American College of Physicians: Internal Medicine — Doctors for Adults ®

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Wednesday, July 30, 2014

Colonized patients (but not infected patients) contaminate the hospital environment

There is a continuous debate in infection control about whether to actively screen patients for multidrug resistant organisms (MDRO) colonization and subsequent isolation. Alternatives to active screening include passive surveillance, where only patients found to be infected through clinical cultures are isolated. Frequently, passive surveillance is justified by saying that infected patients will have a higher bio-burden compared to colonized patients, so they would be more likely to contaminate healthcare workers hands and the environment. However, is this in fact true? Are infected patients more likely to contaminate their rooms than colonized patients?

In part to answer this question, Lauren Knelson and colleagues from Duke and the University of North Carolina just published a study in the July Infection Control and Hospital epidemiology that measured the contamination of rooms after patients colonized or infected with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) were discharged. 48 rooms (33 from colonized patients, 15 from infected patients) were sampled using Rodac plates after patient discharge but before terminal room cleaning. Numerous sites were sampled including sinks, toilet seats, bedside tables, bed rails, chairs, floors, TV remotes, carts, and laundry bins.

This is a very small study, but even with the limited sample size they found that median colony forming units (CFU) were higher in colonized vs infected patients’ rooms (25 CFU vs. 0 CFU, P=0.033). As you can see in the figure, the distribution of room contamination was greatly skewed towards higher levels of contamination at discharge from colonized patient rooms.

There are some caveats. More surfaces were sampled from colonized patient rooms than infected patient rooms (6.52 ± 2.47 surfaces vs 4.07 ± 2.12 surfaces; P=0.02), so it’s possible that surface selection could have biased these findings. And, colonized patients stayed twice as long prior to discharge as infected patients (median 16 vs. 7 days, P=0.28). Even though The P value was greater than 0.05, this could be important since occupied rooms aren’t “terminally cleaned” and “time in room” must increase contamination.

If these findings are validated, they have important implications. First, isolating infected patients (passive surveillance) would be expected to have less utility than expected. Second, the significant contamination of colonized patient rooms prior to terminal cleaning should be a reminder that we need to identify and implement environmental cleaning technologies that work continuously during the patient stay and not just focus on terminal cleaning. Finally, since infected patients would have received effective therapeutic antibiotics, these findings support the idea that effective antibiotics are important adjuvants for infection control. If true, this suggests that as the MDRO crisis expands in the absence of novel antibiotic discovery, infection control will become far more difficult (see 2011-2012 NIH KPC outbreak).

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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GME education should shift away from academic hospitals to places where patients seek care, report says

A report about a fundamental shift in the way graduate medical education is funded has ACP members taking notice.

The U.S. should significantly reform the federal system for financing graduate medical education (GME) programs because the current methods requires little accountability, allocates funds independent of workforce needs or educational outcomes, and offers insufficient opportunities to train physicians in the health care settings used by most Americans, the Institute of Medicine said in a press release.

The report stated that public financing of GME should remain at its current $15 billion annual level, but Congress should move funding from the teaching hospitals that have traditionally received most of the funding into the clinics or community-based settings where most people now seek care.

Among other reasons for the shift is that physician training slots may be more driven by the needs of the individual teaching hospitals rather than of the populace, the report says. Between 2003 and 2013 there was a disproportionate increase of physicians being trained as specialists despite a greater demand for generalists. Training opportunities are highly concentrated in specific geographic regions and urban areas, and the training system is not increasing the number of physicians willing to locate to rural areas or treat other underserved populations, the release stated.

To encourage training at a variety of sites, funds should be distributed directly to the organizations that sponsor physician training programs including hospitals, clinics, and universities, and the payment methodology should be replaced with a single national, per-resident amount. The committee suggested a 10-year transition period to fully implement its recommendations, because of the complexity of GME education.

ACP members were at the announcement in Washington, D.C., or were following it online, and were tweeting from it:

Tyler Cymet, DO, FACP


Humayun J. Chaudhry, MD, MACP


Susan Hingle, MD, FACP

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Life at Grady: Gratitude

The day is pristine—the sun shining bright like a diamond and the temperature not oppressively hot either. The minute I see that blue-blue sky, I know that it’s going to be a good day. I just know it.

I have great parking-lot karma that day and snag a ground level space. I walk across the street and into Grady. I see the regular sights along the way. The people smoking in the smoking area. For amusement, I always look to see if anyone is puffing in the non-smoking area, too. And, as usual, someone always is. I sort of enjoy that for its irony.

I stride into the main atrium and wave at the man selling newspapers across the way. “Hey there, Miss Manning!” he shouts. And I shout right back to him even though his name escapes me. “Hey there, sir!” Ms. Renee in the gift shop is taking in some inventory at the door and winks in between signing off on boxes. I’m a terrible winker but I wink back.

