP, FAAP
 

Session summary

Dr. Kimberly Manning, associate vice chair of diversity, equity, and inclusion at Emory University, Atlanta, masterfully discussed the dual pandemics of COVID-19 and racism that we are currently experiencing and tried to describe the unique perspective of Black Americans.

Though it is easy to see that COVID-19 is a pandemic, racism is not always seen in this way. Dr. Manning demonstrated that when a pandemic is defined as “that which occurs over a wide geographic area and affects a high proportion of the population,” racism is absolutely a pandemic. She gave a great analogy: when sticking your hand into a bowl of Lucky Charms cereal, you do not expect to always end up with marshmallows alone, yet repeatedly, we see that Black Americans have been disproportionately affected by COVID-19. We often hear that we are in unprecedented times but as far as racism is concerned, there is nothing new about this.

Dr. Manning discussed the life stories of her grandfather, her father, and even her own life’s milestones such as starting college, getting into medical school, finishing residency – all the way to becoming a full professor. She described how each of these instances, though marked by something beautiful, was also marked by something truly awful. Each time she had a reason to smile and laugh, there was something awful happening in the country simultaneously that showed us how racism was still present. Though this was one person’s story, all Black Americans, not just those working in health care, can recount similar stories, emotions, and feelings of grief.

Dr. Manning concluded by telling us how we can “Do the Work” to combat the pandemic of racism:

• Broaden your fund of knowledge: Read books, listen to podcasts, watch documentaries.
• Remember that people are grieving.
• Explore your implicit biases.
• Be a brave bystander.
• Avoid performative allyship.

Key takeaways

• Though the COVID-19 pandemic is unprecedented, the pandemic of racism is not.
• The story of COVID-19 is the story of social determinants of health.
• We all must “Do the Work” to combat everyday racism and be cognizant of what our Black colleagues are going through every day.

Dr. Doraiswamy is an assistant professor of medicine and pediatrics and a med-peds hospitalist at The Ohio State University and Nationwide Children’s Hospital, Columbus.

HM20 Virtual session title

When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics
 

Presenter

Kimberly Manning, MD, FACP, FAAP
 

Session summary

Dr. Kimberly Manning, associate vice chair of diversity, equity, and inclusion at Emory University, Atlanta, masterfully discussed the dual pandemics of COVID-19 and racism that we are currently experiencing and tried to describe the unique perspective of Black Americans.

Though it is easy to see that COVID-19 is a pandemic, racism is not always seen in this way. Dr. Manning demonstrated that when a pandemic is defined as “that which occurs over a wide geographic area and affects a high proportion of the population,” racism is absolutely a pandemic. She gave a great analogy: when sticking your hand into a bowl of Lucky Charms cereal, you do not expect to always end up with marshmallows alone, yet repeatedly, we see that Black Americans have been disproportionately affected by COVID-19. We often hear that we are in unprecedented times but as far as racism is concerned, there is nothing new about this.

Dr. Manning discussed the life stories of her grandfather, her father, and even her own life’s milestones such as starting college, getting into medical school, finishing residency – all the way to becoming a full professor. She described how each of these instances, though marked by something beautiful, was also marked by something truly awful. Each time she had a reason to smile and laugh, there was something awful happening in the country simultaneously that showed us how racism was still present. Though this was one person’s story, all Black Americans, not just those working in health care, can recount similar stories, emotions, and feelings of grief.

Dr. Manning concluded by telling us how we can “Do the Work” to combat the pandemic of racism:

• Broaden your fund of knowledge: Read books, listen to podcasts, watch documentaries.
• Remember that people are grieving.
• Explore your implicit biases.
• Be a brave bystander.
• Avoid performative allyship.

Key takeaways

• Though the COVID-19 pandemic is unprecedented, the pandemic of racism is not.
• The story of COVID-19 is the story of social determinants of health.
• We all must “Do the Work” to combat everyday racism and be cognizant of what our Black colleagues are going through every day.

Dr. Doraiswamy is an assistant professor of medicine and pediatrics and a med-peds hospitalist at The Ohio State University and Nationwide Children’s Hospital, Columbus.

HM20 Virtual session title

When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics
 

Presenter

Kimberly Manning, MD, FACP, FAAP
 

Session summary

Dr. Kimberly Manning, associate vice chair of diversity, equity, and inclusion at Emory University, Atlanta, masterfully discussed the dual pandemics of COVID-19 and racism that we are currently experiencing and tried to describe the unique perspective of Black Americans.

Though it is easy to see that COVID-19 is a pandemic, racism is not always seen in this way. Dr. Manning demonstrated that when a pandemic is defined as “that which occurs over a wide geographic area and affects a high proportion of the population,” racism is absolutely a pandemic. She gave a great analogy: when sticking your hand into a bowl of Lucky Charms cereal, you do not expect to always end up with marshmallows alone, yet repeatedly, we see that Black Americans have been disproportionately affected by COVID-19. We often hear that we are in unprecedented times but as far as racism is concerned, there is nothing new about this.

Dr. Manning discussed the life stories of her grandfather, her father, and even her own life’s milestones such as starting college, getting into medical school, finishing residency – all the way to becoming a full professor. She described how each of these instances, though marked by something beautiful, was also marked by something truly awful. Each time she had a reason to smile and laugh, there was something awful happening in the country simultaneously that showed us how racism was still present. Though this was one person’s story, all Black Americans, not just those working in health care, can recount similar stories, emotions, and feelings of grief.

Dr. Manning concluded by telling us how we can “Do the Work” to combat the pandemic of racism:

• Broaden your fund of knowledge: Read books, listen to podcasts, watch documentaries.
• Remember that people are grieving.
• Explore your implicit biases.
• Be a brave bystander.
• Avoid performative allyship.

Key takeaways

• Though the COVID-19 pandemic is unprecedented, the pandemic of racism is not.
• The story of COVID-19 is the story of social determinants of health.
• We all must “Do the Work” to combat everyday racism and be cognizant of what our Black colleagues are going through every day.

Dr. Doraiswamy is an assistant professor of medicine and pediatrics and a med-peds hospitalist at The Ohio State University and Nationwide Children’s Hospital, Columbus.

HM20 Virtual session title

Call Me Maybe: Balancing Resident Autonomy with Sensible Supervision

Presenter

Daniel Steinberg, MD, SFHM, FACP

Session summary

In this session, Dr. Steinberg, professor of medicine and medical education, associate chair for education, and residency program director in the department of medicine at Icahn School of Medicine at Mount Sinai, New York, presented key factors, techniques, and approaches to supervising residents. He discussed the important balance of resident autonomy and supervision, especially since attendings need to focus on learner education along with patient care and safety.

Dr. Steinberg stated that resident supervision is driven by three factors: what residents need, what residents want, and what the supervisor can provide. Although data is mixed on whether supervision improves patient outcomes, supervision is essential for patient care and resident education. Dr. Steinberg showcased several relevant medical education studies relating to supervision and focused on a key question: Do you trust the resident?

The review of medical education literature discussed the meaning and development of trust, oral case presentations to determine trust, and the influence of supervisor experience. One study looked at the attendings’ remote access of EMR, which allows for remote supervision as a great way to determine trust of the resident. Another study showed that attendings want more communication than what residents provide and that the saying “Page me if you need me” does not encourage communication from residents as much as attendings would desire.
 

Key takeaways

• Resident supervision is driven by what residents need, what residents want, and what the supervisor can provide.
• Trust can be determined from direct supervision, oral presentations, and remote access of EMR, but it is also influenced by attending experience and style.
• To increase resident communication with the attending, do not say “Page me if you need me.” Instead, an attending should specifically state when a call to an attending is required.

Dr. Tantoco is an academic med-peds hospitalist practicing at Northwestern Memorial Hospital in Chicago and Ann & Robert H. Lurie Children’s Hospital of Chicago. She is an instructor of medicine (hospital medicine) and pediatrics at Northwestern University, also in Chicago.

HM20 Virtual session title

Call Me Maybe: Balancing Resident Autonomy with Sensible Supervision

Presenter

Daniel Steinberg, MD, SFHM, FACP

Session summary

In this session, Dr. Steinberg, professor of medicine and medical education, associate chair for education, and residency program director in the department of medicine at Icahn School of Medicine at Mount Sinai, New York, presented key factors, techniques, and approaches to supervising residents. He discussed the important balance of resident autonomy and supervision, especially since attendings need to focus on learner education along with patient care and safety.

Dr. Steinberg stated that resident supervision is driven by three factors: what residents need, what residents want, and what the supervisor can provide. Although data is mixed on whether supervision improves patient outcomes, supervision is essential for patient care and resident education. Dr. Steinberg showcased several relevant medical education studies relating to supervision and focused on a key question: Do you trust the resident?

The review of medical education literature discussed the meaning and development of trust, oral case presentations to determine trust, and the influence of supervisor experience. One study looked at the attendings’ remote access of EMR, which allows for remote supervision as a great way to determine trust of the resident. Another study showed that attendings want more communication than what residents provide and that the saying “Page me if you need me” does not encourage communication from residents as much as attendings would desire.
 

Key takeaways

• Resident supervision is driven by what residents need, what residents want, and what the supervisor can provide.
• Trust can be determined from direct supervision, oral presentations, and remote access of EMR, but it is also influenced by attending experience and style.
• To increase resident communication with the attending, do not say “Page me if you need me.” Instead, an attending should specifically state when a call to an attending is required.

Dr. Tantoco is an academic med-peds hospitalist practicing at Northwestern Memorial Hospital in Chicago and Ann & Robert H. Lurie Children’s Hospital of Chicago. She is an instructor of medicine (hospital medicine) and pediatrics at Northwestern University, also in Chicago.

HM20 Virtual session title

Call Me Maybe: Balancing Resident Autonomy with Sensible Supervision

Presenter

Daniel Steinberg, MD, SFHM, FACP

Session summary

In this session, Dr. Steinberg, professor of medicine and medical education, associate chair for education, and residency program director in the department of medicine at Icahn School of Medicine at Mount Sinai, New York, presented key factors, techniques, and approaches to supervising residents. He discussed the important balance of resident autonomy and supervision, especially since attendings need to focus on learner education along with patient care and safety.

Dr. Steinberg stated that resident supervision is driven by three factors: what residents need, what residents want, and what the supervisor can provide. Although data is mixed on whether supervision improves patient outcomes, supervision is essential for patient care and resident education. Dr. Steinberg showcased several relevant medical education studies relating to supervision and focused on a key question: Do you trust the resident?

The review of medical education literature discussed the meaning and development of trust, oral case presentations to determine trust, and the influence of supervisor experience. One study looked at the attendings’ remote access of EMR, which allows for remote supervision as a great way to determine trust of the resident. Another study showed that attendings want more communication than what residents provide and that the saying “Page me if you need me” does not encourage communication from residents as much as attendings would desire.
 

Key takeaways

• Resident supervision is driven by what residents need, what residents want, and what the supervisor can provide.
• Trust can be determined from direct supervision, oral presentations, and remote access of EMR, but it is also influenced by attending experience and style.
• To increase resident communication with the attending, do not say “Page me if you need me.” Instead, an attending should specifically state when a call to an attending is required.

Dr. Tantoco is an academic med-peds hospitalist practicing at Northwestern Memorial Hospital in Chicago and Ann & Robert H. Lurie Children’s Hospital of Chicago. She is an instructor of medicine (hospital medicine) and pediatrics at Northwestern University, also in Chicago.

In a Q&A session at HM20 Virtual, hosted by the Society of Hospital Medicine, Heather Nye, MD, PhD, SFHM, professor of medicine at the University of California, San Francisco, and David J. Alfandre, MD, MPH, associate professor of medicine at New York University Langone, discussed strategies to help hospitalists tend to their personal wellness during the COVID-19 pandemic.

