What hot topics and best practices in hospital medicine can you expect to hear more about in 2020 and beyond? We asked two experts for their take. Benjamin Frizner, MD, MBA, is Medical Director at BridgePoint Hospital in Washington, DC. David Fromberg, MD, is a hospitalist and family physician based in Marquette, MI.
Q. Let’s turn the discussion to key clinical areas. What important developments in neurology should hospitalists be aware of?
A. Dr. Fromberg: The use of telemedicine to assess patients with possible acute cerebrovascular accident or seizure is becoming important. But keep in mind that it is only one factor involved when making medical decisions. Communication, discussion, and documentation should take place with all involved players: patient, family members, EMS crew, nursing staff, ED physicians, and accepting hospitalists.
Q. What about infectious diseases?
A. Dr. Frizner: Sepsis is one of the trickiest conditions we treat. It is important for hospitalists to keep up with how to manage it. There are so many causes of sepsis, including pneumonia, urinary tract infection, C difficile, and soft tissue and abdominal infections. The most important thing to remember is that early, aggressive intervention decreases mortality.
Dr. Fromberg: The addition of reflex lactic acid orders three hours after admission to the ED can be useful in determining appropriate level of care. An ED provider may think that a patient can be appropriately admitted to the floor, but a safe bet would be to wait for pending results before placing admission orders.
Q. What’s important in the area of nephrology?
A. Dr. Fromberg: Temporizing measures for reducing serum potassium levels have been a mainstay in initial treatment, including IV fluid, IV calcium gluconate, IV insulin, IV dextrose, nebulized albuterol, and even diuretics. Recently, there has been a shift away from using the cation exchange resin or sodium polystyrene sulfonate, since it has not been shown to be more effective in removing potassium from the body than laxative therapy. There is also a small chance that it can produce severe side effects, particularly intestinal necrosis, which can be fatal. I have also seen studies advocating the use of potassium binders, but this option is not currently available in most hospital pharmacies. It is always wise to discuss any concerns with the on-call nephrologist before moving forward.
Q. What about managing cirrhotic patients?
A. Dr. Fromberg: I think it’s important to calculate the patient’s MELD score. I have witnessed a number of cases where a hepatic patient is admitted overnight, waits to see a GI specialist, and then the daytime attending physician is tasked with the time-consuming struggle of trying to transfer a patient to a liver transplant center. Consider referral to a hepatologist or liver transplant center for patients with a MELD score ≥10.
Q. What are you seeing regarding the management of diabetic ketoacidosis?
A. Dr. Fromberg: Every hospital that I have worked at has had their own system in place for managing DKA patients. Some have allowed patients to be managed on floors, while others require ICU admission. Some have had papers with check boxes, while most current locations have order sets in place in their EMR. In the future we should see a standardization in the DKA treatment process nationwide through the use of data-driven technology, sensors, and smart-EMRs.
Q. What about in the area of hematology and oncology?
A. Dr. Fromberg: I think that more hospitals will have palliative care/hospice care teams in place as the responsibility for end-of-life discussion is increasingly handled by either hospitalists or hematology/oncology team members. These are often time-intensive discussions that can hinder optimizing time management for rounding.
Q. What about important developments in critical care?
A. Dr. Fromberg: The use of IV hydrocortisone, IV thiamine, and high doses of IV vitamin C is still being debated. I have seen clinicians use these measures, and others forego them. It will be interesting to see the outcomes of ongoing trials that will help us answer important questions.
Q. Lastly, what is the most important trend hospitalists need to be aware of for 2020, and how would you advise hospitalists to respond?
A. Dr. Fromberg: The implementation of interdisciplinary team (IDT) rounding is underway at my hospital, and it is causing a great deal of commotion. This is a widespread team effort to improve communication, patient care, planning, and discharges. Goals are measured using different metrics, including: location of information sharing, attendance, facilitator/leader, team member roles, physician involvement, and debriefing, which consists of identifying actionable items and responsible team members with plans for follow through.
Attendance by all IDT staff is required. Team members participate by identifying and applying critical thinking skills to mitigate issues. There has been much groaning about increased time to round but, just as with any new program, the kinks are being worked out. I suggest hospitalists embrace this change — seek out ways to improve problem areas, and the results will become evident.