Top 10 issues in hospital medicine for 2007

It’s time again for a year-end wrap up of developments in the field of hospital medicine. What were the defining issues in 2007? Although there are more answers to that question than there are people reading this blog I have a top 10 list, one that reflects my own biases. As I prepare to present it here as a series of posts over the next few days I’m struck by how the list is evolving. Some of the issues (e.g. Natrecor) have gone into dormancy, perhaps to resurface in future top 10 lists. Others, such as quality and safety remain on the front burner with the skeptics still winning the day. Occasional issues (such as sepsis bundles) seem to have come full circle while still others (glycemic control) remain ever-moving targets.

Here are my top 10 lists for 2006 and 2005---

2006:
State of the hospitalist movement.
Surviving sepsis guidelines under fire.
Debates about ALI and ARDS put to rest.
Medication reconciliation.
Outsourcing of hospital services.
Perioperative medicine.
The new C diff.
ER crowding.
EMR and CPOE.
Enthusiasm versus skepticism on the quality movement and core measures.

2005:
Diagnosis of pulmonary embolism.
Inpatient glycemic control.
Quality and accountability.
Combining modalities in treatment of sepsis.
EMR and CPOE.
ACLS, ECC.
Controversies in hypercoagulability.
Emerging infections.
The Natrecor controversy.
State of the hospitalist movement.

Top 10 issues in hospital medicine for 2009

It's time again to reflect on hospital medicine issues of importance for the past year. In a series of posts over the next couple of days I'll be offering my totally subjective and biased top 10 list, a mixture of clinical and organizational issues. I've been doing this for the last several years. You can view previous entries here.

Top 10 issues in hospital medicine for 2008

About this time every year I compile a top 10 list of issues I think were important for hospitalists. This listing is subjective and very biased. As in past years it covers both organizational and clinical issues in hospital medicine. It will be presented as a series of posts, in more or less reverse order of importance, over the next few days.

Top 10 issues in hospital medicine for 2008, issue 4: emergency room handoffs

The handoff between the emergency room physician and the hospitalist is just one of several discontinuities in health care during which patients are vulnerable. Although it has been intuitively known for a good while it earned a place on this year’s top 10 list because of a new study documenting frequent occurrences of patient harm and near misses. This patient safety problem is one of competing agendas: poor communication and handoff errors are driven by administrative pressure on ERs to reduce their wait times and improve “throughput”.

Top 10 issues in hospital medicine for 2007, issue 10: unintended consequences of the 5th vital sign

About a decade ago people began to wake up to the fact that the medical profession was doing a poor job of treating pain. Treatment was all too often irrational and ineffective. Education and quality improvement initiatives were needed. Unfortunately, well-intentioned initiatives were hijacked by activism and pain management became politicized. The scientific rationale of pain management became difficult to distinguish from dogma. As Joint Commission pain management initiatives got into high gear concerns about narcotic addiction, respiratory depression and other adverse effects fell on deaf ears. These were medical myths perpetuated by a culture of undertreatment and underconcern, we were told. Activism really got into high gear and struck fear in the hearts of physicians with the astounding news in 2001 of a $1.5 million verdict against a California internist for undertreating pain. The award was made possible by a novel legal strategy which bypassed California’s malpractice laws and withstood a substantial burden of proof that the doctor had acted with criminal recklessness. This was despite the lack of diagnosis of a terminal condition (only later confirmed to be untreatable lung cancer) and reliance on a nebulous pain scale which had become enshrined as the "5th vital sign." Lacking a firm diagnosis of terminal illness the physician was understandably concerned about the "double effect" of hastening death in the process of providing comfort and was hampered by California’s onerous prescription documentation requirements for strong narcotics.

The case sent shock waves through the media and medical journals. A Western Journal of Medicine editorial about the case was typical:

Another message to physicians implicit in these verdicts is that there is a standard of care for pain management, a significant departure from which constitutes not merely malpractice but gross negligence. Even if professional boards might not hold their licensees to that standard, juries will. With the implementation of the new pain standards by the Joint Commission for the Accreditation of Healthcare Organizations, which recognize the right of patients to the appropriate assessment and management of their pain, public expectations will likely increase exponentially.