The clinic isn’t too busy yet when I get there so I check my email. One of my emails is from Joe, a guy who wanted to know the inner workings of a hospital so decided to work NOT as a tech or even someone shadowing physicians. Instead, he took a job as one of the people pushing patients from place to place at Grady Hospital. And when he told me that, it blew my mind. Even more amazing, though, is that he did that for more than two years while in grad school.

Well. Joe is officially applying to medical school this year and wants me to read his application essay. That’s why he “cold call” emailed me, opening up with “You probably don’t even remember me but. . .” Ha. He must have forgotten who he was talking to.

I am rooting for Joe. Later, I speak to him on the phone for over thirty minutes, hashing out his med school strategy. “Tell them you took a job as a patient transporter at Grady for 2 years. Tell them what you learned because I know it changed your life.”

“It did,” he says. “It has.” And we talk about other things, too, but Grady is the main topic.

So the truth is that I can do this for another thousand words about every little tiny thing that happens around me. Suffice it to say, I love my day in clinic. I notice as much as I can. The encounters are rich and the conversations are ordinary but pivotal. We take really good care of people and I can feel it in my bones that we are. I can.

But I have to share this last thing.

On my way to see one of my last patients, I see a familiar face.

“Dr. Manning? Hey!”

“Hey!” I respond. I stop and turn my head sideways. I know I’ve cared for this patient before but I can’t place when or where.

“You don’t remember me?”

As soon as she says that, I do. This is a young woman who I’d cared for more than a year before. She was supposed to have a few months to live after failing treatment after treatment for a very advanced blood-borne cancer. And there she is. Standing right there in front of me on her way out of a clinic appointment.

And here is the truth: When I discharged her from the hospital back then, I was sure I’d never see her again. And that made me so sad. I remember crying many a day in my office or on my drive home about her. So seeing her . . . alive. . .it just. . .wow. I say, “Of course I remember you. Of course I do!”

I walk down the hall straight to her and, as if scripted, we embrace tight. A long, telling hug. I pull back, put my hands on her shoulders and study her, then pull back in and hug her once more.

“I’m doing really good,” she says.

“You look wonderful. And healthy. I’m so happy you stopped me. I’m so happy to see you.” I say. She looks very different now. Much thinner and hair now grown out from her chemo-induced alopecia that I’d come to know during her hospitalizations. I would have never recognized her.

“It’s good to see you, too,” she says. “How are your sons?”

And I immediately want to cry when she says that. How can she remember anything about me when she’s been so ill? Just. . . .how? ”They are good,” I reply. “Very good. Is your sister doing better?”

I want her to know I that I remember her story, too. Her sister was very, very close in age to her and so worried about my patient that she’d left college to be by her side. This decision was a big deal to my patient who wanted her sister to stay where she was. My patient believed that she was dying and saw no point in robbing her sister of a future since the chance of meaningful recovery was so slim. She’d urged her sister to go back to her university but her sister vehemently refused.

“She’s back in school. Going to graduate this year, actually.”

“That’s great. Just great.” I hug her one more time before leaving. If I stay two more seconds, I’ll break down crying.

I say a little prayer in my head as I walk away and stick them on a Post-it note in my head for prayers later.

The rest of that day is great, too. Quiet moments of wonderful bookmarked by teeny-tiny whispers of grace. All of it so very ordinary. Yet so very extraordinary. Which, like always, is very, very Grady.

I love this job.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Friday, July 25, 2014

Oh, what to do about that background hospital beeping?!

You enter a patient’s room, begin a conversation, and then hear it. It may be from your patient’s machine, or the next bed; from the intravenous infusion or the telemetry monitor.

“Beep, beep, beep!”

What do you do? Do you:

A. Look into the situation yourself and work out what’s wrong?

B. Try to silence the alarm immediately?

C. Call the nurse to look into it?

D. Just let the machine keep beeping for now and carry on your conversation?

Which one you usually do probably depends on the clinical situation and what type of machine the alert is coming from. Obviously an emergency telemetry monitor alarm will provoke an immediate response. However, all hospital medicine doctors will be familiar with the above everyday scenario. More often than not, it’s a simple issue with the IV machine, such as an occluded line or an alert that the infusion has finished.

Interestingly, on occasions where people have shadowed me at work—from both clinical and non-clinical backgrounds—I’ve often heard them remark about all the background noise we hear from the machines on the floors. They also frequently ask me what certain alerts mean, and I must admit I’m not always sure without looking in detail at the machines! The volumes and types of alarms can make hospitals very noisy and confusing places. You wouldn’t have the same situation say on an airplane, hearing alerts that aren’t immediately understood and addressed by the pilot or cabin crew. Quite simply, there are far too many background alarms in the hospital environment. In fact, this phenomenon of “alarm fatigue” probably affects hospital medicine doctors more than any other specialty, because we spend the most time on the hospital floors.