The speakers described the complicated logistics and emotional and psychological strain that has come from working during the pandemic, while balancing home responsibilities and parenting. The session was an opportunity to humanize hospitalists’ experience as they straddle work and family.

Dr. Nye said she was still “warming up to personal wellness” because there have been so many other demands over the past several months, but that taking the time to go for walks – to bring on a feeling of health even more than the physical benefits – has been helpful. Even before the pandemic, she said, she brought a guitar to the office to take a few minutes for a hobby for which she can’t seem to find uninterrupted time at home.

“Bringing a little bit of yourself into your work life goes a long way for a lot of people,” she said.

Child care and odd hours always have been a challenge for hospitalists, the presenters said, and for those in academia, any “wiggle room” in the schedule is often taken up by education, administration, and research projects.

Dr. Alfandre said etching out time for yourself must be “a priority, or it won’t happen.” Doing so, he said, “feels indulgent but it’s not. It’s central to being able to do the kind of work you do when you’re at the hospital, at the office, and when you’re back home again.”

Dr. Nye observed that, while working from home on nonclinical work, “recognizing how little I got done was a big surprise,” and she had to “grow comfortable with that” and learn to live with the uncertainty about when that was going to change.

Both physicians described the emotional toll of worrying about their children if they have to continue distance learning.

Dr. Alfandre said that a shared Google calendar for his wife and him – with appointments, work obligations, children’s doctor’s appointments, recitals – has been helpful, removing the strain of having to remind each other. He said that there are skills used at work that hospitalists can use at home – such as not getting upset with a child for crying about a spilled drink – in the same way that a physician wouldn’t get upset with a patient concerned about a test.

“We empathize with our patients, and we empathize with our kids and what their experience is,” he said. Similarly, seeing family members crowd around a smartphone video call to check in with a COVID-19 patient can be a helpful reminder to appreciate going home to family at the end of the day.

When her children get upset that she has to go in to work, Dr. Nye said, it has been helpful to explain that her many patients are suffering and scared and need her help.

“I feel like sharing that part of our job [with] our kids helps them understand that there are very, very big problems out there – that they don’t have to know too much about and be frightened about – but [that knowledge] just gives them a little perspective.”

Dr. Nye and Dr. Alfandre said they had no financial conflicts of interest.

In a Q&A session at HM20 Virtual, hosted by the Society of Hospital Medicine, Heather Nye, MD, PhD, SFHM, professor of medicine at the University of California, San Francisco, and David J. Alfandre, MD, MPH, associate professor of medicine at New York University Langone, discussed strategies to help hospitalists tend to their personal wellness during the COVID-19 pandemic.

The speakers described the complicated logistics and emotional and psychological strain that has come from working during the pandemic, while balancing home responsibilities and parenting. The session was an opportunity to humanize hospitalists’ experience as they straddle work and family.

Dr. Nye said she was still “warming up to personal wellness” because there have been so many other demands over the past several months, but that taking the time to go for walks – to bring on a feeling of health even more than the physical benefits – has been helpful. Even before the pandemic, she said, she brought a guitar to the office to take a few minutes for a hobby for which she can’t seem to find uninterrupted time at home.

“Bringing a little bit of yourself into your work life goes a long way for a lot of people,” she said.

Child care and odd hours always have been a challenge for hospitalists, the presenters said, and for those in academia, any “wiggle room” in the schedule is often taken up by education, administration, and research projects.

Dr. Alfandre said etching out time for yourself must be “a priority, or it won’t happen.” Doing so, he said, “feels indulgent but it’s not. It’s central to being able to do the kind of work you do when you’re at the hospital, at the office, and when you’re back home again.”

Dr. Nye observed that, while working from home on nonclinical work, “recognizing how little I got done was a big surprise,” and she had to “grow comfortable with that” and learn to live with the uncertainty about when that was going to change.

Both physicians described the emotional toll of worrying about their children if they have to continue distance learning.

Dr. Alfandre said that a shared Google calendar for his wife and him – with appointments, work obligations, children’s doctor’s appointments, recitals – has been helpful, removing the strain of having to remind each other. He said that there are skills used at work that hospitalists can use at home – such as not getting upset with a child for crying about a spilled drink – in the same way that a physician wouldn’t get upset with a patient concerned about a test.

“We empathize with our patients, and we empathize with our kids and what their experience is,” he said. Similarly, seeing family members crowd around a smartphone video call to check in with a COVID-19 patient can be a helpful reminder to appreciate going home to family at the end of the day.

When her children get upset that she has to go in to work, Dr. Nye said, it has been helpful to explain that her many patients are suffering and scared and need her help.

“I feel like sharing that part of our job [with] our kids helps them understand that there are very, very big problems out there – that they don’t have to know too much about and be frightened about – but [that knowledge] just gives them a little perspective.”

Dr. Nye and Dr. Alfandre said they had no financial conflicts of interest.

In a Q&A session at HM20 Virtual, hosted by the Society of Hospital Medicine, Heather Nye, MD, PhD, SFHM, professor of medicine at the University of California, San Francisco, and David J. Alfandre, MD, MPH, associate professor of medicine at New York University Langone, discussed strategies to help hospitalists tend to their personal wellness during the COVID-19 pandemic.

The speakers described the complicated logistics and emotional and psychological strain that has come from working during the pandemic, while balancing home responsibilities and parenting. The session was an opportunity to humanize hospitalists’ experience as they straddle work and family.

Dr. Nye said she was still “warming up to personal wellness” because there have been so many other demands over the past several months, but that taking the time to go for walks – to bring on a feeling of health even more than the physical benefits – has been helpful. Even before the pandemic, she said, she brought a guitar to the office to take a few minutes for a hobby for which she can’t seem to find uninterrupted time at home.

“Bringing a little bit of yourself into your work life goes a long way for a lot of people,” she said.

Child care and odd hours always have been a challenge for hospitalists, the presenters said, and for those in academia, any “wiggle room” in the schedule is often taken up by education, administration, and research projects.

Dr. Alfandre said etching out time for yourself must be “a priority, or it won’t happen.” Doing so, he said, “feels indulgent but it’s not. It’s central to being able to do the kind of work you do when you’re at the hospital, at the office, and when you’re back home again.”

Dr. Nye observed that, while working from home on nonclinical work, “recognizing how little I got done was a big surprise,” and she had to “grow comfortable with that” and learn to live with the uncertainty about when that was going to change.

Both physicians described the emotional toll of worrying about their children if they have to continue distance learning.

Dr. Alfandre said that a shared Google calendar for his wife and him – with appointments, work obligations, children’s doctor’s appointments, recitals – has been helpful, removing the strain of having to remind each other. He said that there are skills used at work that hospitalists can use at home – such as not getting upset with a child for crying about a spilled drink – in the same way that a physician wouldn’t get upset with a patient concerned about a test.

“We empathize with our patients, and we empathize with our kids and what their experience is,” he said. Similarly, seeing family members crowd around a smartphone video call to check in with a COVID-19 patient can be a helpful reminder to appreciate going home to family at the end of the day.

When her children get upset that she has to go in to work, Dr. Nye said, it has been helpful to explain that her many patients are suffering and scared and need her help.

“I feel like sharing that part of our job [with] our kids helps them understand that there are very, very big problems out there – that they don’t have to know too much about and be frightened about – but [that knowledge] just gives them a little perspective.”

Dr. Nye and Dr. Alfandre said they had no financial conflicts of interest.

Thyroid storm is a life-threatening endocrine emergency for which, remarkably, there are no definitive diagnostic tests, and the management of which is supported by a startlingly weak evidence base.

“What’s tricky is there really are no specific biochemical level cutoffs for thyroid storm, and also no unique laboratory abnormalities. So in the end, it’s a clinical diagnosis and a clinical judgment,” Stephanie B. Mayer, MD, MHSc, observed at HM20 Virtual, hosted by the Society of Hospital Medicine.

Moreover, there are no prospective clinical trials addressing the treatment of thyroid storm, and the 2016 American Thyroid Association clinical practice guidelines on the topic are based upon low-quality evidence from case reports and studies dating back to the 1970s and 1980s. UpToDate reached the same conclusion in 2020, noted Dr. Mayer, an endocrinologist at Virginia Commonwealth University, Richmond.

Thinking that perhaps the guideline writing panel had missed something, she asked a university medical research librarian to custom-build a comprehensive search for studies on thyroid storm management. The search proved unrewarding.

“The evidence is, unfortunately, a little disappointing,” Dr. Mayer said.

Thyroid storm is a rare condition, but one that hospitalists must be ready for. She highlighted current best practices in diagnosis and management.
 

A high-mortality emergency

Thyroid storm is an extreme manifestation of thyrotoxicosis, which is marked by multiorgan dysfunction and rapid decompensation. In a large, first-of-its-kind, national retrospective U.S. study, the incidence of thyroid storm was 0.57-0.76 cases per 100,000 persons per year. Thyroid storm accounted for 16% of the more than 121,000 hospital discharges featuring a primary diagnosis of thyrotoxicosis. The in-hospital mortality rate for patients with thyroid storm was 1.2%-3.6% during the 10-year study period, a rate 12-fold higher than that among patients with thyrotoxicosis without thyroid storm (Thyroid. 2019 Jan;29[1]:36-43).

Dr. Mayer highlighted a multicenter French study that underscored the current hefty morbidity and mortality associated with thyroid storm. Among 92 patients admitted to the ICU for thyroid storm, the in-ICU mortality rate was 17%, and the mortality rate 6 months after admission was 22%. Independent risk factors for in-ICU mortality were multiorgan failure and the occurrence of cardiogenic shock within the first 48 hours in the ICU (Crit Care Med. 2020 Jan;48[1]:83-90).
 

How to recognize thyroid storm

The most user-friendly system for assistance in diagnosing thyroid storm is the one put forth by the Japan Thyroid Association and the Japan Endocrine Society, in Dr. Mayer’s view. As a prerequisite to the diagnosis a patient must have thyrotoxicosis as evidenced by elevated free thyroxine (free T4) and free or total triiodothyronine (T3), which in the vast majority of cases, is accompanied by low thyroid stimulating hormone (TSH).

The Japanese diagnostic system for thyroid storm relies on five categories of organ system–based clinical features. This approach places greater weight on disturbances of consciousness – restlessness, delirium, agitation, psychosis, lethargy, coma – than the other four components, which consist of fever of at least 100.4° F, tachycardia of 130 or more beats per minute, heart failure signs and symptoms, and gastrointestinal/hepatic involvement as evidenced by nausea, vomiting, hyperdefecation, and/or a total bilirubin level of 3.0 mg/dL or more.

The Japanese approach offers two paths to a definite diagnosis of thyroid storm. One requires at least one CNS manifestation plus symptoms drawn from any one of the other four categories. The other route, for patients without evident CNS symptoms, requires the presence of symptoms from at least three of the other four categories.

A patient is categorized as having suspected rather than definite thyroid storm if the CNS criterion isn’t met but any two of the others are. A patient also qualifies for suspected thyroid storm when CNS manifestations plus symptoms from at least one other category are present, but thyroid hormone levels aren’t available (Endocr J. 2016 Dec 30;63[12]:1025-64).

Management of thyroid storm

There is usually a precipitating event that drives the transition from smoldering thyrotoxicosis to thyroid storm.

“The big thing is to look for and treat the underlying precipitating event,” the endocrinologist stressed.

It’s often a systemic insult: severe infection, trauma, surgery, an acute MI, diabetic ketoacidosis, pulmonary embolism, or perhaps having just gone through labor. Iodine exposure in the form of IV contrast or taking amiodarone, which contains 37% iodine by weight, can also fan thyrotoxicosis into thyroid storm. Abrupt discontinuation of antithyroid medication is another common cause.