Indeed they did. Scientific discourse about pain management was now hopelessly tainted by popular debate. An otherwise well appearing patient walking into the emergency department announcing pain at "10 out of 10" was an urgent indication for narcotics. Adverse effects of narcotics administered on the wards were minimized in importance.

Many of us who realized that the teaching about pain management was based more on dogma than science were worried about unintended consequences. This past year the adverse consequences have been brought to light. A JAMA news report earlier this year documents an alarming rising trend in narcotic related deaths which began in 1999, about the time the new pain management initiatives began to be promulgated. Our pain management dogma that "addiction is rare" was challenged by this systematic review of outcomes for opioid treatment of chronic back pain, which showed addictive behavior to be quite common. Thought leaders this year began to question the science behind the rise in opioid use, calling for the same standards of scientific rigor we apply to other treatments. Finally, a paper from the Journal of the American College of Surgeons earlier this year (H/T Aggravated Doc Surg) demonstrated that since the promulgation of recent pain management initiatives we have changed from a culture of undertreating pain to one of overmedication and underconcern for adverse effects of narcotics, resulting in patient deaths.

Perhaps 2007 will be remembered as the year of appreciation of the adverse consequences of pain treatment dogma.

Top 10 issues in hospital medicine for 2006---issue 10: state of the hospitalist movement

As 2006 draws to a close it’s time again to reflect on important issues in the field of hospital medicine for the past year. As was the case last year the selections are confined to adult hospital medicine and reflect the opinions of a biased committee of one: me.

I ranked the state of the hospitalist movement first last year. I’m ranking it number 10 this time because 2006 saw no movement-defining developments.

Economic pressures a decade ago created a niche for the movement in areas of heavy managed care penetration. The pressures of managed care relented, but a new niche was created as more and more primary care physicians chose to increase their efficiency by dropping hospital practice. These physicians can more easily stay on schedule in their offices, a patient satisfaction advantage counterbalanced by some patients’ frustration with receiving in patient care from strangers.

Some feel that hospitalist medicine is opposed to the agenda of primary care. Robert Wachter, M.D., a leader in hospital medicine, disagreed in a recent interview in Internal Medicine World Report: “Rather than feeling that hospitalists are another nail in the coffin of primary care, I hear from many primary care doctors that hospitalists have helped them tremendously. They realized long ago that they simply could not take care of sick hospitalized patients and manage their office practice simultaneously, and hospitalists have helped them make their jobs more survivable.”

Professional satisfaction seems to be shifting in favor of hospital medicine. It’s at an all time low in traditional primary care practice leading more and more internal medicine trainees to choose hospital medicine. According to Wachter, Society of Hospital Medicine surveys show a high rate of professional satisfaction among hospitalists. Wachter also predicted that the number of hospitalists needed may reach 50,000, a higher estimate than those made previously.

A few decades ago the hospital was a jungle, a combat zone inhabited by people with competing agendas and a culture of blame. Booby traps posed dangers to patients at every turn requiring the vigilance of the “superdoc” to head them off. The dream for the hospital of tomorrow is that of a safe place where a nurturing spirit of teamwork pervades the facility and computer enhanced system improvements all but eliminate errors. Movement along this path may gradually shift the role of the hospitalist from superdoc to systems management team member. But we’re not there yet. It’s a slow journey and in 2006 we’re somewhere between The House of God and the safe place. Systems improvement is too early in its development to solve the problem of patient safety. There will be a role for vigilance on the part of the individual hospital physician for years to come.

Top 10 issues in hospital medicine for 2009, issue 8: the abyss of post hospital care

An important NEJM paper published this year reported these findings on discharged Medicare patients:

Almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days; 67.1% of patients who had been discharged with medical conditions and 51.5% of those who had been discharged after surgical procedures were rehospitalized or died within the first year after discharge.

