NEW APPROACHES IN INPATIENT MEDICINE THAT MIGHT CHANGE YOUR PRACTICE - PowerPoint PPT Presentation

NEW APPROACHES IN INPATIENT MEDICINE THAT MIGHT CHANGE YOUR PRACTICE Jack Chase, MD FAAFP FHM Director of Operations, UCSF Family Medicine Inpatient Service San Francisco General Hospital Assistant Clinical Professor UCSF Dept. of Family and Community Medicine

Presentation Goal & Objectives • Discuss recent innovations which may impact family medicine across the continuum of care • Highlight selected evidence • Give links to resources for point-of-care use

Disclosures & Acknowledgements • No disclosures • Appreciation to Tracy Minichiello (UCSF) for teaching on anticoagulation at UCSF Hospital Medicine Update, and to Steven Cohn MD (Miami) & Nick Fitterman MD (Hofstra) for teaching on steroids in CAP at SHM National Conference.

What’s Pnew in Pneumonia? Mr. Lattimore, a 67 yo man, comes to the office with 3 days of productive cough, dyspnea and fever • PMHx: weekly wound clinic visits for venous stasis • CURB-65 = 1 (~2% mortality) You elect to give outpatient treatment with close follow-up

Questions? • What kind of pneumonia is this? • What antibiotics to prescribe? • Duration of therapy? • Other EBM treatments?

Healthcare Associated Pneumonia • 2005 & 2007 ATS/IDSA guideline: different treatments for CAP, HCAP, HAP, VAP • based on microbiology studies and assumption that each diagnosis has distinct organisms, drug susceptibility, etc. • 2016 IDSA guidelines remove HCAP • Studies: HCAP ≈ CAP flora • Risk for MDR organisms ≈ patient-specific factors (not simply interaction with healthcare)

Why does it matter? • Empiric treatment for community-living patients with pneumonia irrespective of recent healthcare exposure OP (uncomplicated) macrolide OR doxycyline OP (comorbidities)* respiratory FQ or β -lactam + macrolide Inpatients (non-ICU) Ceftriaxone + macrolide OR doxycycline • Shorter courses (5 days) of antibiotics are effective • New IDSA CAP guidelines coming Summer, 2017! • Validated MDR organism risk screen, ?new antibiotic recs

‘ Roid rage! • 2005 & 2007 IDSA guidelines: no recommendation on corticosteroids in pneumonia • Consider in septic shock and non-responders to antibiotics • 2015: new meta-analysis in Annals of Internal Medicine evaluates corticosteroids in CAP

Steroids for CAP? • Meta-analysis of 13 placebo- controlled RCT’s among inpatients with CAP (N > 2000): • Decreased mortality (NNT 38, sCAP: NNT 7) • Lower risk of ARDS (NNT 38) • Decreased need for mechanical ventilation (NNT 38) • Decreased length of stay (1-2.9 days less) Benefit most evident among patients with severe CAP

Why does it matter? • Steroids appear to benefit hospitalized patients with severe CAP (eg. hospitalized in ICU) • Start early! (within 36 hours) • No consensus on dosing. Trials used short course ≈ COPD exacerbation (eg. prednisone 40mg QD x 5 days) • Post-discharge patients may be finishing steroids

Pneumonia Prevention • ACIP 2015 immunization guidelines • Adults > 65 yo and 19-64 with comorbidities* should receive two phase pneumococcal immunization 13-valent pneumococcal 23-valent pneumococcal → 12 months → conjugate vaccine (PCV13; polysaccharide vaccine Prevnar 13) (PPSV23; Pneumovax 23) *Comorbidities: diabetes mellitus, chronic lung or heart disease, tobacco use, alcoholism, chronic liver disease or cirrhosis, functional asplenia, cerebrospinal fluid leaks, or cochlear implant. • Reduce PPI use (RR 1.5 for CAP, most prominent in first month of use). No increase RR with H2B’s.

SOFA’s and CVP’s and CVC’s? Oh my! Ms. Cortez, a 37 yo woman with DM2, drops in to the office with dysuria, flank pain, fever and vomiting. VS: T39C, 96/54 , P126, R26 , O 2 Sat 98% Exam: ill, +R CVAT

Questions? • Next management steps? • Location of care? • Risk of adverse outcomes?

