Download Hospitalist Bootcamp

Hospitalist Bootcamp
Dr Scott Samis Hospitalist at PLC
Dr Henry Lo Hospitalist SHC
Dr Bhavini Gohel Hospitalist at SHC
Disclosures
None
Objectives
• Overview of the hospitalist program
• Tips to succeed during the rotation
• Expectations of the residents and Evaluations
• Clinical Pearls on common medical problems
Why?
• Requests from residents as no formal teaching during rotations
• Ensure you are prepared
• Change in the curriculum fewer acute care rotations
• We want you to get the best out of the rotation
• We want you to succeed
A role of Hospitalist
• Family doctors that provide inpatient care
• Unique to North America in that done by GP’s as well as Internists
• In the major cities hospitalists do not have a previous relationship
with their inpatients (exception)
• Patients are general, complex medical and ALC patients
• Often co-managed with other sub specialities
• Paid via ARP
Criteria for admission
• Can be rounded on once per day.
• Cannot be unstable
• There is no other speciality that the patient would be better cared
under
• Often a grey area
• Our scope of practice has changed over time
• Conditions we will not manage by us: Bacterial meningitis,
endocarditis, complicated biliary obstruction, IBD (except at SHC),
DKA, Hepatic encephalopathy, High risk GIB, Severe HONKS, severe
metabolic derangements………
Expectations of a Resident
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Call your preceptor before hand arrange a meeting time and place
Arrive on time
Have goals and objectives
Expect to carry 5-6 patients on your first day this will increase to 8-10
Introduce yourself to charge nurse and touch base daily regarding issues for your
patients
Give each unit your pager and patients you will be looking after
Expected to fully manage patients- including family meetings and updates, consultations
etc
Should be seeing 3 patients an hour
Handover to on call if you need to
Histories/Progress notes/Plans some Pearls
• Histories-Call family and facilities for collateral, Comprehensive past
medical history including names of consultants, ensure patients
BADLS and IADLs are covered. Use Netcare and SCM
• Progress notes- ensure notes are written in way that the on call can
reasonably manage the patient without having to go through the
entire chart. If pt is sick ensure a good written plan is in place
• Plans- Ensure issues and plan outlined clearly and with all
conversations with family and consultants documented
Discharge summaries
• Typed or dictated
• Ensure a clear plan outlined, relevant consultants copied, dates of
appointments listed
• Details regarding primary dx and other diagnosis affects length of stay
Presentation- admission
• Brief ID
• Presenting complaint
• Overview of relevant medical conditions
• Summary of HPI
• Summary of relevant physical exam findings
• Summary of relevant investigations
• Your issues and then plan
Presentation post admission
• Summarize reason for admission
• Relevant PMH
• Course in hospital and treatment so far
• Your current plan
• Disposition
Medication Reconciliation
The Evidence: on Admission
• Errors in medications: 54%,
• 40% potential serious harm.
Etchells et al.
The Evidence: Acute Care
Canadian Adverse Events Study
• 1 in 9 patients are potentially given the
wrong medication or wrong dose.
Norton et al.
The Solution:
Med Rec is where we take this…
and turn it into this…
(for now…)
1.
2.
3.
Document Sources
List medications, dosage, route
and frequency
Prescriber reconciliation where
medications are indicated to
continue, discontinue, hold, or
change. Also indicate the reason
for why
Med Rec at Discharge
•Compare discharge medications with admission medications
•Explain to next care provider the reasons for the changes
•Ie reason for new medications, changed meds, stopped medications
SCM order sets
Allied Health services
• Team consists of PT, OT, Transition services, SW
• Services each team offer
• MDM Rounds
• Will help with disposition planning
Disposition
• Home- Home care, Palliative home care, C3 program
• Lodge/retirement residence
• Supportive living- SL4 vs SL4D
• Long term care
• Hospice
Clinical Pearls
Acute Stroke
Case 1
•You get the following page at 8am from the ward nurse:
•Mrs Brain is 62 yo female admitted for an unrelated reason. This
morning she has a weak left arm and left leg. She is also speaking
“funny.” Can you please come assess?
• Profile:
•HTN , smoker
What are your thoughts?