Fluid and electrolyte replacement, oxygen if appropriate, cooling blankets, and other supportive measures are also important.

Medical management targets multiple steps in thyroid hormone production and action to quell thyroid storm. The first order of business is to inhibit synthesis of new thyroid hormone by prescribing a thioamide. Dr. Mayer favors propylthiouracil over methimazole for this purpose because, not only does it block the thyroid gland from synthesizing new hormone, it also reduces conversion of T4 to T3. Propylthiouracil is usually given orally as a 500- to 1,000-mg loading dose, then 250 mg every 4 hours. The drug can also be given rectally or by nasogastric tube.

One hour or more after starting the thioamide, inorganic iodine is started to inhibit release of preformed hormone from the thyroid gland. Five drops of saturated solution of potassium iodide given every 6 hours is the recommended dose; it provides 764 mg of iodide per day. Lugol’s solution dosed at four to eight drops every 6-8 hours is an effective alternative.

Simultaneous with starting the patient on inorganic iodine, a low-dose beta blocker is introduced to control adrenergic symptoms.

“Propranolol is first line because it also decreases T4 to T3 conversion and it’s noncardioselective, so it’s better than a cardioselective beta blocker at reducing sympathetic tone-related symptoms, such as agitation, fever, and psychosis,” the endocrinologist explained.

At the same time that propranolol at 60-80 mg is given orally every 4 hours and iodine are started, the patient is placed on glucocorticoids as another means of reducing peripheral conversion of T4 to T3. The options are intravenous hydrocortisone at 100-300 mg/day in divided doses or dexamethasone at 2 mg every 6 hours.

Aspirin and NSAIDs should be avoided as antipyretics because they can actually raise T3 and T4 levels. Acetaminophen is the right fever-lowering agent in the setting of thyroid storm.

Dr. Mayer has occasionally had to reach for one of several backup therapies. Prescribing a bile acid sequestrant – 20-30 g/day of cholestyramine or colestipol – will trap thyroid hormone in the intestine, preventing it from recirculating.

“Be careful to dose it away from the other medications,” she cautioned.

Also, therapeutic plasmapheresis is effective at rapidly removing circulating thyroid hormone in patients who don’t show early clinical improvement in response to multipronged medical therapy.

Dr. Mayer offered a couple of final tips to hospitalists regarding thyroid storm: Know who directs plasmapheresis at your hospital, and keep the American Thyroid Association management guidelines handy (Thyroid. 2016 Oct;26[10]:1343-421).

She reported receiving funding from both NovoNordisk and Astra Zeneca.

 

bjancin@mdedge.com

Thyroid storm is a life-threatening endocrine emergency for which, remarkably, there are no definitive diagnostic tests, and the management of which is supported by a startlingly weak evidence base.

“What’s tricky is there really are no specific biochemical level cutoffs for thyroid storm, and also no unique laboratory abnormalities. So in the end, it’s a clinical diagnosis and a clinical judgment,” Stephanie B. Mayer, MD, MHSc, observed at HM20 Virtual, hosted by the Society of Hospital Medicine.

Moreover, there are no prospective clinical trials addressing the treatment of thyroid storm, and the 2016 American Thyroid Association clinical practice guidelines on the topic are based upon low-quality evidence from case reports and studies dating back to the 1970s and 1980s. UpToDate reached the same conclusion in 2020, noted Dr. Mayer, an endocrinologist at Virginia Commonwealth University, Richmond.

Thinking that perhaps the guideline writing panel had missed something, she asked a university medical research librarian to custom-build a comprehensive search for studies on thyroid storm management. The search proved unrewarding.

“The evidence is, unfortunately, a little disappointing,” Dr. Mayer said.

Thyroid storm is a rare condition, but one that hospitalists must be ready for. She highlighted current best practices in diagnosis and management.
 

A high-mortality emergency

Thyroid storm is an extreme manifestation of thyrotoxicosis, which is marked by multiorgan dysfunction and rapid decompensation. In a large, first-of-its-kind, national retrospective U.S. study, the incidence of thyroid storm was 0.57-0.76 cases per 100,000 persons per year. Thyroid storm accounted for 16% of the more than 121,000 hospital discharges featuring a primary diagnosis of thyrotoxicosis. The in-hospital mortality rate for patients with thyroid storm was 1.2%-3.6% during the 10-year study period, a rate 12-fold higher than that among patients with thyrotoxicosis without thyroid storm (Thyroid. 2019 Jan;29[1]:36-43).

Dr. Mayer highlighted a multicenter French study that underscored the current hefty morbidity and mortality associated with thyroid storm. Among 92 patients admitted to the ICU for thyroid storm, the in-ICU mortality rate was 17%, and the mortality rate 6 months after admission was 22%. Independent risk factors for in-ICU mortality were multiorgan failure and the occurrence of cardiogenic shock within the first 48 hours in the ICU (Crit Care Med. 2020 Jan;48[1]:83-90).
 

How to recognize thyroid storm

The most user-friendly system for assistance in diagnosing thyroid storm is the one put forth by the Japan Thyroid Association and the Japan Endocrine Society, in Dr. Mayer’s view. As a prerequisite to the diagnosis a patient must have thyrotoxicosis as evidenced by elevated free thyroxine (free T4) and free or total triiodothyronine (T3), which in the vast majority of cases, is accompanied by low thyroid stimulating hormone (TSH).

The Japanese diagnostic system for thyroid storm relies on five categories of organ system–based clinical features. This approach places greater weight on disturbances of consciousness – restlessness, delirium, agitation, psychosis, lethargy, coma – than the other four components, which consist of fever of at least 100.4° F, tachycardia of 130 or more beats per minute, heart failure signs and symptoms, and gastrointestinal/hepatic involvement as evidenced by nausea, vomiting, hyperdefecation, and/or a total bilirubin level of 3.0 mg/dL or more.

The Japanese approach offers two paths to a definite diagnosis of thyroid storm. One requires at least one CNS manifestation plus symptoms drawn from any one of the other four categories. The other route, for patients without evident CNS symptoms, requires the presence of symptoms from at least three of the other four categories.

A patient is categorized as having suspected rather than definite thyroid storm if the CNS criterion isn’t met but any two of the others are. A patient also qualifies for suspected thyroid storm when CNS manifestations plus symptoms from at least one other category are present, but thyroid hormone levels aren’t available (Endocr J. 2016 Dec 30;63[12]:1025-64).

Management of thyroid storm

There is usually a precipitating event that drives the transition from smoldering thyrotoxicosis to thyroid storm.

“The big thing is to look for and treat the underlying precipitating event,” the endocrinologist stressed.

It’s often a systemic insult: severe infection, trauma, surgery, an acute MI, diabetic ketoacidosis, pulmonary embolism, or perhaps having just gone through labor. Iodine exposure in the form of IV contrast or taking amiodarone, which contains 37% iodine by weight, can also fan thyrotoxicosis into thyroid storm. Abrupt discontinuation of antithyroid medication is another common cause.

Fluid and electrolyte replacement, oxygen if appropriate, cooling blankets, and other supportive measures are also important.

Medical management targets multiple steps in thyroid hormone production and action to quell thyroid storm. The first order of business is to inhibit synthesis of new thyroid hormone by prescribing a thioamide. Dr. Mayer favors propylthiouracil over methimazole for this purpose because, not only does it block the thyroid gland from synthesizing new hormone, it also reduces conversion of T4 to T3. Propylthiouracil is usually given orally as a 500- to 1,000-mg loading dose, then 250 mg every 4 hours. The drug can also be given rectally or by nasogastric tube.

One hour or more after starting the thioamide, inorganic iodine is started to inhibit release of preformed hormone from the thyroid gland. Five drops of saturated solution of potassium iodide given every 6 hours is the recommended dose; it provides 764 mg of iodide per day. Lugol’s solution dosed at four to eight drops every 6-8 hours is an effective alternative.

Simultaneous with starting the patient on inorganic iodine, a low-dose beta blocker is introduced to control adrenergic symptoms.

“Propranolol is first line because it also decreases T4 to T3 conversion and it’s noncardioselective, so it’s better than a cardioselective beta blocker at reducing sympathetic tone-related symptoms, such as agitation, fever, and psychosis,” the endocrinologist explained.

At the same time that propranolol at 60-80 mg is given orally every 4 hours and iodine are started, the patient is placed on glucocorticoids as another means of reducing peripheral conversion of T4 to T3. The options are intravenous hydrocortisone at 100-300 mg/day in divided doses or dexamethasone at 2 mg every 6 hours.

Aspirin and NSAIDs should be avoided as antipyretics because they can actually raise T3 and T4 levels. Acetaminophen is the right fever-lowering agent in the setting of thyroid storm.

Dr. Mayer has occasionally had to reach for one of several backup therapies. Prescribing a bile acid sequestrant – 20-30 g/day of cholestyramine or colestipol – will trap thyroid hormone in the intestine, preventing it from recirculating.

“Be careful to dose it away from the other medications,” she cautioned.

Also, therapeutic plasmapheresis is effective at rapidly removing circulating thyroid hormone in patients who don’t show early clinical improvement in response to multipronged medical therapy.

Dr. Mayer offered a couple of final tips to hospitalists regarding thyroid storm: Know who directs plasmapheresis at your hospital, and keep the American Thyroid Association management guidelines handy (Thyroid. 2016 Oct;26[10]:1343-421).

She reported receiving funding from both NovoNordisk and Astra Zeneca.

 

bjancin@mdedge.com

Thyroid storm is a life-threatening endocrine emergency for which, remarkably, there are no definitive diagnostic tests, and the management of which is supported by a startlingly weak evidence base.

“What’s tricky is there really are no specific biochemical level cutoffs for thyroid storm, and also no unique laboratory abnormalities. So in the end, it’s a clinical diagnosis and a clinical judgment,” Stephanie B. Mayer, MD, MHSc, observed at HM20 Virtual, hosted by the Society of Hospital Medicine.

Moreover, there are no prospective clinical trials addressing the treatment of thyroid storm, and the 2016 American Thyroid Association clinical practice guidelines on the topic are based upon low-quality evidence from case reports and studies dating back to the 1970s and 1980s. UpToDate reached the same conclusion in 2020, noted Dr. Mayer, an endocrinologist at Virginia Commonwealth University, Richmond.

Thinking that perhaps the guideline writing panel had missed something, she asked a university medical research librarian to custom-build a comprehensive search for studies on thyroid storm management. The search proved unrewarding.

“The evidence is, unfortunately, a little disappointing,” Dr. Mayer said.

Thyroid storm is a rare condition, but one that hospitalists must be ready for. She highlighted current best practices in diagnosis and management.
 

A high-mortality emergency

Thyroid storm is an extreme manifestation of thyrotoxicosis, which is marked by multiorgan dysfunction and rapid decompensation. In a large, first-of-its-kind, national retrospective U.S. study, the incidence of thyroid storm was 0.57-0.76 cases per 100,000 persons per year. Thyroid storm accounted for 16% of the more than 121,000 hospital discharges featuring a primary diagnosis of thyrotoxicosis. The in-hospital mortality rate for patients with thyroid storm was 1.2%-3.6% during the 10-year study period, a rate 12-fold higher than that among patients with thyrotoxicosis without thyroid storm (Thyroid. 2019 Jan;29[1]:36-43).

Dr. Mayer highlighted a multicenter French study that underscored the current hefty morbidity and mortality associated with thyroid storm. Among 92 patients admitted to the ICU for thyroid storm, the in-ICU mortality rate was 17%, and the mortality rate 6 months after admission was 22%. Independent risk factors for in-ICU mortality were multiorgan failure and the occurrence of cardiogenic shock within the first 48 hours in the ICU (Crit Care Med. 2020 Jan;48[1]:83-90).
 

