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
Implications
In perioperative care, there is a need to focus on multimodal approaches to pain and to implement opioid reducing and sparing strategies that might include options such as acetaminophen, NSAIDs, neuropathic pain medications, and Lidocaine patches. Moreover, at discharge, careful consideration should be given to the quantity and duration of the postoperative opioids.
Rapid Rule-out of Acute Myocardial Infarction with a Single High-Sensitivity Cardiac Troponin T Measurement below the Limit of Detection: A Collaborative Meta-Analysis. Pickering JW et al. Annals of Internal Medicine, 2017;166:715-24.5
Background
High-sensitivity cardiac troponin testing (hs-cTnT) is now available in the United States. Studies have found that these can play a significant role in a rapid rule-out of acute myocardial infarction (AMI).
Findings
In this meta-analysis, the authors identified 11 studies with 9241 participants that prospectively evaluated patients presenting to the emergency department (ED) with chest pain, underwent an ECG, and had hs-cTnT drawn. A total of 30% of the patients were classified as low risk with negative hs-cTnT and negative ECG (defined as no ST changes or T-wave inversions indicative of ischemia). Among the low risk patients, only 14 of the 2825 (0.5%) had AMI according to the Global Task Forces definition.6 Seven of these were in patients with hs-cTnT drawn within 3 hours of a chest pain onset. The pooled negative predictive value was 99.0% (CI 93.8%–99.8%).
Cautions
The heterogeneity between the studies in this meta-analysis, especially in the exclusion criteria, warrants careful consideration when being implemented in new settings. A more sensitive test will result in more positive troponins due to different limits of detection. Thus, medical teams and institutions need to plan accordingly. Caution should be taken for any patient presenting within 3 hours of a chest pain onset.
Implications
Rapid rule-out protocols—which include clinical evaluation, a negative ECG, and a negative high-sensitivity cardiac troponin—identify a large proportion of low-risk patients who are unlikely to have a true AMI.
Prevalence and Localization of Pulmonary Embolism in Unexplained Acute Exacerbations of COPD: A Systematic Review and Meta-analysis. Aleva FE et al. Chest, 2017;151(3):544-54.7
Background
Acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) are frequent. In up to 30%, no clear trigger is found. Previous studies suggested that 1 in 4 of these patients may have a pulmonary embolus (PE).7 This study reviewed the literature and meta-data to describe the prevalence, the embolism location, and the clinical predictors of PE among patients with unexplained AE-COPD.
Findings
A systematic review of the literature and meta-analysis identified 7 studies with 880 patients. In the pooled analysis, 16% had PE (range: 3%–29%). Of the 120 patients with PE, two-thirds were in lobar or larger arteries and one-third in segmental or smaller. Pleuritic chest pain and signs of cardiac compromise (hypotension, syncope, and right-sided heart failure) were associated with PE.
Cautions
This study was heterogeneous leading to a broad confidence interval for prevalence ranging from 8%–25%. Given the frequency of AE-COPD with no identified trigger, physicians need to attend to risks of repeat radiation exposure when considering an evaluation for PE.
Implications
One in 6 patients with unexplained AE-COPD was found to have PE; the odds were greater in those with pleuritic chest pain or signs of cardiac compromise. In patients with AE-COPD with an unclear trigger, the providers should consider an evaluation for PE by using a clinical prediction rule and/or a D-dimer.
Sitting at Patients’ Bedsides May Improve Patients’ Perceptions of Physician Communication Skills. Merel SE et al. Journal of Hospital Medicine, 2016;11(12):865-8.9
Background
Sitting at a patient’s bedside in the inpatient setting is considered a best practice, yet it has not been widely adopted. The authors conducted a cluster-randomized trial of physicians on a single 28-bed hospitalist only run unit where physicians were assigned to sitting or standing for the first 3 days of a 7-day workweek assignment. New admissions or transfers to the unit were considered eligible for the study.
Findings
Sixteen hospitalists saw on an average 13 patients daily during the study (a total of 159 patients were included in the analysis after 52 patients were excluded or declined to participate). The hospitalists were 69% female, and 81% had been in practice 3 years or less. The average time spent in the patient’s room was 12:00 minutes while seated and 12:10 minutes while standing. There was no difference in the patients’ perception of the amount of time spent—the patients overestimated this by 4 minutes in both groups. Sitting was associated with higher ratings for “listening carefully” and “explaining things in a way that was easy to understand.” There was no difference in ratings on the physicians interrupting the patient when talking or in treating patients with courtesy and respect.