•Stroke Mimics
•Seizures with accompanying neurologic deficit
•Todd’s Paresis
•Systemic infection
•Brain tumor
•Toxic-metabolic disorders
•Hyponatremia
•Hypoglycemia
•Conversion disorder
Priorities
•Stabilize the patient
•Establishing the diagnosis by history and physical examination
•Obtaining blood tests, an ECG
•Obtaining a head CT
Stabilize the patient
•Bedside
•What is the patient’s level of consciousness?
•Airway and Vital Signs
•Is the patient in respiratory distress?
•What is the blood pressure?
•What is the heart rate?
•What is the temperature?
Establishing the diagnosis by history and physical
examination
•History
•**Establish when the patient was LAST SEEN WELL
•What are symptoms?
•Antecedent TIAs?
•Medical history and medication history
•Physical Examination
•National Institutes of Health Stroke Scale or NIH Stroke Scale (NIHSS)
Investigations
•CBC, Electrolytes, Creatinine, glucose, INR/PTT, ECG
•Cerebral infarction cannot be disginuished with certainty from
intracerebral hemorrhage on Hx and PE
•CT Scan
•MRI
Treatment
•If within the timeframe for thrombolysis
•Collaborate with stroke neurologist for thrombolysis
•Outside timeframe for thrombolysis
•Antiplatelets
Thrombolysis
• Onset of symptoms < 4.5 hours before beginning treatment
• Exclusion Criteria
• Historical
•Significant stroke or head trauma in the previous 3 months
•Previous intracranial hemorrhage
•Intracranial neoplasm, AV malformation, or aneurysm
•Recent intracranial or intraspinal surgery
•Arterial puncture at a non-compressible site in previous 7 days
• Clinical
•Subarachnoid hemorrhage
•Persistent blood pressure elevation (systolic >/= 185 or diastolic >/= 110)
•Serum glucose < 2.8
•Active internal bleeding
•Hematologic
•Platelet count < 100
•Current anticoagulant use INR > 1.7 or PT > 15 sec
•Current use of direct thrombin inhibitor or direct factor Xa inhibitor
•Head CT scan
•Evidence of hemorrhage
•Relative exclusion criteria
•Only minor and isolated neurological signs
•Rapidly improving stroke symptoms
•Major surgery or serious trauma in prior 14 days
•GI bleeding or Urinary tract bleeding in previous 21 days
•MI in prior 3 months
•Pregnancy
A few points
•Acute Strokes are infrequently encountered on hospitalist service
•If you are at any site other than FMC, contact the stroke neurologist
early if index of suspicion high for acute ischemic stroke (even prior
to CT scan) if still within the window for thrombolysis
•Involve neurology with care plan
Secondary Investigations
•What are the investigations for secondary prevention of ischemic
stroke?
•fasting lipid panel and liver enzymes: for consideration of starting statin
therapy
•echo heart : assess for cardiac source of emboli
•holter moniter: assess for atrial fibrillation
•Anticoagulate if atrial fibrillation found
•carotid dopplers (if CTA not done): assess extent of carotid stenosis and
consideration of carotid endarterectomy
•referral to stroke prevention clinic
Common in hospital Complications post stroke
•repeat stroke
•hemorrhagic conversion
•seizures
•aspiration pneumonia
•PEG tube placement
•delirium
•depression
DVT and PE
Case 2
•62 yo man presented with 5 day history of worsening dyspnea and
orthopnea after returning from a 3 day business trip to Russia.
•On exam: HR 102; BP 110/60; O2 Sat 86% RA
•Diagnostic approach?