And even though most of us have just accepted it as the norm of being in a hospital environment, the issue is finally getting the attention it deserves. The data is truly alarming (no pun intended). One national survey from earlier this year showed that 19 of 20 hospitals ranked alarm fatigue as a top patient safety concern. Statistics frequently cite the number of alarms at up to several hundred per day for some patients. There have even been some well-documented cases in the media of harm resulting to patients when alerts are ignored. As a result of this increased awareness, the Joint Commission recently rated the problem as a National Patient Safety Goal and is requiring hospitals to take steps to address the issue.

It’s easy sometimes for physicians to think about the alarm as a “nurses problem,” but it really isn’t. The issue requires high level thought, because who decides what is or isn’t a necessary alert and is it right that the nurse is typically responsible for adjusting the alarm settings?

Aside from the safety issue, there’s also another elephant in the room. How often have you walked in to see a patient and heard them immediately complain about the fact that their machine has been beeping for a long time and it’s been bothering them? The nurse may have understandably been busy with something else and not gotten to it yet. It can be a big barrier to patient satisfaction and allowing our patients to get a decent rest.

In terms of dealing with the alarm fatigue problem, there are a number of potential solutions. Some institutions such as Boston Medical Center have successfully led initiatives by changing the settings of alert systems, such as those related to non-emergent bradycardia. In the future, different machines could even be designed, quieter for non-urgent alerts, or utilizing built-in systems that automatically page the nurse instead with certain issues such as an occluded IV line. The final option is to just keep the status quo, accepting that hospitals are places that must always have background alarms because of the nature of the work.

There’s no easy answer, but do give it some more thought next time you’re with a patient and hear that beeping …

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Wednesday, July 23, 2014

Life at Grady: Insulin showdown

Grady Primary Care Center, Summer 2014

Patient assessment: Poorly controlled diabetes

Plan: Initiate insulin therapy

“I think I can manage this with diet and exercise.”

“I believe that being careful about your diet and getting more exercise will help. But my recommendation is that we start you on insulin. I know you don’t like needles, but--”

“I’m definitely not taking insulin. That’s out of the question.”

“I see. Remember that blood test we checked? The A1C test?”

“The one that says how your sugars have been for a whole month?”

“Sort of. More like three months. But yes, that.”

“I remember.”

“Well. Yours was very high. In the double digits.”

“Where should it be?”

“I’d be ecstatic if it was between 6% and 7%. It was 12.5%. That calls for insulin.”

“I hate needles. You’ll have to try something else.”

“You’ve tried pills already. They aren’t working. You need insulin.”

“Is there an insulin that isn’t given through needles?”

“Not that I have to offer.”

“Oh well.”

“I’m sorry. I wasn’t sure what you meant by ‘oh well.’”

“I meant, ‘Oh well, guess we in a jam, ain’t we?’”

“Aaaah. I see. I guess we are then.”

“Insulin ain’t gonna happen.”

“I hear you. And I’ve already talked to you at length about the things that can happen if you ignore your high blood sugar, right?”

“You have. And I’m not ‘ignoring’ it.”

“Well, I meant not doing whatever it takes to control it. Sorry about that.”

“I’ll do anything. Just no insulin.”

*pause for a moment*

“Okay. Well listen--I’m pretty disappointed that I can’t convince you to go with my recommendations. I have the pharmacists here and everything to teach you about using insulin. But I guess you’ve made up your mind.”

“So what pills are you going to add?”

“None.”

“None?”

“None.”

“What the hell?”

“You need insulin. And that is my recommendation. You’re already on three different pills for diabetes. They aren’t enough. At this point, you need insulin.”

“Well, I am letting you know that I need an alternative.”

“I don’t have one.”

“So that’s just it? Insulin or nothing? That’s crazy.”

“I’m sorry you feel that way.”

“Why can’t you just up my pills some more?”

“Because that isn’t right. And it won’t be enough.”

“Hmmmph. I feel like you’re forcing insulin on me.”

“I’m sorry you see it that way. I just care.”

“You care about making money.”

“Making money? Um. No. Definitely not the case. You just need insulin.”

“I have a question. If I was your own sister what would you do? Your own sister with high blood sugar who really, really, really didn’t want to take insulin.”

“My sister? Oh, that’s easy.”

“Well?”

“I’d pin you to the ground with my knee in your chest and hold you there until you got your insulin. I’d sit right on top of your and draw it up and stick you in the back of the arm. Sure would. And I’d do it every single day until your A1C was under 7.”

*silence*

“Are you serious? That’s what you’d do to your sister?”

Dead serious.”

“You’d put your knee in her chest?

“You’d better believe it. Or I’d just put her in a headlock.”

*laughter*

“Damn. I’m just not ready for insulin.”

“I hear you, sis. But listen--insulin is ready for you.”

“I hear you, doctor.”

Do you? Like really hear me?”

“Yes. And I can feel your knee on my chest.”

“You can?”

“I can.”

Good.”

*both smiling*

***

Happy Wednesday. And yes, she took insulin.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Send comments to ACP Hospitalist staff at acphospitalist@acponline.org.

Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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