10th Annual Southern Hospital Medicine Conference Wrap-up

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10th Annual Southern Hospital Medicine
ConferenceWrap-up

• Steven B. Deitelzweig
• Daniel Dressler
• Kevin Hude
• David H. Lee
• Alan L. Wang
• October 15-17, 2009

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Welcome to New Orleans
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The Roosevelt WaldorfAstoria
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Advancing Healthcare Delivery

• Evidence-Based Medicine
• Trial Population
• All Hospitalized Patients

The Role of the Hospitalist
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Wednesday, October 15Pre-Conference Courses

• Advanced Stroke Management
• Robert Felberg
• Kenneth Gaines
• Practical Inpatient Billing and Coding
• Yvette Cua

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Thursday, October 15Morning

• Hospital Medicine
• Jeff Wiess
• Kathy Duncan
• Shaun Frost

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Keynote AddressHospital Medicine - Present
Future

• 2012 30,000 Hospitalists projected
• Improving and sustaining quality
• Safe
• Timely
• Effective
• Efficient
• Patient-Centered
• Equitable

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Keynote AddressHospital Medicine - Present
Future

• Challenges of Academic Teaching in the evolving
  hospital /GME setting
• Potential Impact of Healthcare Reform
• ABIM Certification Hospitalist Focus to start
  2010

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Keynote Address Improvement What is Possible

• All improvement will require change, but no all
  changes will result in improvement
• Every system is perfectly designed to achieve the
  results inherent to the system
• System improvement increases the odds the changes
  will result in lasting improvement Act, Plan,
  Do, Study
• Success proven in IHI 10K and 5 Million Lives
  campaigns

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Implementing Systems of Surgical Co-Management

• Surgical Co-Management can add value to patient
  care
• Decreased LOS, Time to surgery, Unnecessary
  testing, Unnecessary medication use, Minor
  post-op complications
• Increased Nurse and Surgeon satisfaction
• Neutral Cost

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Implementing Systems of Surgical Co-Management

• Ethical Issues ACS Statement
• Premise of referral must be quality of care
• Surgeon responsible for proper pre-op preparation
• Surgeon responsible for post-op care
• Surgeon must maintain care coordination
• Surgeon to determine readiness for discharge
• Unethical to turn post-op patient completely to
  referring physician if patient not ready for
  discharge

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Implementing Systems of Surgical Co-Management

• Guidelines on Co-Management Operations Agreement
• Rational for building the service
• Statement of purpose
• Define roles of the co-managers
• Define expectations
• Define mechanism and time of communication
• Define specific services offered

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Thursday, October 15(Morning)

• Vascular Medicine
• Steven Deitelzweig
• Corey Goldman

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VTE Prophylaxis in the Hospital Interventions
for Improving Care

• Failure to institute prophylaxis is a much bigger
  problem with Medical Service patients than
  Surgical Service patients
• Most VTE occurred following hospital discharge.
• After discharge patients may not be receiving the
  recommendation duration of prophylaxis
  FDA-approved duration for appropriate prophylaxis
  is 6-11 days

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VTE Prophylaxis in the Hospital Interventions
for Improving Care

• Low Risk Early and aggressive ambulation
• Moderate Risk
• Pharmacologic Prophylaxis
• UFH 5000 Units q 8 hr (but problem with
  compliance)
• Dalteparin 5000 Units daily
• Enoxaparin 40 mg daily
• Fondaparinux 2.5 mg daily
• High Risk Pharmacologic Mechanical

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PVD Do you mean arterial insufficiency or venous
insufficiency

• Chronic Venous Insufficiency
• Stage I Edema
• Stage 2 Dermatitis, skin changes
• Stage 3 Venous ulcer
• Treatment Compression 20-60 mm Hg (TEDS only 15
  mm Hg). Venous ablation if compression failure

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PVD Do you mean arterial insufficiency or venous
insufficiency

• Pressure Ulcers
• Stage 1 Epidermis - erythema
• Stage 2 Epidermis opening/blisters
• Stage 3 Subcutaneous/fascia
• Stage 4 Fascia bone/tendon/muscle/cartilage
• Recognition and Prevention is key

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PVD Do you mean arterial insufficiency or venous
insufficiency

