Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Highest Quality Care for the Hospitalized Elderly The Hospitalized Elderly: General Principles Jason Stein, MD Emory Reynolds Faculty Scholar Emory Hospital Medicine Service Highest Quality Care in the Hospital Goals for this Module 1) 2) 3) 4) Identify the significance of elderly patients to hospitalists Identify the significance of hospitalizations to elderly patients Appraise the extent of your hospital’s specific approach to its geriatric population Describe how the adverse hospital environment combines with physiologic aging and pathophysiologic changes from disease to impact the hospitalist’s approach to the care of elderly inpatients Emory Reynolds Program Emory Hospital Medicine Service Highest Quality Care in the Hospital: Look at Your Inpatient Census What do half your patients have in common? (whether you’re at EUH, ECLH, Cartersville, Dunwoody, Northlake, or Eastside) Emory Reynolds Program Emory Hospital Medicine Service Highest Quality Care in the Hospital: Look at Your Inpatient Census What is the median age on your census? Emory Reynolds Program Emory Hospital Medicine Service Highest Quality Care in the Hospital: Look at Your Inpatient Census What is the median age of patients on your census? About half your patients are geriatric patients (> 65 years old): patients >65 years old account for ~50% of all inpatient days of care in American hospitals1 (while comprising just 13% of the population) 1Kozak LJ et al. National Hospital Survey: 2000. National Center for Health Statistics. Vital Health Stat. 13 (153). 2002. Emory Reynolds Program Emory Hospital Medicine Service Highest Quality Care in the Hospital: Is Your Patient’s Age Clinically Significant? Why geriatric patients are important to hospitalists… Summary: Half your admission H&Ps Half your progress notes Higher complexity demands disproportionate care time More than half of your in-hospital deaths (75%) Why hospitalizations are important to your geriatric patient… Emory Reynolds Program Emory Hospital Medicine Service Highest Quality Care in the Hospital: Why Hospitalizations Are Important to Your Geriatric Patient Your patient’s age is clinically significant. Emory Reynolds Program Emory Hospital Medicine Service Highest Quality Care in the Hospital: Is Your Patient’s Age Clinically Significant? Hospitalization Facts: Older patients have: More frequent hospitalizations Longer Hospitalizations Higher Mortality Emory Reynolds Program Emory Hospital Medicine Service Highest Quality Care in the Hospital: Is Your Patient’s Age Clinically Significant? Hospitalization Facts: Older patients have: More frequent hospitalizations Patients > 85 years old: – 2x the rate of 65-74 year olds – 5x the rate of middle aged patients (45-64 year olds) Emory Reynolds Program Emory Hospital Medicine Service Highest Quality Care in the Hospital: Is Your Patient’s Age Clinically Significant? Hospitalization Facts: Older patients have: Longer hospitalizations Patients > 85 years old average = 6.2 days Patients 45-64 years old average = 4.8 days Emory Reynolds Program Emory Hospital Medicine Service Highest Quality Care in the Hospital: Is Your Patient’s Age Clinically Significant? Hospitalization Facts: Older patients have: Higher mortality Patients > 85 years old: – 4x the mortality rate of middle aged patients (45-64 year olds) – 75% of in-hospital deaths occur in patients > 65 years old Emory Reynolds Program Emory Hospital Medicine Service Highest Quality Care in the Hospital: Is Your Patient’s Age Clinically Significant? Why hospitalizations are important to your geriatric patient… Emory Reynolds Program Emory Hospital Medicine Service Factors Associated With Development of Disability Beaufort Scale: 1 - 12 (scale of wind velocity) Hurricane = 12 (74 mph) Light breeze = 1 (1 mph) Gill TM. JAMA. 2004; 292: 2115-24 Emory Reynolds Program Emory Hospital Medicine Service Defining A Key Geriatric Term What is Functional Decline? Functional Decline = New Disability Loss of ADLs (basic self-care activities) Transfer out of bed to chair independently Toileting yourself Bathing yourself Dressing yourself Feeding yourself Emory Reynolds Program Emory Hospital Medicine Service Hospitalization: A Threat of Its Own Hospitalization = Functional Decline = Higher Mortality Hospitalization = Functional Decline -Prolonged hospital stays are associated with functional decline1 -35% of older hospitalized patients decline in baseline ADLs b/t admission and discharge2 -Compared with any other event along the road to disability in the elderly, hospitalization is a greater hazard by a full order of magnitude3 1 Palmer RM. Acute Hospital Care. In: Geriatric Medicine, 4th ed. 2 Kozak LJ et al. Vital Health Statistics. 