Evolution of sepsis SIRS Early Goal Directed Surviving Sepsis Process Trial Therapy Campaign Bone RC et al. Chest 1992 Rivers et al. NEJM 2001 Partnership (IHI, SCCM, ProCESS Investigators. NEJM ESICM), 2003-present 2014 ACCP/SCCM consensus Open, randomized, partially Expert meta-analytic Randomized, multi-center conference blinded, single center trial guideline of existing trial in tertiary hospitals publications - Defined SIRS, sepsis, - Aggressive & early - Comprehensive EBM - EGDT = protocol- severe sepsis, septic treatment (IVF, Abx, on diagnostic and based standard shock lactate, CVC for CVP treatment therapy = usual care & scVO 2 , considerations in severe sepsis - SIRS = two or more transfusions & of: T > 38°C or < vasopressors) - Emphasis on early - Common elements = 36°C; HR > 90; R > 20 recognition and early IVF, broad or PaCO 2 < 32; WBC - ↑ oxygen delivery treatment spectrum Abx, > 12K or < 4K or > via hemodynamics lactate and ↑ 10% bands - Popularized sepsis perfusion - ↓ mortality vs bundle - Sepsis = SIRS + standard care by infection 15%.

qSOFA and Prognosis • Quick Sepsis Related Organ Failure Assessment; Seymour et al, JAMA 2016 • Retrospective analysis of 1.3 million EHR encounters in 12 hospitals in Pennsylvania • 3 variable tool (GCS < 15, RR >22, SBP < 100) = risk of poor outcome in patients with suspected infection outside the ICU • Score > 2 = ↑ ICU LOS & 3-14x mortality

Why does it matter? • qSOFA = 3-item risk assessment tool in sepsis • More predictive than SIRS → who is at high risk? • Clinical handoffs (eg. from office to ED) • Prognostication to pts/families re: severity of illness • Key treatment elements from prior studies: • Give broad spectrum antibiotics and fluids ASAP • Lactate & volume/perfusion assessment guides IVF + interventions

Anticoagulation in transition Mr. Tran, a 72 yo man with atrial fibrillation and HTN is scheduled for partial thyroidectomy for a non-toxic goiter. CHA 2 DS 2 -VASC: 2 (2.2% CVA/yr) HAS-BLED: 1 (~1% major bleeding/yr) Meds: warfarin, HCTZ

Questions? • Perioperative anticoagulation? • Bleed risk vs thrombosis risk? • Efficacy and choice of agent?

To Bridge or Not to Bridge? • Randomized, double blind RCT of 1884 patients at multiple US sites • Mean CHADS2 score = 2.3, ie. low-moderate risk for CVA ; multiple exclusions including for mechanical valves, recent CVA or embolism • Compared perioperative treatment: LMWH vs placebo in patients with AF on chronic warfarin treatment

Rechenmacher and Fang, JACC 2015

Bridge Trial Results • No bridging = bridging in prevention of arterial thromboembolism (ie. CVA) over 30 days of follow-up among patients with AF at low-moderate CVA risk. • Bridging increased major bleeding (OR 3.6) . • N.B. Rate of arterial thromboembolism was low (0.3- 0.4%) and very few high risk patients – patients at high risk for CVA should be considered for bridging on a case-by-case basis.

Ok , I’ll stop bridging in low -moderate risk AF. Tell me some good news… • Meta- analysis of 4 RCT’s (2014) comparing warfarin to direct- acting oral anticoagulants (DOAC’s) in treatment of non-valvular AF. • 71,000+ patients, median follow-up 1.8-2.8 years • DOAC’s significantly reduced all -cause mortality (NNT = 132), vascular mortality (NNT = 189) and bleeding mortality (NNT = 313). • DOAC’s = reduced mortality, more non -life threatening GIB, fewer fatal intracranial hemorrhages vs warfarin.

Why does it matter? • Evidence that direct-acting oral anticoagulants are superior to warfarin in reducing mortality. • Using scoring, eg. CHA 2 DS 2 -VASC and HAS-BLED allows patient-specific risk:benefit analysis of anticoagulation • Avoid perioperative anticoagulant bridging in low and most moderate risk AF patients • Anticoagulation Forum/Centers of Excellence – point-of- care resource for anticoagulation management.

Longevity and evidence-based decisions Ms. McGillicuddy, your 92 yo primary care patient, is hospitalized for progressive weakness and malnutrition. The hospitalist calls you to talk with the patient and her family about care planning.

• PMHx: COPD on 2L home oxygen, CAD s/p PCI and DES 16 years ago, HFrEF, mild dementia, HTN, HLP, osteoporosis, DJD/OA • Medications: ASA, aricept, plavix, atorvastatin, Vit D, Calcium, metoprolol, furosemide, spironolactone, senna, tylenol • SHx: Lives with in-home caregiver, uses assistance for eating, toileting and dressing. Decreased oral intake in past 6 months.

Care planning discussion • Hospitalist recommends a feeding tube and a GI consult for colon cancer screening. • The patient wants to “feel better”. • Her family asks “What’s going to help her at this point in her life ?”

Questions? • Prognosis? • Impact on care planning

www.eprognosis.ucsf.edu

Why does it matter? • Prognostication is a primary technique in medicine • Allows risk:benefit analysis of medical decisions appropriate for a patient’s stage in life • Based on “gestalt”, many medical providers routinely overestimate both longevity and potential benefit of interventions • Patients/families & providers generally support truthful prognostic disclosure and counseling with emotional support • ePrognosis = point-of-care tool for evidence-based prognostication, communication and cancer screening recommendations.