• Treatment
• Autolytic , Mechanical using gauzes, Sharps,
  Biosurgical
• Negative Pressure Therapy
• VAC Device for non healing wounds and fecal
  incontinence removes interstitial fluid from the
  wound

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Thursday, October 15(Afternoon)

• Pulmonary Critical Care
• David Taylor
• Leonardo Seoane
• Lorenzo DiFrancesco

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Selected Topics in ARDS

• Mortality
• Traditional 40-60
• Recent Studies 30
• Supportive Care
• Low tidal volume ventilation (6 mL/kg IBW)
• Diuresis/avoidance of volume overload
• Prevent ICU complications
• Give lungs time to recover

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Improving Sepsis Management

• Evidence-based Sepsis Bundles save lives
• IHI 6 hr bundle (sepsis recognition, early
  appropriate abx, EGDT) lactate, blood cx before
  abx, broad spectrum abx within 3 hr (7 increase
  mortality per every 1 hr delay), volume
  resuscitation, vasopressors, CVP gt 8, CVO2 gt 70
• IHI 24 hr bundle Low-dose steroid, Drotrecogin
  Alfa, glycemic control, inspiratory plateau
  pressure lt 30 mm Hg

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Healthcare Associated Pneumonia

• Pneumonia Spectrum
• Community-Acquired (CAP)
• Healthcare-Associated (HCAP)
• Hospital-Acquired (HAP)
• Ventilator-Associated (VAP)
• Pathophysiology Naso/oropharyngeal colonization,
  aspiration, host defense impairment
• Treatment
• Recognize HCAP
• MRSA and double coverage for GN

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Thursday, October 15(Afternoon)

• Infections Disease
• Sandy Kemmerly
• Julia Garcia-Diaz

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Emerging Hospital Infections

• Update on 2009 H1N1
• Teens and young adults disproportionately
  affected with fewer cases among elderly
• Treatment
• Hospitalized patients with suspected H1N1
• Higher risk for seasonal flu complications
• Clinical judgment necessary
• Chemoprophylaxis only reduces duration by 24 hr
• H1N1 Vaccine arriving currently

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New Developments in Infectious Diseases

• Worldwide caMRSA outbreak ongoing 8 are
  invasive and serious
• Emerging virulent strain of C. difficile. Ca-CDAD
  is common and can occur without abx exposure
• Flouroquinolone resistance in meningococcal
  diseases
• Maternal immunization with influenza vaccine
  reduces influenza illness in infants
• Increase awareness of PCN MIC breakpoint for S.
  pneumoniae needed to increase use of PCN vs other
  abx

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Wine Cheese ReceptionAbstract Competition
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Breakfast with the Expert
Richard Milani Robert Felberg
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Friday, October 16(Morning)

• Cardiology
• Richard Milani
• Sammy Khatib
• Hector Ventura

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Acute Coronary Syndrome

• Importance of Risk Stratification
• STEMI
• Invasive (angioplasty) better than conservative
  (fibrinolytic) unless Time (DB DN) gt 60 min
• UA/NSTEMI
• Low risk no difference
• Higher risk Invasive better

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Acute Coronary Syndrome

• UFH vs LMWH
• Low risk UFH
• Higher risk LMWH
• GPIIb/IIIa Inhibitors
• Low risk no benefit
• Higher risk benefit
• Aspirin NSAID
• Aspirin gt30 min before NSAID gt8 hr since last
  NSAID dose

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Acute Coronary Syndrome

• CABG Clopidrogrel
• 600 mg loading, 3-5 day washout period
• Reduced CV events
• Clopidogrel PPI
• Unclear data, stay tuned
• Bleeding Predictor Score
• crusadebleedingscore.org

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Common Arrythmia Management

• Atrial Fibrillation
• Decision for rate control vs rhythm control based
  on symptoms
• Continuous anticoagulation warranted regardless
  of treatment strategy
• Radiofrequency ablation best for paroxysmal vs
  persistent AF
• Atrial Flutter
• Isthmus-dependent high success rate with
  radiofrequency ablation can be off warfarin
• Non-isthmus-dependent ? DC warfarin

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Common Arrythmia Management

• SVT
• Radiofrequency ablation 93.2 success but 2.9
  adverse events
• Tx reassurance, medication (prn or daily) vs
  ablation
• Normal Heart VT
• Not malignant
• Same treatment options as SVT