2002;13(153). 3 Gill TM. JAMA. 2004; 292: 2115-24 Emory Reynolds Program Emory Hospital Medicine Service Hospitalization: A Threat of Its Own Hospitalization = Functional Decline = Higher Mortality Functional Decline = Higher Mortality # basic ADLs absent at discharge strong independent predictor of mortality 4,5 4 Inouye 5 Walter SK et al. JAMA. 1998; 279: 1187-93. LC et al. JAMA. 2001; 85: 2987-94. Emory Reynolds Program Emory Hospital Medicine Service Highest Quality Care in the Hospital Does your hospital have specific processes to drive the best possible outcomes for its geriatric population? Until it does, your elderly inpatients rely on you alone to deliver all – and only – the care they need. Highest Quality Care in the Hospital Does your hospital have specific processes to drive the best possible outcomes for its geriatric population? 1. Does anyone perform a formal assessment of baseline function (2 weeks prior to hospitalization)? 2. Does anyone perform a formal assessment of current function (at time of admission)? 3. Do daily rounds focus on patient-centered interventions? 4. If your hospital has CPOE, do you have a layer of electronic decision support that focuses on geriatric prescribing (~50% reduction in falls)? 5. Does the discharge process address persistent functional deficits that require special support or sites of ongoing care? Guided Prescription of Psychotropic Medications for Geriatric Inpatients.Josh F. Peterson, et al. Arch Intern Med Volume 165:802-807 April 11, 2005 Highest Quality Care in the Hospital Processes Outcomes Every system is perfectly designed to achieve exactly the results it gets. Emory Reynolds Program Emory Hospital Medicine Service Highest Quality Care in the Hospital Processes Outcomes What’s the difference? Emory Reynolds Program Emory Hospital Medicine Service Highest Quality Care in the Hospital Processes Outcomes What do you care more about? Emory Reynolds Program Emory Hospital Medicine Service Highest Quality Care in the Hospital Processes: influence outcomes more amenable to measurement must be tightly associated to outcomes Outcomes: what you really care about ultimately can be difficult to measure in real time Emory Reynolds Program Emory Hospital Medicine Service Towards An Optimal Process Who Will Get Functional Decline? Risk Factors Before Admission Age (increasing age) Body (pressure ulcer) Brain (cognitive impairment) Mood (depressive symptoms) Level of functioning (fewer iADLs¥) Socialization (low social activity level) ¥ iADLs = instrumental ADLs: tasks necessary to run a household (telephone, managing money, shopping, preparing meals, light housework, getting around the community) Emory Reynolds Program Emory Hospital Medicine Service Towards An Optimal Process Who Will Get Functional Decline? Risk Factors After Admission: “Adverse” Hospital environment Acts of Commission Iatrogenic illness Jurisdiction = You Sensory Deprivation Acts of Omission Altered sleep-wake cycles Jurisdiction = Hospital Services Disorientation (Physical Space, Workplace Deconditioning Culture, Multidisciplinary Team Malnutrition skill and availability) (but you still play a role) Emory Reynolds Program Emory Hospital Medicine Service Apart From Preventing Iatrogenic Illness, You Can Dampen the Adverse Hospital Environment Example: Deconditioning from… Illness-induced immobility your usual good care “Neglectful” bed rest: – Insufficient PT/OT – Environmental barriers e.g. lack of handrails in hallways/rooms discourages mobility and self-care insist on handrails and 24/7 PT “Forced” bed rest: – tethered to IV poles and catheters – tethered to the bed by physical or chemical restraints “un-tie” your patient Emory Reynolds Program Emory