How to recognize thyroid storm

The most user-friendly system for assistance in diagnosing thyroid storm is the one put forth by the Japan Thyroid Association and the Japan Endocrine Society, in Dr. Mayer’s view. As a prerequisite to the diagnosis a patient must have thyrotoxicosis as evidenced by elevated free thyroxine (free T4) and free or total triiodothyronine (T3), which in the vast majority of cases, is accompanied by low thyroid stimulating hormone (TSH).

The Japanese diagnostic system for thyroid storm relies on five categories of organ system–based clinical features. This approach places greater weight on disturbances of consciousness – restlessness, delirium, agitation, psychosis, lethargy, coma – than the other four components, which consist of fever of at least 100.4° F, tachycardia of 130 or more beats per minute, heart failure signs and symptoms, and gastrointestinal/hepatic involvement as evidenced by nausea, vomiting, hyperdefecation, and/or a total bilirubin level of 3.0 mg/dL or more.

The Japanese approach offers two paths to a definite diagnosis of thyroid storm. One requires at least one CNS manifestation plus symptoms drawn from any one of the other four categories. The other route, for patients without evident CNS symptoms, requires the presence of symptoms from at least three of the other four categories.

A patient is categorized as having suspected rather than definite thyroid storm if the CNS criterion isn’t met but any two of the others are. A patient also qualifies for suspected thyroid storm when CNS manifestations plus symptoms from at least one other category are present, but thyroid hormone levels aren’t available (Endocr J. 2016 Dec 30;63[12]:1025-64).

Management of thyroid storm

There is usually a precipitating event that drives the transition from smoldering thyrotoxicosis to thyroid storm.

“The big thing is to look for and treat the underlying precipitating event,” the endocrinologist stressed.

It’s often a systemic insult: severe infection, trauma, surgery, an acute MI, diabetic ketoacidosis, pulmonary embolism, or perhaps having just gone through labor. Iodine exposure in the form of IV contrast or taking amiodarone, which contains 37% iodine by weight, can also fan thyrotoxicosis into thyroid storm. Abrupt discontinuation of antithyroid medication is another common cause.

Fluid and electrolyte replacement, oxygen if appropriate, cooling blankets, and other supportive measures are also important.

Medical management targets multiple steps in thyroid hormone production and action to quell thyroid storm. The first order of business is to inhibit synthesis of new thyroid hormone by prescribing a thioamide. Dr. Mayer favors propylthiouracil over methimazole for this purpose because, not only does it block the thyroid gland from synthesizing new hormone, it also reduces conversion of T4 to T3. Propylthiouracil is usually given orally as a 500- to 1,000-mg loading dose, then 250 mg every 4 hours. The drug can also be given rectally or by nasogastric tube.

One hour or more after starting the thioamide, inorganic iodine is started to inhibit release of preformed hormone from the thyroid gland. Five drops of saturated solution of potassium iodide given every 6 hours is the recommended dose; it provides 764 mg of iodide per day. Lugol’s solution dosed at four to eight drops every 6-8 hours is an effective alternative.

Simultaneous with starting the patient on inorganic iodine, a low-dose beta blocker is introduced to control adrenergic symptoms.

“Propranolol is first line because it also decreases T4 to T3 conversion and it’s noncardioselective, so it’s better than a cardioselective beta blocker at reducing sympathetic tone-related symptoms, such as agitation, fever, and psychosis,” the endocrinologist explained.

At the same time that propranolol at 60-80 mg is given orally every 4 hours and iodine are started, the patient is placed on glucocorticoids as another means of reducing peripheral conversion of T4 to T3. The options are intravenous hydrocortisone at 100-300 mg/day in divided doses or dexamethasone at 2 mg every 6 hours.

Aspirin and NSAIDs should be avoided as antipyretics because they can actually raise T3 and T4 levels. Acetaminophen is the right fever-lowering agent in the setting of thyroid storm.

Dr. Mayer has occasionally had to reach for one of several backup therapies. Prescribing a bile acid sequestrant – 20-30 g/day of cholestyramine or colestipol – will trap thyroid hormone in the intestine, preventing it from recirculating.

“Be careful to dose it away from the other medications,” she cautioned.

Also, therapeutic plasmapheresis is effective at rapidly removing circulating thyroid hormone in patients who don’t show early clinical improvement in response to multipronged medical therapy.

Dr. Mayer offered a couple of final tips to hospitalists regarding thyroid storm: Know who directs plasmapheresis at your hospital, and keep the American Thyroid Association management guidelines handy (Thyroid. 2016 Oct;26[10]:1343-421).

She reported receiving funding from both NovoNordisk and Astra Zeneca.

 

bjancin@mdedge.com

The last session of each SHM Annual Conference is traditionally a short presentation titled “What Have We Learned?” that is delivered by next year’s course director (and this year, that is me!). It’s a way to celebrate all the great things about the meeting and get people excited about next year. And this was most certainly a year where we learned a lot.

We’ve learned that by making the heartbreaking decision to cancel the HM20 in-person conference and convert to a virtual platform, SHM leadership is not afraid to do the right thing to protect the health of its members and staff, even when such a decision comes at significant cost to the organization. We’ve learned that the SHM staff are flexible and innovative and are masters of logistics – their ability to pivot so quickly into a virtual format on such short notice is nothing short of amazing. On the Annual Conference Committee (ACC), we already knew that Benji Mathews, the HM20 course director, was an outstanding leader. True to form, despite facing unprecedented uncertainty and tremendous disappointment, Benji continued to lead with the steady, eloquent presence and poise he’s known for, delivering an outstanding HM20 Virtual.

We’ve learned that SHM members can enjoy and engage meaningfully in a virtual format, as evidenced by well-attended sessions, including robust Q&A exchanges that took place during HM20 Virtual’s simulive offerings. Not seeing each other in person this year has reminded us how much the sense of community we enjoy through SHM means to so many of us. I missed catching up with so many colleagues that have become true friends over the years, and I know you did as well.

We also saw how SHM does not hesitate to provide a platform to shine a spotlight on the critical issues of the day. The double pandemic of COVID-19 and structural racism that we face was addressed head-on by expert faculty in sessions such as “Structural Racism and Bias in Hospital Medicine During Two Pandemics,” “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19,” and “When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics.” Sessions on different aspects of COVID-19 enabled our members to stay up to date on the continually evolving knowledge base of this new disease.

We are so excited as we look ahead to HM21. There will be content on COVID-19 at HM21 … but not too much COVID. The ACC is mindful that our members come to the Annual Conference to hear experts speak on a broad range of clinical topics, and HM21 will be sure to deliver. An innovative new track on Diagnostic Safety will address this critical aspect of high-quality care. We will also debut a new leadership track. At HM21, the ACC is also proud to introduce a dedicated track that will include sessions that address diversity, disparities, and equity. And if what happens in Vegas cannot stay in Vegas (does that make some of you nervous …?), and a virtual element needs to be part of HM21, we will utilize a sophisticated and highly functional platform that will provide some things that our HM20 Virtual platform didn’t.

Couldn’t make HM20 Virtual? Don’t worry! You can still experience the in-depth, immersive education courtesy of some of the most knowledgeable faculty in the field through HM20 Virtual On Demand.

It has indeed been a year in which we have learned a lot. Most importantly, we have learned that we are resilient and that we are stronger together. That SHM and the Annual Conference – be it virtual or in person – is a place where we value, respect, and support each other. Have a great year. I look forward to welcoming you to HM21 in May 2021!
 

Dr. Steinberg is associate chair for education and residency program director in the department of medicine at Mount Sinai Beth Israel, New York, and course director of HM21.

The last session of each SHM Annual Conference is traditionally a short presentation titled “What Have We Learned?” that is delivered by next year’s course director (and this year, that is me!). It’s a way to celebrate all the great things about the meeting and get people excited about next year. And this was most certainly a year where we learned a lot.

We’ve learned that by making the heartbreaking decision to cancel the HM20 in-person conference and convert to a virtual platform, SHM leadership is not afraid to do the right thing to protect the health of its members and staff, even when such a decision comes at significant cost to the organization. We’ve learned that the SHM staff are flexible and innovative and are masters of logistics – their ability to pivot so quickly into a virtual format on such short notice is nothing short of amazing. On the Annual Conference Committee (ACC), we already knew that Benji Mathews, the HM20 course director, was an outstanding leader. True to form, despite facing unprecedented uncertainty and tremendous disappointment, Benji continued to lead with the steady, eloquent presence and poise he’s known for, delivering an outstanding HM20 Virtual.

We’ve learned that SHM members can enjoy and engage meaningfully in a virtual format, as evidenced by well-attended sessions, including robust Q&A exchanges that took place during HM20 Virtual’s simulive offerings. Not seeing each other in person this year has reminded us how much the sense of community we enjoy through SHM means to so many of us. I missed catching up with so many colleagues that have become true friends over the years, and I know you did as well.

We also saw how SHM does not hesitate to provide a platform to shine a spotlight on the critical issues of the day. The double pandemic of COVID-19 and structural racism that we face was addressed head-on by expert faculty in sessions such as “Structural Racism and Bias in Hospital Medicine During Two Pandemics,” “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19,” and “When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics.” Sessions on different aspects of COVID-19 enabled our members to stay up to date on the continually evolving knowledge base of this new disease.

We are so excited as we look ahead to HM21. There will be content on COVID-19 at HM21 … but not too much COVID. The ACC is mindful that our members come to the Annual Conference to hear experts speak on a broad range of clinical topics, and HM21 will be sure to deliver. An innovative new track on Diagnostic Safety will address this critical aspect of high-quality care. We will also debut a new leadership track. At HM21, the ACC is also proud to introduce a dedicated track that will include sessions that address diversity, disparities, and equity. And if what happens in Vegas cannot stay in Vegas (does that make some of you nervous …?), and a virtual element needs to be part of HM21, we will utilize a sophisticated and highly functional platform that will provide some things that our HM20 Virtual platform didn’t.

Couldn’t make HM20 Virtual? Don’t worry! You can still experience the in-depth, immersive education courtesy of some of the most knowledgeable faculty in the field through HM20 Virtual On Demand.

It has indeed been a year in which we have learned a lot. Most importantly, we have learned that we are resilient and that we are stronger together. That SHM and the Annual Conference – be it virtual or in person – is a place where we value, respect, and support each other. Have a great year. I look forward to welcoming you to HM21 in May 2021!
 

Dr. Steinberg is associate chair for education and residency program director in the department of medicine at Mount Sinai Beth Israel, New York, and course director of HM21.

The last session of each SHM Annual Conference is traditionally a short presentation titled “What Have We Learned?” that is delivered by next year’s course director (and this year, that is me!). It’s a way to celebrate all the great things about the meeting and get people excited about next year. And this was most certainly a year where we learned a lot.

We’ve learned that by making the heartbreaking decision to cancel the HM20 in-person conference and convert to a virtual platform, SHM leadership is not afraid to do the right thing to protect the health of its members and staff, even when such a decision comes at significant cost to the organization. We’ve learned that the SHM staff are flexible and innovative and are masters of logistics – their ability to pivot so quickly into a virtual format on such short notice is nothing short of amazing. On the Annual Conference Committee (ACC), we already knew that Benji Mathews, the HM20 course director, was an outstanding leader. True to form, despite facing unprecedented uncertainty and tremendous disappointment, Benji continued to lead with the steady, eloquent presence and poise he’s known for, delivering an outstanding HM20 Virtual.