D-dimer
- For admitted
patients many will fall to
high risk category
- Much less useful in
older patients >80,
patients with cancer, or
pregnant women
NEJM, 2008
Imaging
•US of legs
•detects about 20% of patients with pulmonary embolism
•Positive test essentially establishes diagnosis of PE
•CT
•Requires IV contrast
•VQ
•Alternative when contrast dye is a concern
•Less available: M to F business hours
Predictor of Severity
•Prognostic Factors
• Shock and right ventricular dysfunction
•Clinical – clinical evidence of shock
•Radiologic – by echo or CT
•Labs – BNP and/or troponin elevation
•RV thrombus
•Coexisting DVT
PE Severity Index
(PESI)
Simplified PE
Severity Index
(sPESI)
Low risk = 0
High Risk > 1
Arch Intern Med. 2010;
170(15):1383-1389
Therapy
•Hemodynamically unstable patients
•Thrombolytic therapy
•Embolectomy
•Hemodynamically stable patients
•Anticoagulation in patients with low risk of bleeding
•IVC filter if contraindication to anticoagulation or an unacceptably high
bleeding risk
Anticoagulation
Key Players
•Unfractionated heparin - Potentiates the action of antithrombin III and
thereby inactivates thrombin and prevents the conversion of fibrinogen to
fibrin
•Low molecular weight heparin
•Warfarin – blocks a vitamin K dependent step in clotting factor production
•Dabigatran (Pradaxa) – direct thrombin inhibitor
•Rivaroxaban (Xarelto) – Factor Xa inhibitor
•Apixaban (Eliquis) – Factor Xa inhibitor
•Unfractionated heparain – IV drip
•Severe renal failure (CrCl < 30)
•High likelihood of acute reversal of anticoagulation
•Low molecular weight heparin
•Active cancer
•Pregnancy
•Bridging to warfarin or (transitioning to dabigatran)
•Warfain
•Requires bridging with heparin
•Renal failure
•Requires following INR
Direct factor Xa and thrombin inhibitors
•Oral factor Xa inhibitors: rivaroxaban, apixaban
•Evaluated as monotherapy
•Thrombin inhibitors: dabigatran
•In studies all patients treated with heparin prior to their
administration
•Exclusions
•CrCl < 30
•pregnant
Bridging LMWH 
•LMWH  warfarin
•Initiate LMWH and warfarin on day 1
•Stop LMWH after no less than 5 days and when INR is stable at 2.0 or more
for 2 days
•LMWH dabigatran
•Initiate 5 days of LMWH
•Start dabigatran 0 to 2 hours prior to time of LMWH would be due
•Direct factor Xa inhibitors
•Were evaluated without prior administration of heparin
(monotherapy)
•No bridging required to initiate anticoagulation
Case 3 Bridging Peri-operatively
• Mrs Fast Heart is 80 yo female who has a history of atrial fibrillation
and is on warfarin. She has been complaining of weakness and
fatigue. She is found to be anemic at her GP’s office but no signs of
overt bleeding. She is admitted to hospital for investigation of her
anemia. GI plans to complete an upper and lower endoscopy as an
inpatient.
•How should her anti-coagulation be managed peri-operatively for GI
investigations?
Risk of thromboembolism vs risk of bleeding
•Estimating thromboembolic Risk
•Atrial fibrillation: CHADS2 score
•Prosthetic heart valve
•Recent Thromboembolism
•Risk of bleeding
•Discuss with GI or surgeon and depends on the procedure
•Some endoscopists will tolerate an elevated INR
Bridging Anticoagulation
•Typically interrupting warfarin and administration of a short acting
anticoagulant such as LMWH or unfractionated heparin
•Examples when appropriate:
•Embolic stroke or systemic embolic event within the previous 12 weeks
•Mechanical mitral valve
•Mechanical aortic valve
•Atrial fibrillation and very high risk of stroke (CHADS2 score 5 or 6, stroke
within the previous 12 weeks)
•VTE within 12 weeks
•Recent coronary stenting
•Previous thromboembolism during interruption of chronic anticoagulation
Case 3 Bridging Peri-operatively
• Mrs Fast Heart is 80 yo female who has a history of atrial fibrillation
and is on warfarin. She has been complaining of weakness and
fatigue. She is found to be anemic at her GP’s office but no signs of
overt bleeding. She is admitted to hospital for investigation of her
anemia. GI plans to complete an upper and lower endoscopy as an
inpatient.
•How should her anti-coagulation be managed peri-operatively for GI
investigations?
Example
•If otherwise healthy  CHADS2 score 1 for age.
•Can likely avoid bridging
•If Mrs Fast Heart more comorbidites
• Congestive heart failure
• Hypertension
• > Age 75
• Diabetic
• Prior stroke
• Will likely require bridging if wait is prolonged in hospital
• Will likely require bridging if waiting as an outpatient
• BUT WHAT HAPPENS for ADMITTED PATIENTS
•Typically in hospital:
• Warfarin is held once decision for endoscopy made
• INR is monitored every day
• If patient is low risk for thromboembolism, consider reversal with vitamin K
• GI investigations completed once INR is at target for the GI doctor
• If patient high risk for thromboembolism and procedure is delayed, consider
LWMH/unfractionated heparin to bridge
• Post procedure started on LMWH/Unfractionated heparin and then bridged back to
warfarin
Case 4
•67 yo male on warfarin
and has an acute upper
GI bleed. He is dizzy and
pre-syncope. INR is 7.