Hospital Medicine Service Why Are Elderly Patients Especially Vulnerable to the Risk Factors for Functional Decline? “Adverse” hospital environment + Physiologic impairments with age (e.g. less muscle mass, strength, and aerobic capacity) + Pathophysiologic impairments from disease (e.g. painful OA + poor hearing/vision + malaise/dyspnea from pneumonia) Emory Reynolds Program Emory Hospital Medicine Service Why Are Elderly Patients Especially Vulnerable to the Risk Factors for Functional Decline? Three Key Geriatric Principles for the Hospital 1) At the individual level, variability decreases with age 2) Across the geriatric population, variability increases with age 3) To maintain baseline performance, many elderly already have drawn upon physiologic reserves Recognizing the significance of this will make you a better provider. How aging is clinically significant… Emory Reynolds Program Emory Hospital Medicine Service How is Aging Clinically Significant? Most Elderly Are Different from the Young 1) At the individual level, variability decreases with age Individual Variability Narrows Organ function deteriorates (~1% per year, starting ~30yo) and dynamic range of organ/system performance narrows over time e.g. stride length: less nimble (others: HR, FVC, Temp, Na handling, etc) Clinical Implication: detectable extremes tend to be associated with significant underlying illness (or iatrogenesis). Emory Reynolds Program Emory Hospital Medicine Service How is Aging Clinically Significant? Most Elderly Are Different From One Another 2) Across the geriatric population, variability increases c age: Population Variability Widens Time “Normal aging” + Disease Genes/Environment = Wide Variability Clinical Implication: Your next elderly patient is likely to manifest the ravages of time and disease in ways that are totally unlike your previous 20 elderly inpatients. Emory Reynolds Program Emory Hospital Medicine Service How is Aging Clinically Significant? Many Elderly Are Running on Fumes 3) To maintain baseline performance, many elderly already have drawn upon physiologic reserves Homeostenosis the diminished capacity to maintain homeostasis when stressed (limited physiologic reserve + blunted compensatory mechanisms) Clinical Implication: next 3 slides Emory Reynolds Program Emory Hospital Medicine Service The Frail Elderly susceptibility to disease + ability to compensate (homeostenosis) Homeostasis You stress Physiologic Reserve Compensatory Mechanisms You, Compensated Emory Reynolds Program Emory Hospital Medicine Service Homeostenosis Frail Elderly stress Limited Blunted Physiologic Reserve Compensatory Mechanisms “Tapped Out” Clinically Decompensated Emory Reynolds Program Emory Hospital Medicine Service Age-Related Changes Relevant to Inpatient Care Clinical Implication: The acutely ill elderly patient frequently presents with non-specific signs or symptoms. The absence of “classic” findings places greater value on the hospitalist’s diagnostic evaluation. Age-Related Changes Relevant to Inpatient Care Body Composition Renal lean body mass total and visceral body fat GFR RAAS and ADH response to hypovolemia natriuresis (Na excretion in hypervolemia) higher concentration of water soluble drugs longer T1/2 fat-soluble medications risk of excessive medication dose risk of excessive medication schedule delayed clearance of water-soluble medications risk of excessive medication dose risk of excessive medication schedule propensity to DM, HTN, hyperlipidemia risk of under-diagnosis or treatment risk of over-treatment c polypharmacy/ADEs blunted ability to return to euvolemia in face of volume depletion or overload risk of excessive IV fluid administration (type/amount/rate) risk of over-diuresis (or insuff. monitoring) risk of under-diuresis Emory Reynolds Program Emory Hospital Medicine Service Age-Related Changes Especially Relevant to Hospital Medicine Cardiovascular Medial sclerosis (stiffening of LV/arteries) ß-receptor responsiveness maximum HR and CO Diastolic dysfunction risk of under-recognized HF risk of underestimated impact from a.fib on CO (loss of atrial kick) on tolerance of HR (rate control) blunted HR response to stress risk of overlooking enormous significance of sinus