Annals for Hospitalists - 16 May 2017
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2017)

Web Exclusives16 May 2017Annals for Hospitalists - 16 May 2017FREEDavid H. Wesorick, MD* and Vineet Chopra, MD, MSc*David H. Wesorick, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Search for more papers by this author and Vineet Chopra, MD, MSc*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFHO201705160 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesAnnals for Hospitalists Inpatient Notes - Predicting Codes–A Future With Fewer In-Hospital Cardiac Arrestsby Dana P. Edelson, MD, MS, and Matthew M. Churpek, MD, MPH, PhDA large proportion of in-hospital cardiac arrests are predictable and possibly preventable. The authors of this month's commentary explain how the electronic health record of the future may help clinicians not only recognize the earliest signs of clinical deterioration but also institute appropriate interventions to halt progression to a code.Highlights of Recent Articles From Annals of Internal MedicineAssociation Between a Virtual Glucose Management Service and Glycemic Control in Hospitalized Adult Patients: An Observational StudyAnn Intern Med. 2017;166:621-627. Published 28 March 2017. doi:10.7326/M16-1413This observational study examined the association between a virtual glucose management service and glycemic control in hospitalized patients. The service utilized an automated surveillance system to identify hospital patients with poor glycemic control. Diabetes experts then reviewed charts and wrote management recommendations in a note in the electronic health record. There was no direct contact between the experts and the patients (e.g., interview or physical examination) or the primary providers (e.g., pages or telephone calls). Inpatient glycemic control was significantly better during the period when notes were provided than before the intervention (4.0 vs. 6.6 hyperglycemic days per 100 patient-days).Key points for hospitalists include:This study shows that the provision of unsolicited management recommendations by a virtual consultant leads to measurable improvements in glycemic control when applied to certain hospitalized patients.The wide use of a dedicated inpatient glycemic management consultation service can be labor-intensive and costly. However, the virtual intervention in this study was efficient, requiring only 20 to 40 minutes of expert time each day. An editorial notes that this virtual approach is sure to lack some of the benefits of a full bedside consultation and suggests that a hybrid approach, including both virtual and bedside elements of consultation, should be investigated in the future. Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized TrialAnn Intern Med. 2017;166:689-697. Published 25 April 2017. doi:10.7326/M16-1600This randomized trial used a prospective, stepped-wedge, cluster design to assess the effect of calculating the HEART (History, EKG, Age, Risk factors, and initial Troponin) score in 3648 patients with chest pain at 9 hospitals in the Netherlands. The HEART score was formally calculated for patients in the study group, and management recommendations were provided based on the score (e.g., reassurance and discharge, admission, prompt invasive treatment). The major adverse cardiac event (MACE) rate at 6 weeks follow-up for HEART score patients was noninferior to usual care patients, and the score characterized 39% of patients as low risk. Hospital discharge was recommended for low-risk patients who had a 2% incidence of MACE.Key points for hospitalists include:The HEART score may provide a reliable method to risk stratify patients presenting with chest pain and allow for a significant subset of low-risk patients to be reassured and discharged.In this study, use of the HEART score did not result in significant improvements in resource utilization. One possible explanation is the fact that providers did not adhere to the recommendations generated by the score in 41% of low-risk patients. Rather, many of these patients were admitted to the hospital or received additional testing despite recommendations to the contrary.Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection: A Collaborative Meta-analysisAnn Intern Med. 2017;166:715-724. Published 18 April 2017. doi:10.7326/M16-2562This meta-analysis examined data from 9269 patients presenting with chest pain to determine the sensitivity of a single high-sensitivity troponin T (hs-cTnT) measurement below the level of detection, paired with a nonischemic electrocardiogram, in ruling-out myocardial infarction (MI). The pooled estimated sensitivity for MI with this approach was 98.7% (95% CI, 96.6 to 99.5).Key points for hospitalists include:Although the rapid rule-out strategy was quite sensitive for MI in this meta-analysis, the authors recommend using careful local audits to ensure safety if implementing this strategy.Some of the cohorts included in this meta-analysis demonstrated a significantly lower sensitivity for MI with this approach, indicating that this strategy may not be universally safe. Also, the minimal duration of symptoms sufficient to cause an elevation of hs-cTnT is not certain, so it is possible that patients with MI presenting very early after the onset of symptoms may not be detected with this approach.An editorial notes that although this testing strategy holds promise for rapidly ruling out MI in some patients, it lacks specificity and will need to be combined with other testing to identify patients who do need treatment. The Latest Highlights From ACP Journal ClubAre α-blockers effective treatment for ureteral stones?Review: In patients with ureteric lithiasis, α-blockers increase stone expulsionAnn Intern Med. 2017;166:JC42. doi:10.7326/ACPJC-2017-166-8-042This meta-analysis of 67 randomized controlled trials (including 6654 patients) demonstrated that patients treated with α-blocker medications passed their ureteral stones about 4 days sooner than patients treated with placebo or usual care. Unfortunately, this study did not examine if this effect was ultimately associated with fewer urinary procedures.Which upper GI bleeding risk score best predicts death or need for intervention?Glasgow Blatchford score predicted intervention or death better than 4 other prediction models in upper GI bleedingAnn Intern Med. 2017;166:JC47. doi:10.7326/ACPJC-2017-166-8-047This prospective, international cohort study compared the predictive value of several existing risk scores (Glasgow Blatchford [GBS], admission Rockall, AIMS65, full Rockall, and Progetto Nazionale Emorragia Digestiva scores) in 3012 patients who presented with upper gastrointestinal bleeding. The GBS performed best with an area under the receiver-operating characteristic curve of 0.89 for the outcomes of death or need for intervention (defined as red cell transfusion, endoscopy, interventional radiology, or surgery). In this study, almost 1 of 5 patients received a low-risk GBS of ≤1 with a sensitivity of 98.6% for identifying patients who would survive and not require an intervention.Does adding an inhaled anticholinergic to β2-agonist therapy reduce admissions in asthma emergencies?Review: Adding anticholinergics to β2-agonists for asthma exacerbations reduces hospitalizationsAnn Intern Med. 2017;166:JC45. doi:10.7326/ACPJC-2017-166-8-045This meta-analysis of 23 randomized controlled trials included 2724 patients who presented to the emergency department with an asthma exacerbation. Patients treated with a combination of an inhaled β2-agonist (albuterol in 19 trials) and an inhaled anticholinergic (ipratropium in 19 trials) had a lower hospital admission rate than patients treated with only a β2-agonist (relative risk reduction, 28% [95% CI, 13 to 41]).Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Disclosures:Drs. Wesorick and Chopra have disclosed no conflicts of interest. The forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.* The authors are co-first authors and contributed equally to the article. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Predicting Codes—A Future With Fewer In-Hospital Cardiac Arrests Dana P. Edelson and Matthew M. Churpek Metrics 16 May 2017Volume 166, Issue 10Page: HO10KeywordsElectronic medical recordsForecastingHeartHeart rateHemorrhageHospitalistsInpatientsIschemiaLongitudinal studiesPatients ePublished: 16 May 2017 Issue Published: 16 May 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. 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