•How do you reverse the
anticoagulation?
Management of Life-Threatening Bleed on
Warfarin
•Warfarin
•Stop warfarin
•Vitamin K – 10 mg IV
•fresh frozen plasma
•or
•Octaplex: for serious bleeding and INR > 2
•Dosing depends on weight and INR
What about reversal of the other
anticoagulatants?
•Rivaroxaban and apixaban – no antidote
•Interval since last dose. Anticoagulation to have resolved after 5 half-lives
•Drug removal from GI tract: ie activated charcoal
•Antifibrinolytics: tranexamic acid
•Prothrombin complex
•Dabigatran
•As above but antidote idarucizumab
Alcohol withdrawal
Alcohol withdrawal
• CIWA-subjective scoring system to determine presence/severity of
withdrawal-includes things like headache, hallucinations, nausea
• Ativan-shorter acting; can be given sl/po/IV/IVP
• Valium-longer acting; can only be given po/IVPB
• Antipsychotics-adjuvant to Benzos for more severe Withdrawal,
Delirium Tremens
• Beta Blockers(Propranolol),Clonidine-used to blunt adrenergic
overdrive if Tachycardic, Hypertense, Febrile in more severe
withdrawal
• Withdrawal can develop 1-7 days after last alcohol intake
• Keep in mind if delirium develops after admission for another
reason
Electrolytes
Electrolytes
• Hyponatremia-Hypovolemic,Isovolemic,Hypervolemic
• useful labs:Lytes,BUN,Cr,Serum and Urine Osmol,Urine
Lytes,TSH,Cortisol,U/A
• At what level do symptoms occur?
• Don’t overcorrect too fast-risk of Central Pontine Myelinolysis
• Hypernatremia-usually volume related,also Diabetes Insipidus again
don’t overcorrect too fast
Electrolytes
• Hyperkalemia-what level is problematic
• how to determine if level is needing emergent therapy
• therapies:shifting vs elimination
• Hypokalemia-arrhythmias,muscle weakness
• replacement-po vs IV
Pneumonia
Pneumonia
• Antibiotic treatment-multiple options, tailor according to clinical
scenario,comorbidities,suspected organisms
• start broad,narrow as more information available
• po vs IV
• Duration of therapy-5 vs 7 vs 10 days vs longer
• Parapneumonic effusions-reactive,layer out,exudative and not
purulent on thoracentesis tend to not make people ill
Pneumonia
• Empyema-fluid is infected
• Tend to be loculated,don’t layer out,enhancing rim on CT Scan
• On thoracentesis are exudative,purulent,may or may not grow
organisms,high protein,low glucose
• Need to be drained
• Abscesses-Drainage,prolonged antibiotics
• keep TB,cancer in mind
• Hospital Acquired (HAP) vs Community Acquired (CAP)
• Different organisms therefore different antibiotics
Pancreatitis
Pancreatitis
• Bloodwork: CBC,Lytes,BUN,Cr, Liver Enzymes,Lipase,Calcium,Alb
• Blood Gases if sicker
• Radiologic-CXR,Ultrasound,CT Scan,MRI,Alcohol,others
• Causes:Gallstones if evidence of Gallstones-ERCP vs
Cholecystectomy+/-ERCP
• IV Fluid,NPO,Analgesics
• Scoring Systems:Ranson’s Criteria,BISAP Score for Pancreatitis
Mortality (BUN,Impaired Mental Status,SIRS Criteria,Age,Pleural
Effusion),APACHE 2
• To feed or not to feed- when to worry about feeding
Congestive heart failure
Congestive heart failure and Atrial fibrillation
• A-fib-rate vs rhythm management
-what HR to aim for
-what drugs-choices,pitfall
• A-fib with RVR+CHF often “chicken or egg” situation
• CHF-Left CHF vs Right CHF vs HF of Preserved Ejection
Fraction(Diastolic Dysfunction)
• Diagnosis-Hx,Physical,CXR,EKG,Bloodwork-NT proBNP
Congestive heart failure
• Treatment-acute is Diuresis +/-Nitrates
-BIPAP
-ACEI vs ARB
• Echo-determine cause of CHF-treatments will vary
• New drugs-Entresto (Angiotensin Receptor Neprilysin InhibitorSacubitril/Valsartan);Ivabradine (If Channel Blocker)
• Other useful classes of drugs: Aldosterone
Antagonists,Hydralazine,Nitrates
• Digoxin
Infections
Infections
• Sepsis- Fluids fluids and fluids, Urine output, ensure blood cultures
are done, Staphyl aureus bacteremia and continuous bacteremia
think of endocarditis (indicates persistent endovascular infection)
• Wounds- Always look at your wounds and check to see if they probe
to bone. Management- Vac dressing
• Osteomyelitis - When do you suspect Osteomyelitis? Investigation
of choice, definitive diagnosis
• UTI- Urine analysis, Male- think of why they have a UTI
• Cellulitis- Very RARE to have bilateral cellulitis think of other
diagnosis, If not healing feel peripheral pulses, Abx choices
• Aspiration pneumonia vs Aspiration pneumonitis
Delirium and Dementia
Delirium
• Delirium- what is it
• Hypoactive and hyperactive?