We’ve learned that SHM members can enjoy and engage meaningfully in a virtual format, as evidenced by well-attended sessions, including robust Q&A exchanges that took place during HM20 Virtual’s simulive offerings. Not seeing each other in person this year has reminded us how much the sense of community we enjoy through SHM means to so many of us. I missed catching up with so many colleagues that have become true friends over the years, and I know you did as well.

We also saw how SHM does not hesitate to provide a platform to shine a spotlight on the critical issues of the day. The double pandemic of COVID-19 and structural racism that we face was addressed head-on by expert faculty in sessions such as “Structural Racism and Bias in Hospital Medicine During Two Pandemics,” “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19,” and “When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics.” Sessions on different aspects of COVID-19 enabled our members to stay up to date on the continually evolving knowledge base of this new disease.

We are so excited as we look ahead to HM21. There will be content on COVID-19 at HM21 … but not too much COVID. The ACC is mindful that our members come to the Annual Conference to hear experts speak on a broad range of clinical topics, and HM21 will be sure to deliver. An innovative new track on Diagnostic Safety will address this critical aspect of high-quality care. We will also debut a new leadership track. At HM21, the ACC is also proud to introduce a dedicated track that will include sessions that address diversity, disparities, and equity. And if what happens in Vegas cannot stay in Vegas (does that make some of you nervous …?), and a virtual element needs to be part of HM21, we will utilize a sophisticated and highly functional platform that will provide some things that our HM20 Virtual platform didn’t.

Couldn’t make HM20 Virtual? Don’t worry! You can still experience the in-depth, immersive education courtesy of some of the most knowledgeable faculty in the field through HM20 Virtual On Demand.

It has indeed been a year in which we have learned a lot. Most importantly, we have learned that we are resilient and that we are stronger together. That SHM and the Annual Conference – be it virtual or in person – is a place where we value, respect, and support each other. Have a great year. I look forward to welcoming you to HM21 in May 2021!
 

Dr. Steinberg is associate chair for education and residency program director in the department of medicine at Mount Sinai Beth Israel, New York, and course director of HM21.

Paige Wickner, MD, MPH, medical director for quality and safety at Brigham and Women’s Hospital and assistant professor at Harvard Medical School, both in Boston, described a scenario that might sound familiar to hospitalists.

A 72-year-old man is admitted to the hospital for a lung transplant, and has a listed allergy to “sulfa,” contained in antibiotics and other medications. His medical records say his reaction was “rash.”

What do you do?

The answer, Dr. Wickner said, speaking at HM20 Virtual, sponsored by the Society of Hospital Medicine, is to first ask more questions for clarification. How bad was the rash? Was it blistering? To what type of sulfa did the patient have a reaction?

These questions can help determine the next steps. For sulfa-based antibiotics, hospitalists can often desensitize patients with certain reaction characteristics using widely studied protocols to allow the patient to temporarily take a sulfa-containing medication.

The dominant message of Dr. Wickner’s talk on drug allergies was to get clear details on the allergic reaction – it can help guide clinicians through a path forward, either finding an alternate drug or performing further evaluation and perhaps continuing with the drug in question if the allergy turns out not to be a major concern.

“Please, for all of your patients, take an allergy history on every listed medication; often you will be able to remove or clarify the medical record and the changes can be life saving,” she said.

For instance, desensitization to sulfa for patients who’ve had a morbilliform rash without a fever can be done on an outpatient basis. But if the patient had hives, or became short of breath or anaphylactic, it needs to be done as an inpatient by an allergist, she said.

The question of drug allergies is substantial. About 35% of patients have at least one listed drug allergy, with penicillin, NSAIDs, and CT contrast agents topping the list, Dr. Wickner said. Although 10% of the general population and 15% of inpatients have a listed penicillin allergy, more than 90% of listed penicillin allergies turn out not to actually be allergic, in part because penicillin allergies are often diagnosed in childhood and are frequently outgrown over time. Having a listed allergy can impact treatment, Dr. Wickner said, with alternatives not always clear-cut.

She described one patient she saw who had 62 listed drug allergies, prompting her clinicians to wonder, “what can I safely give this patient?” Physicians, she said, subject to drug allergy “alert fatigue,” tend to override about 80% of allergy alerts, but this can sometimes have serious consequences.

“The best time to clarify is when a patient is healthy and well,” said Dr. Wickner, not when they are an inpatient and sick. It is much more difficult to test for an allergy, and to treat an allergic reaction, than when someone’s health is quickly declining.

She urged physicians to ask patients to be specific about the name of a drug they suspect they’re allergic to, about the indications, the symptoms, and the timing – an immediate reaction is much different than a symptom that showed up days later.

“Sometimes they’ll say they’re allergic to penicillin, but will tell you they’ve taken Augmentin or amoxicillin, so you can take that allergy off the list,” Dr. Wickner said.

At Brigham and Women’s Hospital and Massachusetts General Hospital, Boston, physicians have developed protocols for assessing and managing suspected allergies to penicillin, aspirin and NSAIDs, and trimethoprim/sulfamethoxazole – helpful tools, she said, because the nature and context of the reaction can matter a great deal in how to respond to the listed allergy.

If someone has a reaction, and you think it might be anaphylaxis, don’t spend time pondering it, Dr. Wickner said. “If that thought crosses your mind, treat it like anaphylaxis, then analyze after the fact.” Most patients with anaphylaxis have some cutaneous sign, even if it’s just flushing.

Dr. Wickner said that, if an allergist is available, take advantage of that. “If allergy is available in-house, utilize them. Often, skin testing and/or challenge can help patients receive first-line therapy.”

In a question-and-answer session after her presentation, Dr. Wickner said that hospitalists “have a huge role to play” in drug allergy delabeling.

“We would love to have a more standard practice of allergy reconciliation, just like we do with medication reconciliation,” she said. Asking questions to get more specifics is essential – and simply asking directly about each listed allergen is “step one, and you’ll really find it’s going to broaden the things that you can do for your patients.”

Asked about whether reactions listed as allergies are frequently just adverse effects, Dr. Wickner said that patients who say they are frequently nauseous – rather than breaking out into a rash, for example – might not be having a true allergic reaction. After careful consideration, they might be better managed with antinausea medication than avoidance of the drug.

Dr. Wickner reported no relevant financial disclosures.

Paige Wickner, MD, MPH, medical director for quality and safety at Brigham and Women’s Hospital and assistant professor at Harvard Medical School, both in Boston, described a scenario that might sound familiar to hospitalists.

A 72-year-old man is admitted to the hospital for a lung transplant, and has a listed allergy to “sulfa,” contained in antibiotics and other medications. His medical records say his reaction was “rash.”

What do you do?

The answer, Dr. Wickner said, speaking at HM20 Virtual, sponsored by the Society of Hospital Medicine, is to first ask more questions for clarification. How bad was the rash? Was it blistering? To what type of sulfa did the patient have a reaction?

These questions can help determine the next steps. For sulfa-based antibiotics, hospitalists can often desensitize patients with certain reaction characteristics using widely studied protocols to allow the patient to temporarily take a sulfa-containing medication.

The dominant message of Dr. Wickner’s talk on drug allergies was to get clear details on the allergic reaction – it can help guide clinicians through a path forward, either finding an alternate drug or performing further evaluation and perhaps continuing with the drug in question if the allergy turns out not to be a major concern.

“Please, for all of your patients, take an allergy history on every listed medication; often you will be able to remove or clarify the medical record and the changes can be life saving,” she said.

For instance, desensitization to sulfa for patients who’ve had a morbilliform rash without a fever can be done on an outpatient basis. But if the patient had hives, or became short of breath or anaphylactic, it needs to be done as an inpatient by an allergist, she said.

The question of drug allergies is substantial. About 35% of patients have at least one listed drug allergy, with penicillin, NSAIDs, and CT contrast agents topping the list, Dr. Wickner said. Although 10% of the general population and 15% of inpatients have a listed penicillin allergy, more than 90% of listed penicillin allergies turn out not to actually be allergic, in part because penicillin allergies are often diagnosed in childhood and are frequently outgrown over time. Having a listed allergy can impact treatment, Dr. Wickner said, with alternatives not always clear-cut.

She described one patient she saw who had 62 listed drug allergies, prompting her clinicians to wonder, “what can I safely give this patient?” Physicians, she said, subject to drug allergy “alert fatigue,” tend to override about 80% of allergy alerts, but this can sometimes have serious consequences.

“The best time to clarify is when a patient is healthy and well,” said Dr. Wickner, not when they are an inpatient and sick. It is much more difficult to test for an allergy, and to treat an allergic reaction, than when someone’s health is quickly declining.

She urged physicians to ask patients to be specific about the name of a drug they suspect they’re allergic to, about the indications, the symptoms, and the timing – an immediate reaction is much different than a symptom that showed up days later.

“Sometimes they’ll say they’re allergic to penicillin, but will tell you they’ve taken Augmentin or amoxicillin, so you can take that allergy off the list,” Dr. Wickner said.

At Brigham and Women’s Hospital and Massachusetts General Hospital, Boston, physicians have developed protocols for assessing and managing suspected allergies to penicillin, aspirin and NSAIDs, and trimethoprim/sulfamethoxazole – helpful tools, she said, because the nature and context of the reaction can matter a great deal in how to respond to the listed allergy.

If someone has a reaction, and you think it might be anaphylaxis, don’t spend time pondering it, Dr. Wickner said. “If that thought crosses your mind, treat it like anaphylaxis, then analyze after the fact.” Most patients with anaphylaxis have some cutaneous sign, even if it’s just flushing.

Dr. Wickner said that, if an allergist is available, take advantage of that. “If allergy is available in-house, utilize them. Often, skin testing and/or challenge can help patients receive first-line therapy.”

In a question-and-answer session after her presentation, Dr. Wickner said that hospitalists “have a huge role to play” in drug allergy delabeling.

“We would love to have a more standard practice of allergy reconciliation, just like we do with medication reconciliation,” she said. Asking questions to get more specifics is essential – and simply asking directly about each listed allergen is “step one, and you’ll really find it’s going to broaden the things that you can do for your patients.”

Asked about whether reactions listed as allergies are frequently just adverse effects, Dr. Wickner said that patients who say they are frequently nauseous – rather than breaking out into a rash, for example – might not be having a true allergic reaction. After careful consideration, they might be better managed with antinausea medication than avoidance of the drug.

Dr. Wickner reported no relevant financial disclosures.

Paige Wickner, MD, MPH, medical director for quality and safety at Brigham and Women’s Hospital and assistant professor at Harvard Medical School, both in Boston, described a scenario that might sound familiar to hospitalists.

A 72-year-old man is admitted to the hospital for a lung transplant, and has a listed allergy to “sulfa,” contained in antibiotics and other medications. His medical records say his reaction was “rash.”

What do you do?

The answer, Dr. Wickner said, speaking at HM20 Virtual, sponsored by the Society of Hospital Medicine, is to first ask more questions for clarification. How bad was the rash? Was it blistering? To what type of sulfa did the patient have a reaction?

These questions can help determine the next steps. For sulfa-based antibiotics, hospitalists can often desensitize patients with certain reaction characteristics using widely studied protocols to allow the patient to temporarily take a sulfa-containing medication.

The dominant message of Dr. Wickner’s talk on drug allergies was to get clear details on the allergic reaction – it can help guide clinicians through a path forward, either finding an alternate drug or performing further evaluation and perhaps continuing with the drug in question if the allergy turns out not to be a major concern.

“Please, for all of your patients, take an allergy history on every listed medication; often you will be able to remove or clarify the medical record and the changes can be life saving,” she said.

For instance, desensitization to sulfa for patients who’ve had a morbilliform rash without a fever can be done on an outpatient basis. But if the patient had hives, or became short of breath or anaphylactic, it needs to be done as an inpatient by an allergist, she said.