Although differing methodologies make direct comparison difficult these results appear to be worse than those reported in a similar study during the pre-DRG era 25 years ago. It's reasonable to suspect that the arrival of DRG reimbursement made the problem worse. Suddenly Medicare no longer paid for the hospital care patients got, let alone what they actually needed. Hospitals, in order to survive, quickly responded by discharging patients “quicker and sicker.” According to a JAMA report:

Instability at discharge (important clinical problems usually first occurring prior to discharge) predicted the likelihood of postdischarge deaths. At 90 days postdischarge, 16% of patients discharged unstable were dead vs 10% of patients discharged stable. After the PPS introduction, instability increased primarily among patients discharged home. Prior to the PPS, 10% of patients discharged home were unstable; after the PPS was implemented, 15% were discharged unstable, a 43% relative change.

Although the enactment of DRGs, an ill-conceived and reactionary move against the preceding 20 years of gross Medicare largess was, like the health care reform proposals of today, supposed to make care more efficient, it created a mess. Fortunately, back in the 1980s there were plenty of primary care docs to pick up the pieces.

Now things are different. As Medicare continues its increasingly negative cost incentives the primary care work force has diminished. So we shouldn't be surprised that the recent NEJM paper found this:

In the case of 50.2% of the patients who were rehospitalized within 30 days after a medical discharge to the community, there was no bill for a visit to a physician's office between the time of discharge and rehospitalization.

I remain skeptical about government's ability to improve this situation through external pressure. Meanwhile hospitalists, because their model has aggravated the disconnect between hospital and outpatient care, have an obligation to try and improve discharge transitions. Some programs are trying to lead the way in this effort through initiatives like Project Boost. Unfortunately efforts such as these take resources and may come into conflict with hospitals' business models under the DRG system.

Image courtesy of the Missouri Historical archives.

Top 10 issues in hospital medicine for 2006---issue 2: electronic medical records and computerized physician order entry

I elevated this topic from number 6 last year to number 2 due to increasing controversy and pressure for implementation. I sounded a cautionary note in last year's post, citing difficulties in physician acceptance and the potential for computerized physician order entry (CPOE) to increase certain types of errors.

Much more has been published this year including an insightful Medscape General Medicine Video Editorial by hospitalist thought leader and patient safety advocate Robert Wachter, M.D. Wachter sets out to temper irrational enthusiasm, pointing out that early studies which drove this enthusiasm took place in a select group of top notch institutions and looked only at “process” improvements. Until recently we had no data on patient outcomes. Wachter’s editorial reminds us of more recent papers showing a 3 fold increase in mortality in a pediatric hospital population following the implementation of a commercially available CPOE system and a powerful anecdote about a fatal insulin error related to bar code technology.

Issues regarding implementation are controversial. In another Medscape General Medicine Video Editorial AHRQ director Carolyn Clancy, M.D. thinks we should move full speed ahead and implies we should take advantage of readily available “off the shelf” systems. But Wachter warns that the systems that really seem to work are home grown and developed over years.

With the disasters in implementation and adverse patient consequences we’ve seen it would seem wise to move slowly.

Top 10 issues in hospital medicine for 2006---issue 7: medication reconciliation

For years hospitals’ efforts to curb medication errors ignored one of the most important aspects of medication safety: errors which occur at the transitions of care including admission, discharge and transfer from one facility to another. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, which, by the way, in a week or so will no longer be JCAHO) set out to remedy the problem in an initiative known as medication reconciliation across the continuum of care. Although this, one of their more laudable efforts in some time in my opinion, was announced in 2005 it really got into high gear this year thus deserving mention as one of the top issues of 2006.

Although the concept is simple, implementation seems to have proven difficult judging from some of the forums I read. For many initiatives on patient safety big ideas tend to precede evidence, but in the case of medication reconciliation evidence is already trickling in that the process can save lives.

Top 10 issues in hospital medicine for 2008, issue 10: How should hospitalists respond to the pseudoscientific invasion?

Suppose an integrative medicine consult service is introduced at your hospital with plans to offer Therapeutic Touch, Reiki, acupuncture and Tai Chi. You are the medical director of the hospitalist program. The CEO, knowing that your program accounts for most of the consult requests and hoping for a nice revenue stream from the new service, asks for your support. What do you do?

