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Taking a Closer Look at Attending Rounds

Taking a Closer Look at Attending Rounds

Attending rounds has been a long-standing practice for internal medicine physicians, residents, and medical students to direct patient care, communicate with patients and families, and advance their medical education. The model of having senior physicians, trainees, and patients interact has existed for decades, but the features of these rounds have evolved dramatically in more recent years, explains Chad Stickrath, MD. “The format has shifted away from being conducted mostly at the bedside to taking place more frequently in conference rooms and hallways.” The Accreditation Council for Graduate Medical Education (ACGME) program requires that patient-based teaching include direct interaction between residents and attending physicians, bedside teaching, discussion of pathophysiology, and the use of current evidence in diagnostic and therapeutic decisions. The ACGME does not, however, provide additional specific guidelines on how to accomplish these requirements. The structure and content of contemporary attending rounds has not been well described in studies. “Some educators have expressed concerns about how patient communication and physical examination skills are being deemphasized,” adds Dr. Stickrath. Are Patient Rounds Meeting Goals? In a study published in JAMA Internal Medicine, Dr. Stickrath and colleagues sought to determine if current methods of patient rounds are meeting patient care and educational goals. The cross-sectional observational analysis was conducted at four teaching hospitals, involving 56 attending physicians and 279 trainees who treated 807 general medicine inpatients. The study group performed detailed observations of 90 rounds over a course of nearly 2 years.   According to results, most rounds consisted of an attending physician and several resident and student trainees, speaking with a median of nine patients during the course of about...
A Different Strategy to Help Prevent VTE in Trauma Patients

A Different Strategy to Help Prevent VTE in Trauma Patients

Venous thromboembolism (VTE)—consisting of pulmonary embolism (PE) and DVT—is one of the most common and deadliest complications experienced by trauma patients admitted to hospitals. According to recent estimates, trauma is the leading killer of young people in the United States. Other studies suggest that at least 100,000 people die from PE alone every year. In light of the incidence of these events, the AHRQ recently placed interventions to improve VTE prophylaxis on its top 10 list of patient safety practices that are strongly encouraged. Changing the Approach of VTE Prophylaxis “Currently, healthcare practitioners use a complex flow diagram for determining the most appropriate strategies when providing VTE prophylaxis,” explains Elliott R. Haut, MD, FACS. For a study, Dr. Haut and colleagues converted the complex algorithm into a shorter clinical decision support-enabled VTE order set that was built into a computerized provider order entry system (CPOE). The converted algorithm was used at the point of care by trauma services providers at the Johns Hopkins Hospital in the analysis. For the intervention, clinicians checked off appropriate boxes on a short checklist (Table) based on patients’ VTE risk factors and contraindications to pharmacologic VTE prophylaxis. The CPOE system integrated this information into an evidence-based algorithm to stratify patients’ VTE risk. The system then suggested the optimal decision for an appropriate VTE prophylaxis regimen. “Using the order set was mandatory for all adult trauma patients in our study,” adds Dr. Haut, whose research was published in JAMA Surgery. The study team compared compliance with guideline-appropriate VTE prophylaxis during the year prior to implementing the order set with the 3 years after implementation. Increased...

