Saturday, September 14, 2013

Choosing wisely in hospital medicine

The Society of Hospital Medicine has published its top 5 list:

The 5 recommendations that were subsequently approved by the SHM Board are: (1) Do not place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non-critically ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for less than 2 days for urologic procedures; use weights instead to monitor diuresis). (2) Do not prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for gastrointestinal complications. (3) Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms or active coronary disease, heart failure, or stroke. (4) Do not order continuous telemetry monitoring outside of the intensive care unit without using a protocol that governs continuation. (5) Do not perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability.

This is a good start. Recommendation (1) is helpful because it gives specifics to guide foley catheter use though I found the last phrase amusing: ..use weights instead to monitor diuresis. Is the panel implying that it's too much to ask the nursing staff to get an accurate I&O on a voiding patient?

Recommendation (2) concerning stress ulcer prophylaxis is vague but does address a major concern. Clearly stress ulcer prophylaxis is over utilized. The Surviving Sepsis Guidelines are even more restrictive, stating that even among critically ill septic patients GI prophylaxis should be reserved for those with increased bleeding risk. GI prophylaxis though not an official performance measure in terms of P4P or public reporting has become a de facto performance measure due to EMR driven pathways, institutional processes and various care bundles. The harmful effects have only recently been appreciated.

Right off the bat there's a problem with how recommendation (5) reads: Do not perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability. Most patients with clinical and lab stability would not meet criteria for continued hospital stay! But putting that aside, do hospitalized patients need daily labs? Repeated blood testing is driven by the EMR which offers daily draws as a check list option on many order sets and pathways. My subjective impression is that we saw a lot less of this in the paper world. Given the virtual disappearance of arbitrary transfusion targets for most patients daily CBCs are not necessary in hematologically stable patients. With chemistries we have a different set of concerns. Awareness is rising concerning hyponatremia and hypokalemia as safety issues for hospitalized patients. Inpatients have elevated vasopressin levels (and thus SIADH physiology) just by virtue of being sick and in the hospital. They are at risk for hyponatremia even when isotonic fluids are administered. Hypokalemia is common due to multiple factors including the use of diuretics, straight normal saline as the EMR driven default IV fluid, the use of inhaled beta agonists and corticosteroids with mineralocorticoid activity. Its avoidance is particularly important given the multiple QT prolonging drugs used in the hospital. Finally, the daily assessment of renal function is important in many patients for the early detection of acute kidney injury and the adjustment of drug dosages. It's hard to make an evidential case either way but daily chemistries, in my view, are worthwhile in many hospitalized patients.

Here are two more I would add:

Do not order imaging studies for pulmonary embolism without first documenting a pre-test probability assessment.

Do not automatically employ CT angiography as the modality of choice to test for pulmonary embolism. Unless the patient has COPD or an abnormal chest xray V/Q scanning has better test characteristics.

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