tachycardia Pulmonary chest wall compliance elastic recoil of lungs strength diaphragm mucocilliary clearance P02 and A-a gradient* Lower TVs, more atelectasis Weaker, less effective cough Higher risk pulmonary infections risk of not vaccinating (PVX and flu shot) risk of overlooking smoking cessation advice Lower threshold for hypoxemia risk of occult hypoxemia risk of iatrogenic respiratory depression (work-up sinus tachycardia) * Normal A-a gradient: [(age/4)+4] Normal PO2: [110-(0.4 x age)] Emory Reynolds Program Emory Hospital Medicine Service Age-Related Changes Relevant to Inpatient Care Gastrointestinal Immunological swallow coordination/esophageal motility lactase levels colonic motility Dysphagia aspiration risk malnutrition risk barrier integrity (skin, mucous membranes) Altered cytokine response to infection humoral Ab response to infection Susceptibility to skin, urinary, pulmonary infxns decubitus ulcer risk urosepsis risk aspiration risk Lactose Intolerance occult diarrhea risk Tendency to constipation risk of remaining occult risk of being exacerbated Blunted febrile response to infection occult infection risk: (work-up T > 99ºF (37.2ºC)) (work-up new ↑WBC/bandemia) (Up to 25% of septic elders can be afebrile. Using T > 99ºF [37.2ºC] increases sensitivity for detecting fever to 80% and maintains specificity=90%) Emory Reynolds Program Emory Hospital Medicine Service Patient Cases Case #1: Inappropriate 75 yo woman being admitted after falling at home. She hit her head. She lives alone and this is her 2nd ER visit in 2 weeks (last treated for a facial laceration): – Fell in middle of the night on way to bathroom (she felt dizzy) – Has fallen two other times in last month: 1) Tripped over the edge of a rug 2) Lost balance when her cat stepped in her path Emory Reynolds Program Emory Hospital Medicine Service Case #1: Inappropriate PMH: 1. HTN. HCTZ 25mg qd. 2. Depression. Zoloft 100mg qhs and Ativan 1mg bid prn. 3. OA. Ibuprofen prn. Social Hx: lives alone; no tob/ETOH Emory Reynolds Program Emory Hospital Medicine Service Case #1: Inappropriate PE: supine HR 64, BP 132/70 standing HR 70, BP 122/68 HEENT: vision 20/40 (mildly impaired) Neuro: LE strength 5/5 B, gait stable Get-Up-and-Go test = 10 seconds Emory Reynolds Program Emory Hospital Medicine Service Case #1: Inappropriate Which of the following is the most appropriate next step in managing this patient’s recurring falls? A) B) C) D) E) Refer to ophthalmology Discontinue ativan Discontinue HCTZ Refer to physical therapy Substitute buspirone for zoloft Emory Reynolds Program Emory Hospital Medicine Service Case #1: Inappropriate Which of the following is the most appropriate next step in managing this patient’s recurring falls? A) B) C) D) E) Refer to ophthalmology Discontinue ativan Discontinue HCTZ Refer to physical therapy Substitute buspirone for zoloft Emory Reynolds Program Emory Hospital Medicine Service Case #1: Inappropriate Observational studies show medications are the most readily modifiable risk factors for falls – Especially psychotropics (bdz, neuroleptics, TCAs) Emory Reynolds Program Emory Hospital Medicine Service Case #1: Inappropriate RCTs show specific single interventions to reduce falls: – removal of psychotropic medications – home hazard assessment and modification – exercise programs Emory Reynolds Program Emory Hospital Medicine Service Case #1: Inappropriate Falls in elderly: usually multifactorial (so address all potential contributing factors) Emory Reynolds Program Emory Hospital Medicine Service Emory Reynolds Program Emory Hospital Medicine Service Emory Reynolds Program Emory Hospital Medicine Service Emory Reynolds Program Emory Hospital Medicine Service Case #2: Adverse Hospital Environment? 