• History is KEY!
• Work up- CBC, lytes, Cr, Ur, TSH, Liver enzymes, Trop, ECG Urine
culture, CXR, EEG and LP
• Management- Treat underlying causes, Antipsychotics is aggressive
and WAIT!
• Prolonged delirium- Tough!
• Cognitive assessments in Delirium
• Bottom line need to recognise it EARLY and Prevent (Melatonin)
Dementia
• History History History
• Types of dementia- Alzheimer's, Vascular, Lewy Body dementia,
Parkinson's disease Dementia, Frontol- Temporal dementia etc
• Usually come in due to caregiver burnout
• Testing- MOCA, ILS/Functional assessment, RUDAS- OT
• Ensure medical work up is complete
• Hospital will make them worse
Dementia
Managing aggressive behaviours
• Why are they aggressive- Pain, infections, recent changes in
medications other etiology
• Start pain and behavioural mapping see if there is pattern
• Behavioural interventions
• Antipsychotics- Risperidone, Olanzapine, Seroquel
• Other drugs- SSRI, Trazadone, Memantine, Donepezil
• Disposition- this is challenging
Falls
• History again is key- Loss of consciousness, Medication changes.
History does tend to happen over time
• Ensure a full examination is done including MSK and Neuro exam
• Often multifactorial
• Invx- Basic labs, echo, holter, CT/MRI brain, EEG, ?cartoid dopplers,
postural BP, if Diabetes check Blood sugars
• Treatment- Multi disciplinary approach
Pain in the elderly
• Use the pain ladder but avoid NSAIDS
• Pain management is very different in the elderly
• Use low doses in those that are opioid naive and titrate slowly
• Drugs that can be used in those with renal impairmentHydromorphone, fentanyl
• Have a conversion chart remember they all vary slightly
• PCAs and Infusions
• Alternative ways to manage pain- Radiation, local injections,
Kyphoplasty
Housekeeping
• Mental health forms
• PD and EPOA
• Medical assessment forms
• Capacity assessments
• Goals of care
Evaluations- How to succeed
• We want the skills you gain to be transferable to your practice
• Take ownership of your patients look over relevant past medical
history
• You are detectives
• Be able to recognise sick patients and initiate basic work up and
then call for help
• Devise a reasonable good plan with rationale
• Be able to consult and recognise relevant consult services
How are we going to help- Resident modules
Case-Based Worksheet for Hospitalist Patients
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What are the criteria for admitting this patient, as opposed to managing them as an outpatient?
Why would they come to the hospitalist service (compared to a subspecialist or a transition bed)?
What is your differential diagnosis? Include at least three most likely, as well as at least one
sinister hypothesis.
What investigations will you order? What ongoing follow-up should be done during the
admission?
What will be the management principles for the most likely condition? Include both
pharmacologic and non-pharmacologic management. What contra-indications could exist for
these choices? Be ready to discuss these with your preceptor in detail
What complications could arise during this patient’s stay? How could you attempt to prevent
these?
What other resources can you enlist to assist you in the management of this patient?
How will you know this patient is ready for discharge – what parameters will be your guide and
what needs to be in place at their residence?
Questions?
Thank you
• Bhavini Gohel: [email protected] - SHC educational site lead
• Scott Samis
• Henry Lo