The question of drug allergies is substantial. About 35% of patients have at least one listed drug allergy, with penicillin, NSAIDs, and CT contrast agents topping the list, Dr. Wickner said. Although 10% of the general population and 15% of inpatients have a listed penicillin allergy, more than 90% of listed penicillin allergies turn out not to actually be allergic, in part because penicillin allergies are often diagnosed in childhood and are frequently outgrown over time. Having a listed allergy can impact treatment, Dr. Wickner said, with alternatives not always clear-cut.

She described one patient she saw who had 62 listed drug allergies, prompting her clinicians to wonder, “what can I safely give this patient?” Physicians, she said, subject to drug allergy “alert fatigue,” tend to override about 80% of allergy alerts, but this can sometimes have serious consequences.

“The best time to clarify is when a patient is healthy and well,” said Dr. Wickner, not when they are an inpatient and sick. It is much more difficult to test for an allergy, and to treat an allergic reaction, than when someone’s health is quickly declining.

She urged physicians to ask patients to be specific about the name of a drug they suspect they’re allergic to, about the indications, the symptoms, and the timing – an immediate reaction is much different than a symptom that showed up days later.

“Sometimes they’ll say they’re allergic to penicillin, but will tell you they’ve taken Augmentin or amoxicillin, so you can take that allergy off the list,” Dr. Wickner said.

At Brigham and Women’s Hospital and Massachusetts General Hospital, Boston, physicians have developed protocols for assessing and managing suspected allergies to penicillin, aspirin and NSAIDs, and trimethoprim/sulfamethoxazole – helpful tools, she said, because the nature and context of the reaction can matter a great deal in how to respond to the listed allergy.

If someone has a reaction, and you think it might be anaphylaxis, don’t spend time pondering it, Dr. Wickner said. “If that thought crosses your mind, treat it like anaphylaxis, then analyze after the fact.” Most patients with anaphylaxis have some cutaneous sign, even if it’s just flushing.

Dr. Wickner said that, if an allergist is available, take advantage of that. “If allergy is available in-house, utilize them. Often, skin testing and/or challenge can help patients receive first-line therapy.”

In a question-and-answer session after her presentation, Dr. Wickner said that hospitalists “have a huge role to play” in drug allergy delabeling.

“We would love to have a more standard practice of allergy reconciliation, just like we do with medication reconciliation,” she said. Asking questions to get more specifics is essential – and simply asking directly about each listed allergen is “step one, and you’ll really find it’s going to broaden the things that you can do for your patients.”

Asked about whether reactions listed as allergies are frequently just adverse effects, Dr. Wickner said that patients who say they are frequently nauseous – rather than breaking out into a rash, for example – might not be having a true allergic reaction. After careful consideration, they might be better managed with antinausea medication than avoidance of the drug.

Dr. Wickner reported no relevant financial disclosures.

A recently validated, easy-to-use calculator of predicted 7-day mortality risk in patients presenting with acute decompensated heart failure is well worth incorporating into hospitalist clinical practice, Dustin T. Smith, MD, said at HM20 Virtual, hosted by the Society of Hospital Medicine.

The ACUTE study

Heart failure is an area of special interest for Dr. Smith. He has been surprised to find that virtually no hospitalists, emergency medicine physicians, or cardiologists he has spoken with have heard of the EHMRG or its validation in the ACUTE (Acute Congestive Heart Failure Urgent Care Evaluation) study. Yet this is a very handy tool for hospitalists, he observed.

The EHMRG algorithm utilizes nine variables for which data is readily available for every patient who arrives at the emergency department with acute heart failure. The variables are age, arrival by ambulance, heart rate, systolic blood pressure, potassium level, oxygen saturation, troponin, serum creatine, and presence or absence of active cancer. The information is entered into a cell phone app, which spits out the patient’s estimated 7-day mortality risk. The algorithm divides patients into one of five risk groups ranging from very low to very high. With the addition of data input as to the presence or absence of ST-segment depression on the 12-lead ECG, the weighted algorithm will simultaneously generate an estimated 30-day mortality risk.

ACUTE was a prospective, observational, real-world validation study of EHMRG involving 1,983 patients seeking emergency department care for acute heart failure at nine Canadian hospitals. The actual 7-day mortality rate was 0% in the very-low-risk group, 0% in the low-risk group, 0.6% with an intermediate-risk EHMRG, 1.9% with high risk, and 3.9% in the very-high-risk group. The corresponding 30-day mortality rates were 0%, 1.9%, 3.9%, 5.9%, and 14.3%.

The University of Toronto investigators also asked participating physicians for their clinical estimates of 7-day mortality risk while blinded to the EHMRG predictions. The algorithm proved more accurate than physician predictions across the board. Indeed, physicians consistently overestimated the mortality risk for all categories except the very-high-risk one, where they underestimated the true risk (Circulation. 2019 Feb 26;139[9]:1146-56).

Given that heart failure remains year after year at the top of the list of most frequent causes for hospital admission, and that there is compelling evidence that many low-risk patients get hospitalized while potentially unsafe early discharges also occur, the EHMRG score fills an important unmet need.

“I think this can help inform us as to who with acute heart failure potentially needs to come into the hospital and who doesn’t,” Dr. Smith said. “I think the sweet spot here is that if you’re in the low- or very-low-risk category, your 7-day mortality is less than 1%; in fact, in this study it’s zero. But once you get to category 3 – the intermediate category – you’re talking about a 7-day mortality of 1%-2%, which I think is high enough to warrant hospital admission for treatment and to watch them, not just send them home.”
 

The H2FPEF score

Diagnosis of heart failure with preserved ejection fraction (HFpEF) is a challenge in euvolemic patients with clear lungs and dyspnea on exertion. Investigators at the Mayo Clinic have developed and subsequently validated a weighted score known as the H2FPEF score that’s of great assistance in this task. The score is based upon a set of six simple variables universally available in patients undergoing diagnostic workup for the numerous potential causes for dyspnea on exertion. Together these six variables comprise the acronym H2FPEF:

• Heavy: One point for a BMI greater than 30 kg/m^2.
• Hypertension: One point for being on two or more antihypertensive drugs.
• Atrial fibrillation: Three points for paroxysmal or persistent AF.
• Pulmonary hypertension: One point for having a Doppler echocardiographic estimated pulmonary artery systolic pressure greater than 35 mm Hg.
• Elder: One point for age greater than 60 years.
• Filling pressure: One point for a Doppler echocardiographic E/e’ ratio above 9.

The total score can range from 0 to 9. (Circulation. 2018 Aug 28;138[9]:861-70).

Each 1-point increase in the score essentially doubled a patient’s risk of having HFpEF as opposed to pulmonary embolism or some other cause for the dyspnea.

“I really like this H2FPEF score. The score works very, very well. Once you get to a score of 6 or above, the probability of HFpEF is more than 90%, which is pretty powerful. I think this is worthwhile,” Dr. Smith said.

In their derivation and validation cohorts, the Mayo Clinic investigators used as their gold standard for diagnosis of HFpEF invasive hemodynamic exercise testing with a pulmonary artery catheter in place to measure pressures. A score that enables hospitalists to lessen the need for that kind of costly invasive testing is most welcome.

“Here’s how I’d use this score: With an H2FPEF score of 0-1, HFpEF is unlikely. With an intermediate score of 2-5, additional testing is warranted. If the score is high, 6-9, I think HFpEF is likely,” the hospitalist said.

Dr. Smith isn’t the only big fan of the H2FPEF score. In an editorial accompanying publication of the score’s validation study, Walter J. Paulus, MD, PhD, hailed the H2FPEF score as “a unique tour de force” which constitutes a major advance beyond the confusing diagnostic recommendations for HFpEF issued by the European Society of Cardiology and the American Society of Echocardiography, which he said have been “met by skepticism qualifying them as overcomplicated and even triggered disbelief in the existence of HFpEF.”

Particularly interesting were the variables rejected for inclusion in the H2FPEF score because they failed to achieve statistical significance as predictors, even though they’re often considered important in defining HFpEF, he noted. These included left atrial volume index, sex, and levels of circulating N-terminal probrain natriuretic peptide, wrote Dr. Paulus, professor of cardiac pathophysiology at VU University, Amsterdam.
 

Debunking the potassium repletion reflex

Longstanding conventional wisdom holds that patients hospitalized for heart failure need to maintain a serum potassium above 4.0 mEq/L.

“I’m sure you’ve all written orders to keep the potassium greater than 4.0 mEq/L and the magnesium above 2mEq/L about a million times, like I have,” Dr. Smith said.

But it turns out this traditional practice, which involves a huge cost in terms of time, money, and health care resources, is supported by weak evidence – and an important recent study has now debunked what the investigators termed the potassium “repletion reflex.”

The investigators at the University of Massachusetts identified 4,995 patients admitted with exacerbation of acute heart failure and a normal admission serum potassium level of 3.5-5.0 mEq/L. More than 70% received potassium repletion at least once within a 72-hour observation window, during which 2,080 patients maintained a low-normal serum potassium below 4.0 mEq/L, 2,326 had a mid-normal level of 4.0-4.5 mEq/L, and 589 had a high-normal level of more than 4.5 mEq/L but not more than 5.0 mEq/L.

The study had three endpoints: in-hospital mortality, transfer to the intensive care unit, and hospital length of stay. After statistical adjustment for comorbidities, demographics, and severity at admission, there was no difference between the low- and mid-normal serum potassium groups in any of the three endpoints. In contrast, the high-normal potassium group had a significantly longer length of stay, by a median of 0.6 extra days. The high-normal group also had a 78% increased likelihood of ICU transfer and a 51% increased risk of in-hospital mortality, although neither of these differences reached statistical significance (J Hosp Med. 2019 Dec 1;14[12]:729-36).

“A potassium greater than 4.5 mEq/L may be associated with increased risk of worse outcomes,” Dr. Smith observed. “I think the sweet spot may be 3.5-4.5 mEq/L based on this study.”

He reported having no financial conflicts regarding his presentation.

bjancin@mdedge.com

A recently validated, easy-to-use calculator of predicted 7-day mortality risk in patients presenting with acute decompensated heart failure is well worth incorporating into hospitalist clinical practice, Dustin T. Smith, MD, said at HM20 Virtual, hosted by the Society of Hospital Medicine.

The ACUTE study

Heart failure is an area of special interest for Dr. Smith. He has been surprised to find that virtually no hospitalists, emergency medicine physicians, or cardiologists he has spoken with have heard of the EHMRG or its validation in the ACUTE (Acute Congestive Heart Failure Urgent Care Evaluation) study. Yet this is a very handy tool for hospitalists, he observed.

The EHMRG algorithm utilizes nine variables for which data is readily available for every patient who arrives at the emergency department with acute heart failure. The variables are age, arrival by ambulance, heart rate, systolic blood pressure, potassium level, oxygen saturation, troponin, serum creatine, and presence or absence of active cancer. The information is entered into a cell phone app, which spits out the patient’s estimated 7-day mortality risk. The algorithm divides patients into one of five risk groups ranging from very low to very high. With the addition of data input as to the presence or absence of ST-segment depression on the 12-lead ECG, the weighted algorithm will simultaneously generate an estimated 30-day mortality risk.

ACUTE was a prospective, observational, real-world validation study of EHMRG involving 1,983 patients seeking emergency department care for acute heart failure at nine Canadian hospitals. The actual 7-day mortality rate was 0% in the very-low-risk group, 0% in the low-risk group, 0.6% with an intermediate-risk EHMRG, 1.9% with high risk, and 3.9% in the very-high-risk group. The corresponding 30-day mortality rates were 0%, 1.9%, 3.9%, 5.9%, and 14.3%.

