Update in Hospital Medicine: Practical Lessons from the Literature
BACKGROUND: Hospital Medicine has a widening scope of practice. This article provides a summary of recent high-impact publications for busy clinicians who provide care to hospitalized adults.
METHODS: The authors reviewed articles published between March 2016 and March 2017 for the Update in Hospital Medicine presentations at the 2017 Society of Hospital Medicine and Society of General Internal Medicine annual meetings. Nine of the 20 articles presented were selected for this review based on the article quality and potential to influence practice.
RESULTS: The key insights gained include: pulmonary embolism may be a more common cause of syncope and acute exacerbation of COPD than previously recognized; nonthoracic low-tesla MRI is safe following a specific protocol for patients with cardiac devices implanted after 2001; routine inpatient blood cultures for fever are of a low yield with a false positive rate similar to the true positive rate; chronic opioid use after surgery occurs more frequently than in the general population; high-sensitivity troponin and a negative ECG performed 3 hours after an episode of chest pain can rule out acute myocardial infarction; sitting at patients’ bedsides enhances patients’ perception of provider communication; 5 days of antibiotics for community-acquired pneumonia is equivalent to longer courses; oral proton pump inhibitors (PPI) are as effective as IV PPIs after an esophagogastroduodenoscopy (EGD) for the treatment of bleeding peptic ulcers.
CONCLUSIONS: Recent research provides insight into how we approach common medical problems in the care of hospitalized adults. These articles have the potential to change or confirm current practices.
© 2018 Society of Hospital Medicine
Findings
The authors prospectively followed up 1500 adults with cardiac devices placed since 2001 who received nonthoracic MRIs according to a specific protocol available in the supplemental materials published with this article in the New England Journal of Medicine. Of the 1000 patients with pacemakers only, they observed 5 atrial arrhythmias and 6 electrical resets. Of the 500 patients with implantable cardioverter defibrillators (ICDs), they observed 1 atrial arrhythmia and 1 generator failure (although this case had deviated from the protocol). All of the atrial arrhythmias were self-terminating. No deaths, lead failure requiring an immediate replacement, a loss of capture, or ventricular arrhythmias were observed.
Cautions
Patients who were pacing dependent were excluded. No devices implanted before 2001 were included in the study, and the MRIs performed were only 1.5 Tesla (a lower field strength than the also available 3 Tesla MRIs).
Implications
It is safe to proceed with 1.5 Tesla nonthoracic MRIs in patients, following the protocol outlined in this article, with non–MRI conditional cardiac devices implanted since 2001.
Culture If Spikes? Indications and Yield of Blood Cultures in Hospitalized Medical Patients. Linsenmeyer K et al. Journal of Hospital Medicine, 2016;11(5):336-40.3
Background
Blood cultures are frequently drawn for the evaluation of an inpatient fever. This “culture if spikes” approach may lead to unnecessary testing and false positive results. In this study, the authors evaluated rates of true positive and false positive blood cultures in the setting of an inpatient fever.
Findings
The patients hospitalized on the general medicine or cardiology floors at a Veterans Affairs teaching hospital were prospectively followed over 7 months. A total of 576 blood cultures were ordered among 323 unique patients. The patients were older (average age of 70 years) and predominantly male (94%). The true-positive rate for cultures, determined by a consensus among the microbiology and infectious disease departments based on a review of clinical and laboratory data, was 3.6% compared with a false-positive rate of 2.3%. The clinical characteristics associated with a higher likelihood of a true positive included: the indication for a culture as a follow-up from a previous culture (likelihood ratio [LR] 3.4), a working diagnosis of bacteremia or endocarditis (LR 3.7), and the constellation of fever and leukocytosis in a patient who has not been on antibiotics (LR 5.6).
Cautions
This study was performed at a single center with patients in the medicine and cardiology services, and thus, the data is representative of clinical practice patterns specific to that site.
Implications
Reflexive ordering of blood cultures for inpatient fever is of a low yield with a false-positive rate that approximates the true positive rate. A large number of patients are tested unnecessarily, and for those with positive tests, physicians are as likely to be misled as they are certain to truly identify a pathogen. The positive predictive value of blood cultures is improved when drawn on patients who are not on antibiotics and when the patient has a specific diagnosis, such as pneumonia, previous bacteremia, or suspected endocarditis.
Incidence of and Risk Factors for Chronic Opioid Use among Opioid-Naive Patients in the Postoperative Period. Sun EC et al. JAMA Internal Medicine, 2016;176(9):1286-93.4
Background
Each day in the United States, 650,000 opioid prescriptions are filled, and 78 people suffer an opiate-related death. Opioids are frequently prescribed for inpatient management of postoperative pain. In this study, authors compared the development of chronic opioid use between patients who had undergone surgery and those who had not.
Findings
This was a retrospective analysis of a nationwide insurance claims database. A total of 641,941 opioid-naive patients underwent 1 of 11 designated surgeries in the study period and were compared with 18,011,137 opioid-naive patients who did not undergo surgery. Chronic opioid use was defined as the filling of 10 or more prescriptions or receiving more than a 120-day supply between 90 and 365 days postoperatively (or following the assigned faux surgical date in those not having surgery). This was observed in a small proportion of the surgical patients (less than 0.5%). However, several procedures were associated with the increased odds of postoperative chronic opioid use, including a simple mastectomy (Odds ratio [OR] 2.65), a cesarean delivery (OR 1.28), an open appendectomy (OR 1.69), an open and laparoscopic cholecystectomy (ORs 3.60 and 1.62, respectively), and a total hip and total knee arthroplasty (ORs 2.52 and 5.10, respectively). Also, male sex, age greater than 50 years, preoperative benzodiazepines or antidepressants, and a history of drug abuse were associated with increased odds.
Cautions
This study was limited by the claims-based data and that the nonsurgical population was inherently different from the surgical population in ways that could lead to confounding.