While integrative medicine programs commonly offer harmless treatments whose modest benefits are self evident (relaxation modalities, music therapy) these tend to be mixed with other claims which are scientifically unsound. As hospitalists we are (or claim to be) all about ethics and scientific integrity. As quackery spreads throughout mainstream academic and community medical institutions like cancer the individual hospitalist is increasingly likely to confront the issue.

At the organizational level there has been little discussion. I have attended one hospital medicine course sponsored by a large academic institution which promoted non-evidence based alternative medicine. The Society of Hospital Medicine has been silent. It’s time to take a stand.

Tolerance for the promotion of quackery in mainstream medicine is a violation of fiduciary duty.

Top 10 issues in hospital medicine for 2009, issue 10: the rising importance of statin drugs in hospitalized patients

This year we saw continued and growing interest in this subject. Here are the highlights:

Statins improve the COPD outcomes of mortality, frequency of exacerbations, frequency of mechanical ventilation and frequency of need for emergency care.

Perioperative statin use cuts myocardial ischemic events in half in patients undergoing vascular surgery.

More rapid titration of statin drugs to goal may reduce events.

Acute statin dosing may improve acute coronary syndrome outcomes.

Pleiotropic statin effects improve stroke outcomes.

Statins improve outcomes in sepsis.

Acute statin use in ACS and perioperative statin use represent potential opportunities for intervention. The data for COPD, sepsis and stroke represent comparisons between users and non users. That may be important for hospitalists in deciding which home medications to continue in the hospital when patients are admitted with these conditions.

Don't be surprised in a few years if statin administration, like DVT prophylaxis, shows up on your hospital safety check list.

Top 10 issues in hospital medicine for 2006---issue 1: enthusiasm versus skepticism in quality and patient safety

With great fanfare, and with the help of the media, the Institute for Healthcare Improvement (IHI) this year announced the “success” of its campaign to save 100,000 lives. But a more sober assessment of the campaign cited methodological flaws and problems with the analysis of “lives saved” with the conclusion that the true impact of the campaign is unknown. This point-counterpoint illustrates the growing tension between the enthusiasts and the skeptics, and at the end of 2006 the skeptics are winning. The debate was nicely framed in a recent JAMA commentary by Robert Wachter, M.D.

Let’s look at some recent evidence.

Measured against Medicare’s performance measures, the difference in mortality between the top and bottom performing hospitals was of statistical, but questionable clinical significance. (JAMA editorial comment here).

Rapid response teams, recommended by the IHI and being considered for a Joint Commission initiative, are not supported by high level evidence. [1] [2]

Computerized Physician Order Entry was associated with an increase in mortality in a pediatric hospital population.

The four hour antibiotic mandate for pneumonia, a widely promulgated quality measure, is associated with unnecessary antibiotic use and has not been proven to improve outcomes.

Pneumococcal vaccination, another core quality and P4P measure, does not prevent pneumonia and is not cost effective with the preparation now licensed for use in adults.

What does it all mean? It means the quality and patient safety movements should move forward but individual measures should withstand scientific scrutiny before they are mandated by federal agencies and advocacy groups.

Top 10 issues in hospital medicine for 2006---issue 5: perioperative medicine

The relationship between medical and surgical hospital services was adversarial in The House of God, representative of the hospital of a few decades ago. The epitome of good case management was to turf your patient to a competing specialty service whenever the opportunity presented itself. Nowadays that relationship is changing. A model of collaboration between hospitalists and surgeons is emerging.

The year 2006 saw the publication of three new resources in perioperative medicine which merit inclusion in this year’s top ten list:

The proceedings of the second annual Cleveland Clinic Perioperative Medicine Summit appeared in a September supplement to CCJM. There’s a world of helpful stuff there.

Guidelines for perioperative pulmonary risk assessment and management were developed by the American College of Physicians and appeared in the April 18 issue of Annals of Internal Medicine.

After a frustrating back-and-forth on just which patients should receive perioperative beta blockers the American College of Cardiology helped settle the issue, at least for now, with new guidelines.