The University of Toronto investigators also asked participating physicians for their clinical estimates of 7-day mortality risk while blinded to the EHMRG predictions. The algorithm proved more accurate than physician predictions across the board. Indeed, physicians consistently overestimated the mortality risk for all categories except the very-high-risk one, where they underestimated the true risk (Circulation. 2019 Feb 26;139[9]:1146-56).

Given that heart failure remains year after year at the top of the list of most frequent causes for hospital admission, and that there is compelling evidence that many low-risk patients get hospitalized while potentially unsafe early discharges also occur, the EHMRG score fills an important unmet need.

“I think this can help inform us as to who with acute heart failure potentially needs to come into the hospital and who doesn’t,” Dr. Smith said. “I think the sweet spot here is that if you’re in the low- or very-low-risk category, your 7-day mortality is less than 1%; in fact, in this study it’s zero. But once you get to category 3 – the intermediate category – you’re talking about a 7-day mortality of 1%-2%, which I think is high enough to warrant hospital admission for treatment and to watch them, not just send them home.”
 

The H2FPEF score

Diagnosis of heart failure with preserved ejection fraction (HFpEF) is a challenge in euvolemic patients with clear lungs and dyspnea on exertion. Investigators at the Mayo Clinic have developed and subsequently validated a weighted score known as the H2FPEF score that’s of great assistance in this task. The score is based upon a set of six simple variables universally available in patients undergoing diagnostic workup for the numerous potential causes for dyspnea on exertion. Together these six variables comprise the acronym H2FPEF:

• Heavy: One point for a BMI greater than 30 kg/m^2.
• Hypertension: One point for being on two or more antihypertensive drugs.
• Atrial fibrillation: Three points for paroxysmal or persistent AF.
• Pulmonary hypertension: One point for having a Doppler echocardiographic estimated pulmonary artery systolic pressure greater than 35 mm Hg.
• Elder: One point for age greater than 60 years.
• Filling pressure: One point for a Doppler echocardiographic E/e’ ratio above 9.

The total score can range from 0 to 9. (Circulation. 2018 Aug 28;138[9]:861-70).

Each 1-point increase in the score essentially doubled a patient’s risk of having HFpEF as opposed to pulmonary embolism or some other cause for the dyspnea.

“I really like this H2FPEF score. The score works very, very well. Once you get to a score of 6 or above, the probability of HFpEF is more than 90%, which is pretty powerful. I think this is worthwhile,” Dr. Smith said.

In their derivation and validation cohorts, the Mayo Clinic investigators used as their gold standard for diagnosis of HFpEF invasive hemodynamic exercise testing with a pulmonary artery catheter in place to measure pressures. A score that enables hospitalists to lessen the need for that kind of costly invasive testing is most welcome.

“Here’s how I’d use this score: With an H2FPEF score of 0-1, HFpEF is unlikely. With an intermediate score of 2-5, additional testing is warranted. If the score is high, 6-9, I think HFpEF is likely,” the hospitalist said.

Dr. Smith isn’t the only big fan of the H2FPEF score. In an editorial accompanying publication of the score’s validation study, Walter J. Paulus, MD, PhD, hailed the H2FPEF score as “a unique tour de force” which constitutes a major advance beyond the confusing diagnostic recommendations for HFpEF issued by the European Society of Cardiology and the American Society of Echocardiography, which he said have been “met by skepticism qualifying them as overcomplicated and even triggered disbelief in the existence of HFpEF.”

Particularly interesting were the variables rejected for inclusion in the H2FPEF score because they failed to achieve statistical significance as predictors, even though they’re often considered important in defining HFpEF, he noted. These included left atrial volume index, sex, and levels of circulating N-terminal probrain natriuretic peptide, wrote Dr. Paulus, professor of cardiac pathophysiology at VU University, Amsterdam.
 

Debunking the potassium repletion reflex

Longstanding conventional wisdom holds that patients hospitalized for heart failure need to maintain a serum potassium above 4.0 mEq/L.

“I’m sure you’ve all written orders to keep the potassium greater than 4.0 mEq/L and the magnesium above 2mEq/L about a million times, like I have,” Dr. Smith said.

But it turns out this traditional practice, which involves a huge cost in terms of time, money, and health care resources, is supported by weak evidence – and an important recent study has now debunked what the investigators termed the potassium “repletion reflex.”

The investigators at the University of Massachusetts identified 4,995 patients admitted with exacerbation of acute heart failure and a normal admission serum potassium level of 3.5-5.0 mEq/L. More than 70% received potassium repletion at least once within a 72-hour observation window, during which 2,080 patients maintained a low-normal serum potassium below 4.0 mEq/L, 2,326 had a mid-normal level of 4.0-4.5 mEq/L, and 589 had a high-normal level of more than 4.5 mEq/L but not more than 5.0 mEq/L.

The study had three endpoints: in-hospital mortality, transfer to the intensive care unit, and hospital length of stay. After statistical adjustment for comorbidities, demographics, and severity at admission, there was no difference between the low- and mid-normal serum potassium groups in any of the three endpoints. In contrast, the high-normal potassium group had a significantly longer length of stay, by a median of 0.6 extra days. The high-normal group also had a 78% increased likelihood of ICU transfer and a 51% increased risk of in-hospital mortality, although neither of these differences reached statistical significance (J Hosp Med. 2019 Dec 1;14[12]:729-36).

“A potassium greater than 4.5 mEq/L may be associated with increased risk of worse outcomes,” Dr. Smith observed. “I think the sweet spot may be 3.5-4.5 mEq/L based on this study.”

He reported having no financial conflicts regarding his presentation.

bjancin@mdedge.com

A recently validated, easy-to-use calculator of predicted 7-day mortality risk in patients presenting with acute decompensated heart failure is well worth incorporating into hospitalist clinical practice, Dustin T. Smith, MD, said at HM20 Virtual, hosted by the Society of Hospital Medicine.

The ACUTE study

Heart failure is an area of special interest for Dr. Smith. He has been surprised to find that virtually no hospitalists, emergency medicine physicians, or cardiologists he has spoken with have heard of the EHMRG or its validation in the ACUTE (Acute Congestive Heart Failure Urgent Care Evaluation) study. Yet this is a very handy tool for hospitalists, he observed.

The EHMRG algorithm utilizes nine variables for which data is readily available for every patient who arrives at the emergency department with acute heart failure. The variables are age, arrival by ambulance, heart rate, systolic blood pressure, potassium level, oxygen saturation, troponin, serum creatine, and presence or absence of active cancer. The information is entered into a cell phone app, which spits out the patient’s estimated 7-day mortality risk. The algorithm divides patients into one of five risk groups ranging from very low to very high. With the addition of data input as to the presence or absence of ST-segment depression on the 12-lead ECG, the weighted algorithm will simultaneously generate an estimated 30-day mortality risk.

ACUTE was a prospective, observational, real-world validation study of EHMRG involving 1,983 patients seeking emergency department care for acute heart failure at nine Canadian hospitals. The actual 7-day mortality rate was 0% in the very-low-risk group, 0% in the low-risk group, 0.6% with an intermediate-risk EHMRG, 1.9% with high risk, and 3.9% in the very-high-risk group. The corresponding 30-day mortality rates were 0%, 1.9%, 3.9%, 5.9%, and 14.3%.

The University of Toronto investigators also asked participating physicians for their clinical estimates of 7-day mortality risk while blinded to the EHMRG predictions. The algorithm proved more accurate than physician predictions across the board. Indeed, physicians consistently overestimated the mortality risk for all categories except the very-high-risk one, where they underestimated the true risk (Circulation. 2019 Feb 26;139[9]:1146-56).

Given that heart failure remains year after year at the top of the list of most frequent causes for hospital admission, and that there is compelling evidence that many low-risk patients get hospitalized while potentially unsafe early discharges also occur, the EHMRG score fills an important unmet need.

“I think this can help inform us as to who with acute heart failure potentially needs to come into the hospital and who doesn’t,” Dr. Smith said. “I think the sweet spot here is that if you’re in the low- or very-low-risk category, your 7-day mortality is less than 1%; in fact, in this study it’s zero. But once you get to category 3 – the intermediate category – you’re talking about a 7-day mortality of 1%-2%, which I think is high enough to warrant hospital admission for treatment and to watch them, not just send them home.”
 

The H2FPEF score

Diagnosis of heart failure with preserved ejection fraction (HFpEF) is a challenge in euvolemic patients with clear lungs and dyspnea on exertion. Investigators at the Mayo Clinic have developed and subsequently validated a weighted score known as the H2FPEF score that’s of great assistance in this task. The score is based upon a set of six simple variables universally available in patients undergoing diagnostic workup for the numerous potential causes for dyspnea on exertion. Together these six variables comprise the acronym H2FPEF:

• Heavy: One point for a BMI greater than 30 kg/m^2.
• Hypertension: One point for being on two or more antihypertensive drugs.
• Atrial fibrillation: Three points for paroxysmal or persistent AF.
• Pulmonary hypertension: One point for having a Doppler echocardiographic estimated pulmonary artery systolic pressure greater than 35 mm Hg.
• Elder: One point for age greater than 60 years.
• Filling pressure: One point for a Doppler echocardiographic E/e’ ratio above 9.

The total score can range from 0 to 9. (Circulation. 2018 Aug 28;138[9]:861-70).

Each 1-point increase in the score essentially doubled a patient’s risk of having HFpEF as opposed to pulmonary embolism or some other cause for the dyspnea.

“I really like this H2FPEF score. The score works very, very well. Once you get to a score of 6 or above, the probability of HFpEF is more than 90%, which is pretty powerful. I think this is worthwhile,” Dr. Smith said.

In their derivation and validation cohorts, the Mayo Clinic investigators used as their gold standard for diagnosis of HFpEF invasive hemodynamic exercise testing with a pulmonary artery catheter in place to measure pressures. A score that enables hospitalists to lessen the need for that kind of costly invasive testing is most welcome.

“Here’s how I’d use this score: With an H2FPEF score of 0-1, HFpEF is unlikely. With an intermediate score of 2-5, additional testing is warranted. If the score is high, 6-9, I think HFpEF is likely,” the hospitalist said.

Dr. Smith isn’t the only big fan of the H2FPEF score. In an editorial accompanying publication of the score’s validation study, Walter J. Paulus, MD, PhD, hailed the H2FPEF score as “a unique tour de force” which constitutes a major advance beyond the confusing diagnostic recommendations for HFpEF issued by the European Society of Cardiology and the American Society of Echocardiography, which he said have been “met by skepticism qualifying them as overcomplicated and even triggered disbelief in the existence of HFpEF.”

Particularly interesting were the variables rejected for inclusion in the H2FPEF score because they failed to achieve statistical significance as predictors, even though they’re often considered important in defining HFpEF, he noted. These included left atrial volume index, sex, and levels of circulating N-terminal probrain natriuretic peptide, wrote Dr. Paulus, professor of cardiac pathophysiology at VU University, Amsterdam.
 

Debunking the potassium repletion reflex

Longstanding conventional wisdom holds that patients hospitalized for heart failure need to maintain a serum potassium above 4.0 mEq/L.

“I’m sure you’ve all written orders to keep the potassium greater than 4.0 mEq/L and the magnesium above 2mEq/L about a million times, like I have,” Dr. Smith said.

But it turns out this traditional practice, which involves a huge cost in terms of time, money, and health care resources, is supported by weak evidence – and an important recent study has now debunked what the investigators termed the potassium “repletion reflex.”