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Update on Heart Failure Disease Management
Programs

• HF Core Measure
• ACE-I/ARB if EF lt 40
• EF evaluation
• DC Instructions (medication, activity, weight,
  diet, symptoms)
• Smoking cessation counseling

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Update on Heart Failure Disease Management
Programs

• Challenges to reduce readmission rate
• Best intervention so far with discharge planning
  through nurse and clinical pharmacist

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Friday, October 16(Morning)

• Gastroenterology
• Nigel Girgrah
• Nathaniel Winstead

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End Stage Liver Disease

• Variceal Bleeding
• 30-60 of newly diagnosed cirrhotics already have
  varices
• 30 cirrhotics will have a variceal bleed by 2
  yrs
• Hemorrhagic risk when hepatic venous gradient gt
  12 mm Hg
• Treatment
• Under-transfuse to keep Hgb/Hct 9/30
• Octreotide bridging to variceal ligation
• TIPS for failure, OLT bridging, gastric varices

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End Stage Liver Disease

• SBP
• Prevalence in cirrhotics with ascites in hospital
  10-30
• 1-Yr survival 30-50, 2-Yr 25-20
• Treatment 3rd-Generation cephalosporin
• IV albumin reduces renal impairment
• Antibiotic prophylaxis to all cirrhotics with
  UGIB with or without ascites
• Hepatic Encephalopathy Lactulose ? add
  antibiotics ? second line tx (sodium benzoate) ?
  Transplant Evaluation

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End Stage Liver Disease

• Hepatorenal Syndrome
• Type I (aggressive) mean survival lt 2 weeks if
  not treated almost all die within 8-10 wks post
  onset of renal failure
• Type II median survival of 6 months
• Treatment
• Midodrine Octreotide Albumin
• TIPS augmentation
• Prevention
• IV albumin in SBP
• Pentoxyfylline in alcoholic hepatitis

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Gastrointestinal Bleeding

• NG Lavage
• Not if melena or hematemesis
• Perhaps if BRBPR
• IV PPI prior to endoscopy
• IV Erythromycin decreases need for second
  look endoscopy
• Active bleeding limits the utility of
  biopsy-based H. pylori testing (order serology)
• Variceal bleeding patients probably do not
  benefit from PPI after etiology discovered

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Friday, October 16(Afternoon)

• Breakout Session I
• Quality and Practice Management
• Samantha Collier
• Renee Meadows
• Alan Wang
• Jason Stein

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Quality Markers

• Measurement Improvement
• Hospital performance measures predict small
  differences in hospital risk-adjusted mortality
  rates. Efforts should be made to develop
  performance measures that are tightly linked to
  patient outcomes.
• Align measure with strategy
• More is not better
• Change must be compelling, transparent readily
  available

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LEAN

• Without change there is no innovation, creativity
  or incentive for improvement
• LEAN Culture
• Interdisciplinary teams
• High performance, absence of waste
• Root cause analysis
• Share information transparency
• Customer focus process driven

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Leadership in Hospital Medicine

• Ideal Leader visionary, integrity, motivating,
  inspiring, communicating
• Great performers are not necessary leaders
• Leading begins with knowing and self-evaluation
• Collaborative partnership essential
• Faculty development, mentoring and team building
  essential for program growth

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Quality, Frontline and Health IT

• Hospital Medicine is team work
• Team play requires standardization
• Wide variability is hallmark of poor quality
• Predictability reduces error
• Let the good medical evidence be automatic so
  doctors can concentrate on the rest
• Mediocrity Wide variability in practice, Weak
  teamwork, Meaningless data, Short-sighted
  solutions (not transferable /scalable
  /reliable/durable)
• Meaningful changes through incremental quality
  improvement small projects, morale building,
  vision reinforcement and 100 participation

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Friday, October 16(Afternoon)

• Breakout Session II
• Pharmacological Management
• Marianne Billeter
• Deborah Simonson
• Nicole Fabre-LaCoste

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Managing Adverse Drug Events