Top 10 issues in hospital medicine for 2005------issue 4

Controversies in hypercoagulability

Recent guidelines have recommended testing certain patients for hypercoagulable states following an episode of venous thromboembolism (VTE) and others suggest how such test results might influence treatment decisions. But controversy arose last May with the publication of this study in JAMA of patients who underwent thrombophilia testing after an episode of VTE. The study showed that certain clinical factors, but not laboratory testing, were predictive of recurrent VTE events. The popular spin, simplistic as always, was that thrombophilia testing be abandoned.

How can this seemingly disparate evidence be integrated with what was known before? Older data, upon which the guidelines were based, had established that thrombophilia testing was predictive of the relative risk for initial VTE. The situation is completely different for patients who have already had a spontaneous VTE. Why? It has long been known that patients with spontaneous VTE are hypercoagulable, (untreated recurrence rates of 2% to 5% per year) no matter the result of thrombophilia testing. In part this is because comprehensive laboratory testing of clinically thrombophilic patients will yield negative results---no “laboratory lesion”--- in about 30%-40% of cases. The thinking is that those patients have a thrombophilic state that hasn’t been discovered yet. To keep it in perspective, remember that the concept of hereditary thrombophilia has been around since the discovery, in 1963, of antithrombin deficiency (Egeberg O: Inherited antithrombin deficiency causing thrombophilia. Thrombosis Diathesis Haemorrhagica 1963; 13: 516) but it was not until about a decade ago that the most common hereditary thrombophilia, Factor V Leiden, was discovered. The field will mature and as additional disorders are characterized thrombophilia testing will become more “evidence based.”

In a related controversy “NORVIT: Randomised trial of homocysteine-lowering with B vitamins for secondary prevention of cardiovascular disease after acute myocardial infarction” was presented at the European Society of Cardiology this year. The media spin---that the homocysteine hypothesis is a “bust”---was irresponsible. Forget the media reports and view the presentation slides. What the study actually did was to suggest that the popular notion of an upper “safe” limit of homocysteine for cardiovascular health of 9 or 10 may not be valid. It also debunked the popular practice (which was never evidence based in the first place) of giving everyone combination B vitamins for secondary prevention. Homocysteine testing and selective use of folic acid and/or B6 may be clinically valid.

Top 10 issues in hospital medicine for 2009, issue 7: rapid response teams, telemetry and early warning scores

The premise behind rapid response teams (RRTs), that intervention in deteriorating patients should avert cardiac arrests and reduce hospital mortality, is appealing. Yet, despite widespread claims that such teams save lives, extensive research has failed to show that they do.

Why wouldn't it be effective? Maybe because customary use of RRTs is to intervene at the last minute when, in most cases, physiologic deterioration begins hours before the crash. That physiologic deterioration may, in cases such as sepsis, be irreversible in the final moments leading to cardiopulmonary arrest. Having a RRT is not a substitute for clinical vigilance.

The consensus of a panel of speakers at SHM 2009 was that while research evidence doesn't show an impact on meaningful clinical outcomes individual institutions may realize intangible benefits. Nurses love the concept. Rapid response calls may lead to advance health care planning discussions. Perhaps most importantly, rapid response systems can be educational tools. When reviewed systematically they may uncover safety issues and drive process improvement.

The panelists discussed tips for more effective use of RRTs, learned from their own institutions. The process should be structured. Define the patient changes that should trigger a call. Formally review all RRT call records. Define post-RRT care and hand-off procedures. The RRT concept can be extended in novel ways such as proactive rounds on high acuity patients and extending coverage beyond the wards to the ED and other areas of the facility.

Whatever the benefits of the RRT for the individual institution, based on the disappointing literature on RRT outcomes no one can legitimately claim that their institution is saving lives just because they have a RRT. Moreover, there is no research basis for making the RRT a reportable quality measure.

Before leaving the topic of RRTs, a word about Joint Commission. Contrary to popular belief Joint Commission does not require hospitals to have RRTs. Instead they require hospitals to have a structured mechanism in place, specific to the needs of the individual facility, whereby help is summoned for deteriorating patients. In addition hospitals are to monitor outcomes before and after implementation.

