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
Cautions
The study had a small sample size, was limited to English-speaking patients, and was a single-site study. It involved only attending-level physicians and did not involve nonphysician team members. The physicians were not blinded and were aware that the interactions were monitored, perhaps creating a Hawthorne effect. The analysis did not control for other factors such as the severity of the illness, the number of consultants used, or the degree of health literacy.
Implications
This study supports an important best practice highlighted in etiquette-based medicine 10: sitting at the bedside provided a benefit in the patient’s perception of communication by physicians without a negative effect on the physician’s workflow.
The Duration of Antibiotic Treatment in Community-Acquired Pneumonia: A Multi-Center Randomized Clinical Trial. Uranga A et al. JAMA Intern Medicine, 2016;176(9):1257-65.11
Background
The optimal duration of treatment for community-acquired pneumonia (CAP) is unclear; a growing body of evidence suggests shorter and longer durations may be equivalent.
Findings
At 4 hospitals in Spain, 312 adults with a mean age of 65 years and a diagnosis of CAP (non-ICU) were randomized to a short (5 days) versus a long (provider discretion) course of antibiotics. In the short-course group, the antibiotics were stopped after 5 days if the body temperature had been 37.8o C or less for 48 hours, and no more than 1 sign of clinical instability was present (SBP < 90 mmHg, HR >100/min, RR > 24/min, O2Sat < 90%). The median number of antibiotic days was 5 for the short-course group and 10 for the long-course group (P < .01). There was no difference in the resolution of pneumonia symptoms at 10 days or 30 days or in 30-day mortality. There were no differences in in-hospital side effects. However, 30-day readmissions were higher in the long-course group compared with the short-course group (6.6% vs 1.4%; P = .02). The results were similar across all of the Pneumonia Severity Index (PSI) classes.
Cautions
Most of the patients were not severely ill (~60% PSI I-III), the level of comorbid disease was low, and nearly 80% of the patients received fluoroquinolone. There was a significant cross over with 30% of patients assigned to the short-course group receiving antibiotics for more than 5 days.
Implications
Inpatient providers should aim to treat patients with community-acquired pneumonia (regardless of the severity of the illness) for 5 days. At day 5, if the patient is afebrile and has no signs of clinical instability, clinicians should be comfortable stopping antibiotics.
Is the Era of Intravenous Proton Pump Inhibitors Coming to an End in Patients with Bleeding Peptic Ulcers? A Meta-Analysis of the Published Literature. Jian Z et al. British Journal of Clinical Pharmacology, 2016;82(3):880-9.12
Background
Guidelines recommend intravenous proton pump inhibitors (PPI) after an endoscopy for patients with a bleeding peptic ulcer. Yet, acid suppression with oral PPI is deemed equivalent to the intravenous route.
Findings
This systematic review and meta-analysis identified 7 randomized controlled trials involving 859 patients. After an endoscopy, the patients were randomized to receive either oral or intravenous PPI. Most of the patients had “high-risk” peptic ulcers (active bleeding, a visible vessel, an adherent clot). The PPI dose and frequency varied between the studies. Re-bleeding rates were no different between the oral and intravenous route at 72 hours (2.4% vs 5.1%; P = .26), 7 days (5.6% vs 6.8%; P =.68), or 30 days (7.9% vs 8.8%; P = .62). There was also no difference in 30-day mortality (2.1% vs 2.4%; P = .88), and the length of stay was the same in both groups. Side effects were not reported.
Cautions
This systematic review and meta-analysis included multiple heterogeneous small studies of moderate quality. A large number of patients were excluded, increasing the risk of a selection bias.
Implications
There is no clear indication for intravenous PPI in the treatment of bleeding peptic ulcers following an endoscopy. Converting to oral PPI is equivalent to intravenous and is a safe, effective, and cost-saving option for patients with bleeding peptic ulcers.