• Adults gt 65 years
• 12.5 of US population
• 30 of US health care expenditure
• 25 of US drug expenditures
• 3 billion annually
• 61 taking at least 1 medication
• 60 of physician visit result in a prescription
• Poly-pharmacy in 25
• Often adverse drug events and reactions go
  unnoticed

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Antifungal Update

• Fungal infection 7th leading cause of death among
  infectious diseases
• Candida is the 4th leading cause of nosocomial
  bloodstream infections
• Increasing expense of antifungal therapy

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Managing Adverse Drug Events

• Adults gt 65 years
• 12.5 of US population
• 30 of US health care expenditure
• 25 of US drug expenditures
• 3 billion annually
• 61 taking at least 1 medication
• 60 of physician visit result in a prescription
• Poly-pharmacy in 25
• Often adverse drug events and reactions go
  unnoticed

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Drug Dosing in Obese Patients

• Loading dose (LD) is based on Volume of
  distribution (Vd)
• If drug distribution restricted to lean tissues,
  LD is based on IBW
• If drug distribution to lean tissues and partly
  fatty tissues, LD is based on IBW a percentage
  of IBW
• If drug distribution evenly to lean and fat
  tissues, LD is based on TBW

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Friday, October 16(Afternoon)

• Breakout Session III
• Clinical Cases
• Suma Jain
• Ronald Amedee
• William Davis
• Catherine Staffeld-Coit

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Clinical Cases

• Critical Care Medicine

• Propofol Infusion Syndrome
• Parapneumonic Effusion Management
• Thrombolytics in VTE

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Clinical Cases

• Rheumatology

• Septic Arthritis
• Gout in Cardiovascular Disease
• Complex Regional Pain Syndrome
• Anti-TNF Agents
• Idiopathic Inflammatory Myopathies

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Clinical Cases

• Dialysis and CKD

• Staging of CKD
• Overview of Dialysis Therapy
• Complications of Renal Failure
• Intradialytic hypotension
• Malnutrition
• GI Bleed
• Nephrogenic Systemic Fibrosis
• Secondary Hyperparathyroidism

• Neuropathy
• CVD
• Infection
• Acquired Cystic Disease

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Linking Outcomes to Care to the ACGME Competencies

• Matrix of STEEPE X Competencies
• Patient Care
• Medical Knowledge
• Interpersonal and Communication Skills
• Professionalism
• System Based Practice
• Practice-Based Learning and Improving

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Saturday, October 17(Morning)

• Perioperative Medicine
• Hospital Medicine Update 2009
• Amir Jaffer
• Dan Dressler

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Perioperative Medicine

• Perioperative Risk Patient, Procedure,
  Anesthesia Surgeon
• JACC/AHA Guidelines
• Perioperative risk with lt 4 MET Workload
• Non-Invasive Preoperative Cardiac Testing?
• High NPV, Low PPV
• Consider only if it will change management
• CARP No difference for revascularization
  strategy (LM disease and severe AS excluded)

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Perioperative Medicine

• POISE Reduced 1st,, Increased 2nd events,
  Increased hypotension and bradycardia high dose
  problem?
• DECREASE IV slow dosing, improved outcomes
• ß-Blockers
• Continued for patients already on them
• Should be used with CAD with ischemia
• Maybe used with clinical risk factors
• Initial days to weeks before elective surgery if
  possible
• Titrate HR to 60-56
• Long-acting form preferred
• Consider Statin in Vascular Surgery patients

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Perioperative Medicine

• Antiplatelet Therapy and Non-Cardiac Surgery
• BMS (Bare Metal Stent) or balloon angioplasty if
  patients need surgery within 12 months
• Postpone elective procedures until 1 month post
  BMS or 12 months post DES (Drug-Eluting Stent)
• DES patients should be continued on ASA if at all
  possible perioperatively for urgent situations
  with restart of thienopyridine ASAP post
  procedure

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Hospital Medicine Update 2009
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Check-Out List

• CME Certificate
• Complete verification form and turn in at
  registration table
• Certificate will be mailed in 2 weeks
• Evaluation
• Final Lunch Symposium

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• 11th Annual Southern Hospital Medicine Conference
  
• Loews Hotel - Atlanta, Georgia October 20 23,
  2010

For additional details, please email inquires to
hospital.medicine_at_emoryhealthcare.org or call
404.778.5334.