Have other means of averting cardiac arrest proven effective? Earlier this year I wrote a post about telemetry monitoring. Telemetry monitoring alerts nursing staff of cardiac arrest in progress, but only rarely prevents cardiac arrest and is over-utilized.

Because physiologic changes which progress to cardiac arrest often unfold over hours and may be irreversible in the moments preceding cardiopulmonary arrest, early warning assessment methods have been used. Perhaps the most popular is the modified early warning score (MEWS) a physiologic scoring tool which, in this study, was highly predictive of the risk of in hospital deterioration. This tool can be used at the time of hospital admission and periodically thereafter for early identification of patients at risk so that intervention can take place before the patient is in crisis.

Finally, of related interest this year was this note about Vanderbilt's in patient sepsis early warning and management system.

Image courtesy of the Missouri Historical archives.

Top 10 issues in hospital medicine for 2008, issue 7: emerging problems in the treatment of MRSA

We live with the fear that suddenly, one day, we will wake up to find vancomycin resistant Staphylococcus aureus (VRSA) in our community. Although rare reports of the sudden appearance of high level vancomycin resistance due to the vanA gene known to cause vancomycin resistance in enterococci have surfaced, the reality is that the major threats are different: vancomycin is gradually wearing out its welcome, by multiple mechanisms, while new strategies evolve. Hospitalists must be aware of these mechanisms and evolving strategies.

The mechanisms:

There are inherent weaknesses in vancomycin compared to beta lactam antibiotics. This relates to less effective killing action and a narrower therapeutic window for vancomycin. This is not a new problem, and accounts for higher mortality in MRSA infections (in which vancomycin is usually administered) than in MSSA infections (in which beta lactam antibiotics are used). This issue is reviewed here.

Vancomycin treatment failures increase in proportion to increasing MICs even well within the “sensitive” range below 2 mcg/ml.

Transient heteroresistance to vancomycin, in which small subpopulations of organisms show vancomycin MICs in the intermediate range, is common and may lead to treatment failure in patients whose isolates test “sensitive”.

Vancomycin tolerance, defined as a wide discrepancy between the MIC and MBC, may lead to treatment failure in patients whose isolates test “sensitive”.

Traditional vancomycin dosing regimens have resulted in low trough levels. This can lead to treatment failure, since vancomycin’s effectiveness is time dependent rather than peak concentration dependant.

Poor penetration of vancomycin in lung tissue, requiring trough levels several fold above MIC.

These concerns have led to a lowering of the vancomycin sensitivity breakpoints for MRSA.

Evolving strategies:

Aiming for higher vancomycin trough levels. Although newer vancomycin preparations have been considered relatively non toxic, recent trends in higher dosing may be producing nephrotoxicity.

Use of other older antibiotics such as trimethoprim/sulfa, clindamycin and tetracyclines. In contrast to HA-MRSA, CA-MRSA isolates are usually sensitive to these antibiotics. Their use as an alternative to vancomycin in serious MRSA infections has been limited, has not been validated in high level studies, and is controversial.

Newer agents. Linezolid has been suggested as an alternative to vancomycin for pneumonia. The jury is still out. Daptomycin has been found non-inferior in intravascular infections. It is not effective against pneumonia. Tygecycline has efficacy against MRSA but is not approved for a wide variety of clinical indications. Limitations are that it is bacteriostatic and may not be effective against infections in which bacteriocidal activity is required. Moreover, serum levels tend to be low, a possible limitation in bacteremic infections.

Acknowledgment: Several issues raised here were covered by Dr. James Pile in his presentation at SHM 2008, which was the inspiration for this post.

Top 10 issues in hospital medicine for 2009, issue 6: resuscitation and post-resuscitation care

For several years I've been writing about aspects of resuscitation and post-resuscitation care starting with a post on Dr. Gordon Ewy's cardiocerebral resuscitation. Therapeutic hypothermia following cardiac arrest received increased attention this year and I posted on the subject here, here, here and here.

Accumulating evidence on other aspects of post resuscitation care, particularly aggressive coronary angiography and PCI strategies, has led to the notion of the post-cardiac arrest syndrome and post-resuscitation bundle, recently promulgated as an ILCOR consensus statement.