The investigators at the University of Massachusetts identified 4,995 patients admitted with exacerbation of acute heart failure and a normal admission serum potassium level of 3.5-5.0 mEq/L. More than 70% received potassium repletion at least once within a 72-hour observation window, during which 2,080 patients maintained a low-normal serum potassium below 4.0 mEq/L, 2,326 had a mid-normal level of 4.0-4.5 mEq/L, and 589 had a high-normal level of more than 4.5 mEq/L but not more than 5.0 mEq/L.

The study had three endpoints: in-hospital mortality, transfer to the intensive care unit, and hospital length of stay. After statistical adjustment for comorbidities, demographics, and severity at admission, there was no difference between the low- and mid-normal serum potassium groups in any of the three endpoints. In contrast, the high-normal potassium group had a significantly longer length of stay, by a median of 0.6 extra days. The high-normal group also had a 78% increased likelihood of ICU transfer and a 51% increased risk of in-hospital mortality, although neither of these differences reached statistical significance (J Hosp Med. 2019 Dec 1;14[12]:729-36).

“A potassium greater than 4.5 mEq/L may be associated with increased risk of worse outcomes,” Dr. Smith observed. “I think the sweet spot may be 3.5-4.5 mEq/L based on this study.”

He reported having no financial conflicts regarding his presentation.

bjancin@mdedge.com

With the United States spending the most per capita on health care among industrialized nations but having the worst aggregate health outcomes, there’s a stark need for improvement, according to an expert at HM20 Virtual, hosted by the Society of Hospital Medicine.

Broadening the focus beyond the four walls of the hospital can bring better results while also saving money, said Adam Myers, MD, chief of population health at Cleveland Clinic. Dr. Myers described the way his health system has begun to pay more careful attention to the needs of specific kinds of patients and tailoring posthospitalization care accordingly, with in-person and virtual home visits, and postdischarge clinics.

With an increasing attention to value, health care organizations have to change their structure or risk going the way of the Choluteca Bridge in Honduras, Dr. Myers said. The Choluteca Bridge was built to be hurricane proof, but was nonetheless rendered useless in 1998 after Hurricane Mitch shifted the very course of the river beneath it.

Similarly, the way health care is delivered often does not meet the needs of the population.

“Our national system has been focused almost entirely on inpatient care,” Dr. Myers said. “A lot of the transition in care is outside of facilities and outside the walls of our inpatient settings.”

Instead, he said a focus on population health – understanding and tending to the needs of people rather than just treating them when they show up at clinics – should involve more outpatient care that is less centralized, fees based on outcomes and patient experience rather than simply volume of services, team approaches rather than single-provider care, and a general attention to preserving health rather than treating sickness.

At Cleveland Clinic, care teams try to understand not just the care that is medically necessary, but what is wanted and justified, as well as how to deliver that care safely, reliably, and affordably with outcomes that patients and families desire.

The results are striking. After increasing the number of ambulatory patient “touches” for those with chronic disease, inpatient care – disliked by patients and costly to health centers – decreased. From the first quarter of 2018, outpatient visits increased 9%, while inpatient visits dropped 7.4%, Dr. Myers said.

“As we managed patients more effectively on an outpatient basis, their need for inpatient care diminished,” he said. “It works.”

Cleveland Clinic has also made changes designed to reduce costly readmissions, using virtual visits, house calls, time reserved for team meetings to identify patients with gaps in their care, and attention to nonmedical determinants of health, such as assessing fall risk at home and addressing lack of nutritious food options in a community.

The health system has seen a 28% reduction in the cost of care attributed to house calls, 12% cost reduction attributed to better care coordination, and a 49% decrease in hospital days for “superutilizers” of the ED, Dr. Myers said.

Postdischarge clinics – where patients can be seen for the first few visits after hospitalization – have also been valuable for many health systems, because they are closely in tune with what happened during the inpatient stay. These clinics are staffed by hospitalists, interns, residents, or ambulatory clinicians. Dr. Myers said hospitalists tend to have an improved perspective after working in a discharge clinic, with more concern about a patient’s needs once they leave the hospital bed.

“Those hospitalists that I know who have participated in programs like this start to act a bit more like primary care physicians,” he said.

In a Q&A session after Dr. Myers’ presentation, he discussed how hospitalists can affect the many layers of health care policy, factors that often overlap with population health.

He noted that medical care accounts for only about 20% of patient outcomes – the rest involve social and environmental factors.

“I don’t know about you , but I’m not satisfied only impacting 20% of health outcomes,” he said. First, physicians need to understand what is happening in their communities, and the health policies that are preventing improvement. Then, build partnerships to help fix these problems. He pointed to lead poisoning as an example.

“If you think about it, lead poisoning is a social housing problem that shows up as a health care issue. Unless we are getting out into the community and mitigating the root problem, we will have to treat it over and over again,” he said.

Dr. Myers reported no relevant financial disclosures.

With the United States spending the most per capita on health care among industrialized nations but having the worst aggregate health outcomes, there’s a stark need for improvement, according to an expert at HM20 Virtual, hosted by the Society of Hospital Medicine.

Broadening the focus beyond the four walls of the hospital can bring better results while also saving money, said Adam Myers, MD, chief of population health at Cleveland Clinic. Dr. Myers described the way his health system has begun to pay more careful attention to the needs of specific kinds of patients and tailoring posthospitalization care accordingly, with in-person and virtual home visits, and postdischarge clinics.

With an increasing attention to value, health care organizations have to change their structure or risk going the way of the Choluteca Bridge in Honduras, Dr. Myers said. The Choluteca Bridge was built to be hurricane proof, but was nonetheless rendered useless in 1998 after Hurricane Mitch shifted the very course of the river beneath it.

Similarly, the way health care is delivered often does not meet the needs of the population.

“Our national system has been focused almost entirely on inpatient care,” Dr. Myers said. “A lot of the transition in care is outside of facilities and outside the walls of our inpatient settings.”

Instead, he said a focus on population health – understanding and tending to the needs of people rather than just treating them when they show up at clinics – should involve more outpatient care that is less centralized, fees based on outcomes and patient experience rather than simply volume of services, team approaches rather than single-provider care, and a general attention to preserving health rather than treating sickness.

At Cleveland Clinic, care teams try to understand not just the care that is medically necessary, but what is wanted and justified, as well as how to deliver that care safely, reliably, and affordably with outcomes that patients and families desire.

The results are striking. After increasing the number of ambulatory patient “touches” for those with chronic disease, inpatient care – disliked by patients and costly to health centers – decreased. From the first quarter of 2018, outpatient visits increased 9%, while inpatient visits dropped 7.4%, Dr. Myers said.

“As we managed patients more effectively on an outpatient basis, their need for inpatient care diminished,” he said. “It works.”

Cleveland Clinic has also made changes designed to reduce costly readmissions, using virtual visits, house calls, time reserved for team meetings to identify patients with gaps in their care, and attention to nonmedical determinants of health, such as assessing fall risk at home and addressing lack of nutritious food options in a community.

The health system has seen a 28% reduction in the cost of care attributed to house calls, 12% cost reduction attributed to better care coordination, and a 49% decrease in hospital days for “superutilizers” of the ED, Dr. Myers said.

Postdischarge clinics – where patients can be seen for the first few visits after hospitalization – have also been valuable for many health systems, because they are closely in tune with what happened during the inpatient stay. These clinics are staffed by hospitalists, interns, residents, or ambulatory clinicians. Dr. Myers said hospitalists tend to have an improved perspective after working in a discharge clinic, with more concern about a patient’s needs once they leave the hospital bed.

“Those hospitalists that I know who have participated in programs like this start to act a bit more like primary care physicians,” he said.

In a Q&A session after Dr. Myers’ presentation, he discussed how hospitalists can affect the many layers of health care policy, factors that often overlap with population health.

He noted that medical care accounts for only about 20% of patient outcomes – the rest involve social and environmental factors.

“I don’t know about you , but I’m not satisfied only impacting 20% of health outcomes,” he said. First, physicians need to understand what is happening in their communities, and the health policies that are preventing improvement. Then, build partnerships to help fix these problems. He pointed to lead poisoning as an example.

“If you think about it, lead poisoning is a social housing problem that shows up as a health care issue. Unless we are getting out into the community and mitigating the root problem, we will have to treat it over and over again,” he said.

Dr. Myers reported no relevant financial disclosures.

With the United States spending the most per capita on health care among industrialized nations but having the worst aggregate health outcomes, there’s a stark need for improvement, according to an expert at HM20 Virtual, hosted by the Society of Hospital Medicine.

Broadening the focus beyond the four walls of the hospital can bring better results while also saving money, said Adam Myers, MD, chief of population health at Cleveland Clinic. Dr. Myers described the way his health system has begun to pay more careful attention to the needs of specific kinds of patients and tailoring posthospitalization care accordingly, with in-person and virtual home visits, and postdischarge clinics.

With an increasing attention to value, health care organizations have to change their structure or risk going the way of the Choluteca Bridge in Honduras, Dr. Myers said. The Choluteca Bridge was built to be hurricane proof, but was nonetheless rendered useless in 1998 after Hurricane Mitch shifted the very course of the river beneath it.

Similarly, the way health care is delivered often does not meet the needs of the population.

“Our national system has been focused almost entirely on inpatient care,” Dr. Myers said. “A lot of the transition in care is outside of facilities and outside the walls of our inpatient settings.”

Instead, he said a focus on population health – understanding and tending to the needs of people rather than just treating them when they show up at clinics – should involve more outpatient care that is less centralized, fees based on outcomes and patient experience rather than simply volume of services, team approaches rather than single-provider care, and a general attention to preserving health rather than treating sickness.

At Cleveland Clinic, care teams try to understand not just the care that is medically necessary, but what is wanted and justified, as well as how to deliver that care safely, reliably, and affordably with outcomes that patients and families desire.

The results are striking. After increasing the number of ambulatory patient “touches” for those with chronic disease, inpatient care – disliked by patients and costly to health centers – decreased. From the first quarter of 2018, outpatient visits increased 9%, while inpatient visits dropped 7.4%, Dr. Myers said.

“As we managed patients more effectively on an outpatient basis, their need for inpatient care diminished,” he said. “It works.”

Cleveland Clinic has also made changes designed to reduce costly readmissions, using virtual visits, house calls, time reserved for team meetings to identify patients with gaps in their care, and attention to nonmedical determinants of health, such as assessing fall risk at home and addressing lack of nutritious food options in a community.

The health system has seen a 28% reduction in the cost of care attributed to house calls, 12% cost reduction attributed to better care coordination, and a 49% decrease in hospital days for “superutilizers” of the ED, Dr. Myers said.

Postdischarge clinics – where patients can be seen for the first few visits after hospitalization – have also been valuable for many health systems, because they are closely in tune with what happened during the inpatient stay. These clinics are staffed by hospitalists, interns, residents, or ambulatory clinicians. Dr. Myers said hospitalists tend to have an improved perspective after working in a discharge clinic, with more concern about a patient’s needs once they leave the hospital bed.

“Those hospitalists that I know who have participated in programs like this start to act a bit more like primary care physicians,” he said.

In a Q&A session after Dr. Myers’ presentation, he discussed how hospitalists can affect the many layers of health care policy, factors that often overlap with population health.

He noted that medical care accounts for only about 20% of patient outcomes – the rest involve social and environmental factors.

“I don’t know about you , but I’m not satisfied only impacting 20% of health outcomes,” he said. First, physicians need to understand what is happening in their communities, and the health policies that are preventing improvement. Then, build partnerships to help fix these problems. He pointed to lead poisoning as an example.

“If you think about it, lead poisoning is a social housing problem that shows up as a health care issue. Unless we are getting out into the community and mitigating the root problem, we will have to treat it over and over again,” he said.

Dr. Myers reported no relevant financial disclosures.