78 yo woman with DM 2 admitted with cellulitis, top of R foot, which seemed to start spontaneously. No improvement after one week outpatient Keflex. – 3 days of increased pain and redness. Unchanged localized swelling. No fever, chills. No open wound. – She is not able to give you an estimate of the highest/lowest BG in the last 2 weeks. Emory Reynolds Program Emory Hospital Medicine Service Case #2: Adverse Hospital Environment? PMH/Meds: 1. DM 2. Recent HgA1C 8.5%. No h/o microvascular disease. Metformin 500mg bid Glyburide 10mg qd 2. Hypothyroidism. Synthroid increased by PCP 2 months ago when TSH = 8. Synthroid 150 mcg qd 3. HTN. Lisinopril 40mg qd Emory Reynolds Program Emory Hospital Medicine Service Case #2: Adverse Hospital Environment? PE: T 37.4°C HR 90 BP 154/85 RR 12 Gen: non-toxic appearing Lungs/CV/abd: normal Ext: well-demarcated area of tender erythema dorsum of R foot. No ulcer. No fluctuance in surrounding soft tissue; palpation of adjacent bone shows no point tenderness; peripheral pulses 1+ B Neuro: A&O to time, place, situation. Light touch intact. Lab: BG 188, WBC 9K (70% neutrophils, no bands) EKG: NSR, 90 Rad: non-diagnostic for OM Emory Reynolds Program Emory Hospital Medicine Service Case #2: Adverse Hospital Environment? Hospital Day #1: 1) Cellulitis. Start Vancomycin. Serial exams. 2) Pain. Hydrocodone and acetaminophen. Laxative. 3) DM2. Continue home medications. Target good glycemic control. 4) DVT prophylaxis. Age and anticipated immobility. →Lovenox 40mg SQ QD. On night of first hospital stay, she can’t sleep. X-cover writes for ambien 5mg qhs. Emory Reynolds Program Emory Hospital Medicine Service Case #2: Adverse Hospital Environment? Hospital Day #2: Not oriented to month or year. Correctly identifies place. NL vitals and O2 sat. NL PE Bedside BG = 54. Other labs NL. You start D50W and halve glyburide to 5mg qd. Check back in on her 45 minutes later: fully oriented to time and place, NL BG. On night of 2nd hospital stay, she complains of itching and so cross cover writes for hydroxyzine 10mg q6hrs prn. Any thoughts, commentary? Emory Reynolds Program Emory Hospital Medicine Service Case #2: Adverse Hospital Environment? Hospital Day #3: On rounds again not oriented to month or year. VS review normal except for a single HR recorded at 100 at 5am. O2 sat NL. On PE you note an irregular rhythm, rate ~90s. BG = 55. EKG → afib, rate 98. CBC NL, Trop negative, CMP NL except BG 64. What’s going on? Emory Reynolds Program Emory Hospital Medicine Service Case #2: Adverse Hospital Environment? The most likely cause of this patient’s hospital complications is: A) Polypharmacy with adverse effects from hydrocodone and ambien B) Adverse drug event from hydroxyzine C) Surreptitious ETOH use and withdrawal following hospitalization D) Forced adherence with adverse effects from outpatient medications glyburide and synthroid Emory Reynolds Program Emory Hospital Medicine Service Case #2: Adverse Hospital Environment? The most likely cause of this patient’s hospital complications is: A) Polypharmacy with adverse effects from hydrocodone and ambien B) Adverse drug event from hydroxyzine C) Surreptitious ETOH use and withdrawal following hospitalization D) Enforced adherence with adverse effects from outpatient medications glyburide and synthroid Emory Reynolds Program Emory Hospital Medicine Service Case #2: Adverse Hospital Environment? Enforced Adherence in the Hospitalized Elderly Anticipate likelihood of poor compliance before hospitalization e.g. from HPI…patient not responding to appropriate or increasing doses of medications Suspect when you see different problems evolving at once e.g. in hospital…new confusion, hypoglycemia, low BP, atrial fibrillation Emory Reynolds Program Emory Hospital Medicine Service Case #2: Adverse Hospital Environment? Enforced Adherence in the Hospitalized Elderly Why Enforced Adherence is Particularly Relevant to Your Elderly Patient: High Incidence: Polypharmacy - non-compliance due to: multiple medications cost complexity unwanted side effects, or just lack of support Identifiable and Correctable: Homeostenosis - effects of medications dosed too high tend to reveal themselves (if you’re looking) Emory Reynolds Program Emory Hospital Medicine Service Case #3: Non-specific 81 yo male admitted with altered mental status, poor po intake, and involuntary weight loss over the last 5 weeks. Baseline: Historically very active. Until two months ago he was collaborating with his wife on writing and distributing a bi-monthly newsletter to the WWII vets from his military battalion. Until 1 month ago was driving and doing own yard work. Emory Reynolds Program Emory Hospital Medicine Service Case #3: Non-specific Four weeks ago went to