Superbug threat lurks in sewer

The threat of antibiotic resistance is attributed mainly to the overprescribing and overuse of antibiotics, but a new study explores a new, often-overlooked, danger: sewage sludge.

The study, by the Swedish National Veterinary Institute and the Finnish Food Safety Authority and published in the journal Acta Veterinaria Scandinavica, analyzes vancomycin-resistant enterococci (VRE) found in sewage sludge from a waste-water treatment plan. Researchers performed the unenviable task of collecting sludge from the plant weekly for four months and found that 79% of the 77 samples tested positive for drug-resistant superbugs. The danger, the researchers noted, is that VRE may pass on resistant genes to other bacteria.

Since sewage sludge is often used as fertilizer, its use threatens to spread antimicrobial resistance throughout the animal and human food chains, researchers warned. More efficient hygienic treatment of sewage sludge, they concluded, must become another weapon in the public health arsenal against superbugs.

Labels: drug resistance, superbugs

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posted by Janet Colwell at 8:00 AM   0 Comments

Watch out, bad doctors.

The interest group Public Citizen is launching a new campaign to get hospitals to step up their reporting of physician wrongdoing. Under a federal law, hospitals are required to submit to a database the names of any physicians who have lost their admitting privileges for more than 30 days. However the database has gotten very few reports; more than half of hospitals have never submitted a single name.

So either physicians have been being very, very good, or the hospitals are covering up their wrongdoing. Public Citizen suspects the latter and is urging the Obama administration to crack down on the failure to report. Doc are also on the hook: the organization's press release specifically calls them out for "lax peer review, including a culture among doctors of not wanting to 'snitch' on a colleague."

That's right; snitching isn't just for elementary schoolers and TV characters anymore. Let's hope that the next steps don't involve hair-pulling or cootie-catching.

Labels: quality reporting

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posted by Stacey Butterfield at 1:54 PM   0 Comments

Hospitals becoming more like hotels - part II

Add NYU Langone Medical Center to the list of facilities creating a better class of hospital room. It debuts The Critical Care Center, an intensive care unit in Tisch Hospital that promises plenty of extras thrown in with medical care.

As previously reported, hospitals are adding creature comforts to their wards.

Tisch Hospital promises the ward will include 18 ICU beds; all but one will be private. Each will have a large window view of New York City, brand new equipment, flat-screen televisions and more elbow room. It will also have its own 24/7 intensivist physicians with advanced critical care board certification.

Other features include computerized charting, multi-patient video surveillance technology and patient simulator technology. Another 17 beds will be built this summer.

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posted by Ryan DuBosar at 11:50 AM   1 Comments

The crossroads between care and documentation

At an afternoon Hospital Medicine session today, Bryce Gartland, MD, of Emory University offered hospitalists practical advice on improving their clinical documentation. He first provided a brief review of the 2008 change from CMS-DRGs to Medicare Severity DRGs (MS-DRGs). Under the new system, diagnoses are now classified as being with or without complications/comorbidities (CCs) or major complications/comorbidities (MCCs). Nonspecific codes can cost a facility money: The reimbursement for heart failure and shock with MCC is $8,218 versus $3,959 for heart failure without CC or MCC.

"Documentation of this has astonishing financial impact for hospitals," Dr. Gartland said. He offered the following tips to optimize documentation:

1. Be specific. "If you're not specific, it usually doesn't correspond with a specific code with an ICD-9."
2. Emphasize acute diseases and chronic diseases with acute exacerbations, those that are end-stage or those with extensive disability. "For those who like acronyms, we've come up with ACE3," he said.
3. Remember that "In coding world, the words 'possible,' 'probable,' 'likely,' and 'suspected' all count."
4. Don't forget the small stuff, such as electrolytes and nutrition status.

Accurate coding is linked to quality, Dr. Gartland said, because failing to accurately document comorbidities or complications makes the risk for death look lower than expected. Accurate and complete documentation, on the other hand, helps align expected and accurate mortality.

"Clinical language does not equal coding language," Dr. Gartland said. "We have to retrain our brains to understand that we actually have to document not only to convey knowledge from one care team member to another but also to make sure that coding understands specifically what we're doing."

Labels: billing and coding, Hospital Medicine 2009

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posted by Jennifer Kearney-Strouse at 6:55 PM   0 Comments

Managing the pregnant patient

When speaker Anna Kho, MD, asked the audience today how many people had done a consult on a pregnant patient, nearly every hand in the room shot up. Yet only about 1/4 of people kept their hands raised when asked if they'd had any training for such consults.

Dr. Kho made quick work of correcting that, by outlining the symptoms and treatment for the four main conditions pregnant women present with: asthma, hypertension, VTE and diabetes. Following are some key points from her lecture:

• When considering drug therapy, think about whether lifestyle changes can be recommended, and whether there's a similar drug that's safer. Avoid new medications, think twice when prescribing medication in the first trimester, and never use a drug without an indication.
• You don't need to treat chronic hypertension until the diastolic blood pressure goes above 105. The evidence shows no added benefit to mother or child for treating when DBP is below this mark. Methyldopa is the drug of choice for hypertension; avoid ACE inhibitors and ARBS, because they can lead to renal agenesis and fetal demise.
• Treat asthma the same way you would in a non-pregnant patient. Avoid epinephrine. It's fine to order radiologic studies when needed, as long as the cumulative exposure during pregnancy is less than 5 rads. A single dose of iodine is unlikely to be harmful.
• Pregnant women are at higher risk of VTEs; it's the leading cause of non-OB maternal mortality in the U.S. The rate is pretty much the same in all three trimesters. To diagnose, look for unilateral leg edema and pain, and note that 90% of DVTs occur on the left side in pregnant women.
• Treatment for DVTs in pregnant women should be unfractionated heparain, and low molecular weight heparin. Avoid warfarin due to extreme teratogenicity.
• Oral hypoglycemics should almost never be used with pregnant patients with diabetes. Insulin is pretty much the only treatment.