This Medscape Viewpoint piece provides a helpful perspective on the current evidence for the role of emergency PCI in resuscitated patients:

Reynolds' study further supports previously published reports encouraging urgent catheterization for survivors of cardiac arrest regardless of ECG evidence of STEMI. Recent publications also show that therapeutic hypothermia can be used safely in these patients during and after PCI without producing delays in time to balloon inflation.

The significance of this new literature cannot be overstated. If further studies confirm these findings, it would strongly argue for enormous changes in prehospital systems of care. All survivors of primary cardiac arrest would be recommended for immediate transport to hospitals that have the capability of performing urgent PCI in conjunction with therapeutic hypothermia. Based on the current literature, it certainly seems advisable that emergency healthcare practitioners who care for resuscitated victims of primary cardiac arrest should engage in conversations with cardiology consultants and urge them to take an aggressive approach to PCI in these patients.

This new integrated approach to cardiac arrest care will require changes in the way we assess neurologic prognosis after cardiac arrest. We won't be giving up so soon, because assessment of neurologic prognosis will have to be delayed in patients who receive therapeutic hypothermia. Again, from the Medscape article (my emphasis):

The authors determined that improved survival and good outcome were associated with coronary angiography regardless of the presence of new left bundle branch block or STEMI, and also regardless of presenting rhythm or neurologic status immediately after resuscitation.

A nice overview of resuscitation and post-resuscitation care is contained in this review from Current Opinion in Cardiology. According to that review post-resuscitation care should include:

...mild hypothermia (32–348C) for patients in coma after arrest. Urgent cardiac catheterizationand PCI unless contraindicated .

Top 10 issues in hospital medicine for 2009, issue 3: hospitalist outcomes and efficiency

This year as in past years leaders of the hospitalist movement continued to promote the model as superior to the traditional model of hospital care in terms of outcomes and efficiency even though the weight of evidence fails to back up the claims. This year also saw the publication of yet another systematic review which made the same claims. The review, like others preceding it, suffered from a case of publication bias as I pointed out here.

A paper in the Archives of Internal Medicine this year purported that hospitalists improve quality, but suffered from confusion on quality and performance. Dr. Robert Centor gave us a dose of healthy skepticism.

Top 10 issues in hospital medicine for 2008, issue 6: weaning from ventilators is obsolete

---(with only a few exceptions). Despite this fact the term “weaning” remains popular in critical care. The new thinking is that most patients should not be weaned. Rather, on any given day they are either ready for extubation or they are not. The job of the clinician is to do a daily assessment for readiness.

While this fact has been known for over a decade it made my 2008 top10 list because of a pivotal study this year in which the assessment was validated as an integrated protocol combining the daily sedation interruption with the spontaneous breathing trial, resulting in a striking mortality benefit.

Top 10 issues in hospital medicine for 2008, issue 2: patient safety and the culture of blame

Just as the quality movement has led to a culture of shame, the safety movement has exacerbated a culture of blame. That’s pretty ironic given that the seminal document of the patient safety movement, IOM’s To Err is Human, viewed the culture of blame as counterproductive and sought to mitigate it. This statement is from the executive summary of the book:

The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system. This does not mean that individuals can be careless. People must still be vigilant and held responsible for their actions. But when an error occurs, blaming an individual does little to make the system safer and prevent someone else from committing the same error.

Why did this unfortunate and unintended consequence come about? It’s an example of what happens when a nuanced and highly complex issue gets thrown into the arena of unenlightened and uninformed public debate. Policy wonks distort it. Media spin it egregiously. Trial lawyers take notice.

We’ve seen the consequences this year. CMS’s ill-conceived and manifestly unfair never events policy went into effect, redefining many unavoidable events in hospitals as errors. With such redefinition comes a strong implication of widespread institutional and individual blame. The idea of patient harm as a “never event” has also spawned a new legal principle in which any patient harm is prima facie evidence of negligence, leading to more law suits and a shift in the burden of proof. Ready for the next malpractice crisis?