PCP with fatigue, rising agitation, and with R shoulder pain. Told he probably had early Alzheimer’s. Given Rx for Bextra for OA of shoulder. Two weeks ago went back to PCP reporting same symptoms and now poor appetite. PCP note describes “focal point tenderness over trapezius.” Given Rx for Flexeril and Darvocet for “muscle spasms,” referral to outpatient geriatric-psychiatrist. Today he agreed to let his wife to drive him to the ER b/c he felt like he couldn’t get out of bed. He ate almost nothing yesterday. The geriatric-psychiatry appointment is four days away. Emory Reynolds Program Emory Hospital Medicine Service Case #3: Non-specific Collateral history: Wife tells you he’s seeing “little women” and “little tigers.” Patient corroborates and goes on to say he’s very much aware that they can’t be real and that he knows nobody else sees them. Wife also points out that: 1) this 5-week illness interrupted a course of chemotherapy he’d been getting as an outpatient for bladder CA 2) they’ve been to another hospital ER twice in the last month to try to get this explained Emory Reynolds Program Emory Hospital Medicine Service Case #3: Non-specific Other collateral history: You talk to the nurse taking care of him in the ER. She tells you he seemed to choke a bit on the sandwich she’d given him an hour ago. Patient and wife acknowledge that he’s had difficulty swallowing his food. Emory Reynolds Program Emory Hospital Medicine Service Case #3: Non-specific PMH: 1. Bladder CA. Currently receiving outpatient chemotherapy. 2. H/O Prostate CA. S/p prostatectomy. 3. H/O Tobacco Abuse. Quit 20 yrs ago after 25 pack-years. PSH: 1. S/p cholecystectomy 2. S/p prostatectomy Emory Reynolds Program Emory Hospital Medicine Service Case #3: Non-specific Allergies: NKDA Meds: 1. 2. 3. 4. 5. Risperdal 0.5mg bid MVI c iron daily Bextra qd Darvocet prn Flexeril prn ROS: no fever, chills, malaise. No abd pain, N/V/D. No SOB/cough. No focal weakness but poor balance. No CP/LH/syncope. Emory Reynolds Program Emory Hospital Medicine Service Case #3: Non-specific PE: T 100.8°F HR 102 BP 120/72 RR 16 Gen: non-toxic appearing, well-nourished HEENT: OP very dry; neck supple; NL vision CV: No JVD, RRR, II/VI systolic murmur at RUS border Lungs/abd: normal Ext: No synovitis. No lesions. 2+ peripheral pulses. Skin: Warm and dry. No rash. Neuro: A&O to time, place, and situation, and o/w NL Lab: Na 130, Cl 96, Cr 1.4, WBC 12K (85% neutrophils), UA ketones, 10-25 RBCs and WBCs. No leuk est or nitrite. EKG: NSR, 96. Micro: urine culture growing gram+ cocci Emory Reynolds Program Emory Hospital Medicine Service Case #3: Non-specific Hospital Day #1: 1) Hyponatremia. Appears hypovolemic. NS at 150cc/hr for 2L and re-evaluate. 2) Fever/leukocytosis. 3 sets of blood cultures over next 24 hrs. No antibiotic until infection confirmed. TEE if blood cultures c/w SBE. 3) Dysphagia. Observe at bedside. Formal swallow evaluation. Nutritional assessment and support. Aspiration precautions. 4) DVT prophylaxis. Age and anticipated immobility. →Lovenox 40mg SQ QD. Emory Reynolds Program Emory Hospital Medicine Service Case #3: Non-specific Hospital Day #2: In AM, urine cultures growing Enterococcus. In PM, blood cultures also growing Enterococcus. – Start Ampicillin and Gentamicin Follow Cr closely – Order TEE Emory Reynolds Program Emory Hospital Medicine Service Case #3: Non-specific Hospital Day #3: TEE: aortic leaflet vegetation, 1cm; moderate-severe AI, NL LV Subsequent Hospital Course: Hallucinations, anorexia, fatigue, and dysphagia resolved. Started ace-inhibitor. Follow Up: Completed 2 weeks Amp/Gent, another 4 weeks Ampicillin. Returned completely to previous baseline. Echo 3 months later with no changes in LV. Emory Reynolds Program Emory Hospital Medicine Service Especially if Your Hospital Lacks Specific Geriatric Processes… 1) Your elderly inpatients need you to minimize the impact of hospitalization, with special emphasis on appropriate prescribing 2) Your elderly inpatients need you to decipher the root cause of their non-specific signs & symptoms 3) Your elderly inpatients need you to be able to explain and address their sinus tachycardia, T > 99, and leukocytosis Emory Reynolds Program Emory Hospital Medicine Service