Managing Thromboembolism in Pregnancy

Thromboembolism is a leading cause of maternal morbidity and mortality in the United States. The risk of venous thromboembolism (VTE) is increased four-fold during pregnancy and another five-fold for 6 weeks following delivery. The increased VTE risk for these women is mainly attributed to pregnancy because it puts the body in an increased thrombogenic state, but physiologic factors, such as an enlarged uterus and compressed blood vessels at the time of childbirth, also play a role. Other risk factors include having a prior VTE, family history of thrombosis, smoking, high blood pressure, obesity, and operative delivery. The consequences of VTE during pregnancy can be severe and often stem from a failure in diagnosis rather than inadequate therapy. An updated practice bulletin from the American College of Obstetricians & Gynecologists (ACOG) was published in the September 2011 issue of Obstetrics & Gynecology to provide clinicians with updated information on the risk factors, diagnosis, management, and prevention of VTE. “This document places more emphasis on the acquired risk factors for VTE during pregnancy,” says Andra H. James, MD, who helped develop the bulletin. “The recommendations explain how to monitor women for thromboembolic events, address certain risk factors, and treat suspected or acute cases of VTE. The hope is that maternal deaths can be reduced if more clinicians adopt the recommendations provided in the bulletin.” New Recommendations to Manage VTE A major recommendation offered in the ACOG update is the use of compression ultrasonography of the proximal veins when signs or symptoms are suggestive of new onset DVT (Figure). Use of compression ultrasonography will indicate if treatment should be started or surveillance...
Managing Pulmonary Embolism in the ED

Managing Pulmonary Embolism in the ED

Venous thromboembolism (VTE), which includes DVT and pulmonary embolism (PE), is the third leading cause of cardiovascular death among Americans and is especially fatal if these events go undiagnosed and are not treated promptly. PE is most frequently diagnosed in the ED and is associated with 14- and 30-day mortality rates of about 10% and 20%, respectively. Research has shown that a prompt diagnosis of acute PE—within 48 hours of ED arrival—is associated with improved outcomes. Factors Associated with Delays in PE Diagnosis My colleagues and I previously reported that administra­tion of anticoagulants within 24 hours of ED arrival is as­sociated with reduced mortality. Current guidelines from the American College of Chest Physicians recommend that anticoagulation be initiated even before a confirmed diag­nosis, when the probability of PE is believed to be high. However, studies have indicated that there is potential for significant delays from the time of symptom onset to PE diagnosis in the ED. A prompt diagnosis of acute PE—within 48 hours of ED arrival—is associated with improved outcomes. In an effort to better understand the factors associated with timing of a PE diagnosis in the ED, my colleagues and I conducted a review that was published in the January 2012 Journal of Emergency Medicine. Following univariate and multivariate analyses, we found that the following factors appeared to be associated with delays in PE diagnoses of more than 12 hours: Age older than 65. Concurrent cardiovascular disease (CVD). Morbid obesity (BMI >40 kg/m2). A history of recent immobility (eg, recent surgery) and pre­sentation to the ED with tachycardia were factors associ­ated with a relatively early diagnosis of...

Reducing VTE Risk After Hip & Knee Replacement

Venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE), is one of the most common reasons for readmission following primary hip or knee replacement surgery. However, recent studies suggest that only 0.7% to 0.9% of patients undergoing hip or knee replacements require rehospitalization because of VTE in the first 3 months after surgery. “These surgeries put patients at risk for thromboembolic disease because they affect multiple aspects of Virchow’s triad,” explains Joshua J. Jacobs, MD. Virchow’s triad consists of hypercoagulability, venous stasis, and injury to the vascular endothelium. All three components of the triad can be present following hip or knee replacement surgery and predispose individuals to thrombosis, according to Dr. Jacobs. “DVT occurs in about 37% of patients following primary hip or knee replacement surgery who have not been treated with prophylactic agents. The rate of clinically symptomatic VTE events is far less, but VTE should be an important concern of orthopedic surgeons performing these procedures.” New Guidelines on Preventing VTE Dr. Jacobs chaired a workgroup that updated guidelines from the American Academy of Orthopaedic Surgeons (AAOS) on preventing VTE in patients undergoing elective hip and knee arthroplasty. The guidelines were released on September 24, 2011 and are available for free at www.aaos.org/guidelines. “The AAOS felt it was necessary to update these guidelines for the first time since 2007 because of the increasing availability of study data that impacted the previous recommendations and to maintain inclusion in the AHRQ’s National Guideline Clearinghouse, which requires an update every 5 years,” says Dr. Jacobs. The American College of Chest Physicians has also published guidelines on VTE...
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