Labels: Hospital Medicine 2009, pregnancy

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posted by Jessica Berthold at 5:23 PM   0 Comments

Sessions on aortic aneurysm, pandemics, and practice finances

Here are some quick hits from today's Hospital Medicine sessions:

A clinical standout on Friday was Kim Eagle, MD, who gave an excellent lecture on aortic aneurysms. Attendees learned who's really at risk for aortic aneurysm, the signs and symptoms, and the best methods of follow-up, among other topics. See next week's issue of ACP HospitalistWeekly for more on this session.

Erin Egan, MD, JD, gave a timely lecture on the legal and ethical issues surrounding pandemics. She argued that the U.S. hasn't done enough to create a true public discourse on the ethics involved in triaging and rationing care. Unless these things are discussed ahead of time, she said, uncontrolled discrimination is likely.

Finally, an afternoon session by Scott Enderby, DO, aimed to untangle the complexities of practice finances for hospitalists who may feel a little over their heads in this area. He walked attendees through the definitions of some basic financial terms and taught them how to read and understand financial statements. Dr. Enderby stressed that the biggest expense for hospitalist practices is the physician workforce, and noted that practice leaders should make sure that this resource is utilized appropriately.

Labels: Hospital Medicine 2009

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posted by Jennifer Kearney-Strouse at 11:30 PM   0 Comments

The heartache of heart failure

Heart failure is already the #1 reason people over age 65 years old are hospitalized. What with the Baby Boomers getting older, and the transition of ACS from a life-threatening problem to a more chronic disease, it will soon become "something hospitalists deal with on a daily basis," said John B. O'Connell, MD, at the annual SHM conference in Chicago today.
(O'Connell is executive director of the heart failure program at St. Joseph Heart and Vascular Institute in Atlanta.)

Here's the scary part: By the time a person's heart failure is bad enough to warrant admission to the hospital, his or her chances aren't so great. The post-discharge event rate--ie, either readmission or death-- for Acute Heart Failure Syndromes is a whopping 35% at 60 days.

Also scary is the fact that there isn't a great deal of solid evidence on how to treat heart failure. Rather than being mostly "evidence-based", or level A evidence, a whopping 86% of HFSA Guidelines are level C-- ie, based on expert opinion. "Instead of 'evidence-based medicine', it's 'eminence-based', Dr. O'Connell quipped. "The fact is, we are all flying by the seat of our pants."

Rather than adding yet another drug to the regimen of treatment for HF, Dr. O'Connell thinks the future lies in a genetic, molecular and cellular approach to therapy. As well, devices will become more sophisticated such that they will go beyond pacing and defibrillating, to sending meaningful information back to the doctor and perhaps instituting treatment automatically.

Labels: heart failure, Hospital Medicine 2009

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posted by Jessica Berthold at 7:53 PM   0 Comments

Housing for the chronically ill homeless

Last week, JAMA published a study on a housing and case management program aimed at reducing ED visits and hospital stays in the chronically ill homeless. Researchers in Chicago randomly assigned 407 homeless adults with ailments like diabetes and congestive heart failure to the intervention group, which received additional support after hospital discharge, or the usual care group, which received standard discharge planning. Patients in the intervention group were offered postdischarge case management and help finding long-term housing. Over 18 months, intervention group patients were less likely to return to the hospital for care, with a relative reduction of 29% in hospitalizations (95% CI, 10% to 44%) and 24% in emergency department visits (95% CI, 3% to 40%).

The study findings are encouraging, but at the same time it's hard to avoid wondering how these kinds of interventions would work on a larger or longer-term scale. The title of the accompanying editorial says it all: "Housing the chronically homeless: High hopes, complex realities". The real challenge, the editorialists write, is determining which subgroups are most likely to benefit.

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posted by Jennifer Kearney-Strouse at 3:06 PM   0 Comments

Playing tag in the ED

The emergency department staff at Beth Israel Deaconess Medical Center in Boston are trying a novel way to improve compliance with measures like hand hygiene: They're playing tag. As CEO Paul Levy explains on his blog, a doc or nurse who doesn't wash his hands after a patient encounter or who violates any other patient safety rules can be "tagged" by a coworker. "Tag Joe is it" is displayed at the top of computer monitors throughout the hospital until Joe tags someone new. Richard Wolfe, chair of the ED, told HealthLeaders Media that the staff is enjoying the game, which carries no punishment but does give an award each month to the person who tags the most folks. Of course, it's anyone's guess whether there will be any lasting benefit, but in the meantime it sounds fun, easy, and definitely worth a try.

Labels: patient safety

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posted by Jennifer Kearney-Strouse at 3:43 PM   0 Comments