Denice Cora-Bramble, MD, of Children’s National Medical Center in Washington, D.C., presented “The Business of Medicine” breakout Friday at HM13.

Key Points

• Whether you are salaried, work for productivity, or have a combination of the two, it is important for hospitalists to understand the business side of medicine.
• Even if you are not a hospitalist group leader, there are several things that you should know about the finances of your hospitalist program. Dr. Cora-Bramble reviewed the basics of financial statements, hospital revenue reports, and expense reports. She also reviewed how the hospitalist division partners with the entire hospital.
• After understanding the basic finances of your program, there are ways to enhance your financial performance. These include noting any lack of payments, billing and patient trends, and looking at program losses.

Key Takeaways

• It is important to understand the general principles of financial statements, budgets and financial decision making.
• There are multiple strategies to improve your division’s financial performance.
• There are financial challenges inherent in leading an academic division.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, and a Team Hospitalist member.

Denice Cora-Bramble, MD, of Children’s National Medical Center in Washington, D.C., presented “The Business of Medicine” breakout Friday at HM13.

Key Points

• Whether you are salaried, work for productivity, or have a combination of the two, it is important for hospitalists to understand the business side of medicine.
• Even if you are not a hospitalist group leader, there are several things that you should know about the finances of your hospitalist program. Dr. Cora-Bramble reviewed the basics of financial statements, hospital revenue reports, and expense reports. She also reviewed how the hospitalist division partners with the entire hospital.
• After understanding the basic finances of your program, there are ways to enhance your financial performance. These include noting any lack of payments, billing and patient trends, and looking at program losses.

Key Takeaways

• It is important to understand the general principles of financial statements, budgets and financial decision making.
• There are multiple strategies to improve your division’s financial performance.
• There are financial challenges inherent in leading an academic division.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, and a Team Hospitalist member.

Denice Cora-Bramble, MD, of Children’s National Medical Center in Washington, D.C., presented “The Business of Medicine” breakout Friday at HM13.

Key Points

• Whether you are salaried, work for productivity, or have a combination of the two, it is important for hospitalists to understand the business side of medicine.
• Even if you are not a hospitalist group leader, there are several things that you should know about the finances of your hospitalist program. Dr. Cora-Bramble reviewed the basics of financial statements, hospital revenue reports, and expense reports. She also reviewed how the hospitalist division partners with the entire hospital.
• After understanding the basic finances of your program, there are ways to enhance your financial performance. These include noting any lack of payments, billing and patient trends, and looking at program losses.

Key Takeaways

• It is important to understand the general principles of financial statements, budgets and financial decision making.
• There are multiple strategies to improve your division’s financial performance.
• There are financial challenges inherent in leading an academic division.

Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston, and a Team Hospitalist member.

NATIONAL HARBOR, MD—Amir Jaffer, MD, and Steven Cohn, MD, chaired an excellent pre-course centered on common problems hospitalists encounter in managing medical problems in surgical patients. Topics covered were: the pre-operative evaluation and role of the consultant, cardiac risk assessment, pulmonary risk assessment, perioperative medication management, old and new antithrombotic therapy, diabetes management, co-management of the hip fracture, VTE prevention, and management of perioperative anemia.

Among other takeaway points, the physicians emphasized the importance of personal communication between surgeons and hospitalists. Frank Michota, MD, made an analogy using the patient as the plane, the surgeon as the pilot, the anesthesiologist as the co-pilot, and the hospitalist as the mechanic.

Check out The Hospitalist's Day One video from Hospital Medicine 2013

Others commented on cardiac management of the surgical patient, the risk assessment calculators available, and how noninvasive testing is rarely needed. Physicians also noted that partial functional dependence is the strongest predictor for patients needing recommendations regarding risk of postoperative respiratory failure. In reviewing patients’ medications in the perioperative phase, the speakers noted it is important to ask about herbal remedies and OTC drugs, as these may cause problems during and after surgery.

Additional topics addressed included: bridge therapy for anti coagulation, and the need to take into account the risk of bleeding among some, but not all, patients; how diabetic management should focus on a pre-meal glucose measurement of less than 140 mg/dl, and that all other glucose readings be under 180 mg/dl; how extended prophalyxis for VTE prevention is needed for elective hip surgery; and that hospitalists should be versed in the latest recommendations regarding restricted blood transfusion criteria. TH

NATIONAL HARBOR, MD—Amir Jaffer, MD, and Steven Cohn, MD, chaired an excellent pre-course centered on common problems hospitalists encounter in managing medical problems in surgical patients. Topics covered were: the pre-operative evaluation and role of the consultant, cardiac risk assessment, pulmonary risk assessment, perioperative medication management, old and new antithrombotic therapy, diabetes management, co-management of the hip fracture, VTE prevention, and management of perioperative anemia.

Among other takeaway points, the physicians emphasized the importance of personal communication between surgeons and hospitalists. Frank Michota, MD, made an analogy using the patient as the plane, the surgeon as the pilot, the anesthesiologist as the co-pilot, and the hospitalist as the mechanic.

Check out The Hospitalist's Day One video from Hospital Medicine 2013

Others commented on cardiac management of the surgical patient, the risk assessment calculators available, and how noninvasive testing is rarely needed. Physicians also noted that partial functional dependence is the strongest predictor for patients needing recommendations regarding risk of postoperative respiratory failure. In reviewing patients’ medications in the perioperative phase, the speakers noted it is important to ask about herbal remedies and OTC drugs, as these may cause problems during and after surgery.

Additional topics addressed included: bridge therapy for anti coagulation, and the need to take into account the risk of bleeding among some, but not all, patients; how diabetic management should focus on a pre-meal glucose measurement of less than 140 mg/dl, and that all other glucose readings be under 180 mg/dl; how extended prophalyxis for VTE prevention is needed for elective hip surgery; and that hospitalists should be versed in the latest recommendations regarding restricted blood transfusion criteria. TH

NATIONAL HARBOR, MD—Amir Jaffer, MD, and Steven Cohn, MD, chaired an excellent pre-course centered on common problems hospitalists encounter in managing medical problems in surgical patients. Topics covered were: the pre-operative evaluation and role of the consultant, cardiac risk assessment, pulmonary risk assessment, perioperative medication management, old and new antithrombotic therapy, diabetes management, co-management of the hip fracture, VTE prevention, and management of perioperative anemia.

Among other takeaway points, the physicians emphasized the importance of personal communication between surgeons and hospitalists. Frank Michota, MD, made an analogy using the patient as the plane, the surgeon as the pilot, the anesthesiologist as the co-pilot, and the hospitalist as the mechanic.

Check out The Hospitalist's Day One video from Hospital Medicine 2013

Others commented on cardiac management of the surgical patient, the risk assessment calculators available, and how noninvasive testing is rarely needed. Physicians also noted that partial functional dependence is the strongest predictor for patients needing recommendations regarding risk of postoperative respiratory failure. In reviewing patients’ medications in the perioperative phase, the speakers noted it is important to ask about herbal remedies and OTC drugs, as these may cause problems during and after surgery.

Additional topics addressed included: bridge therapy for anti coagulation, and the need to take into account the risk of bleeding among some, but not all, patients; how diabetic management should focus on a pre-meal glucose measurement of less than 140 mg/dl, and that all other glucose readings be under 180 mg/dl; how extended prophalyxis for VTE prevention is needed for elective hip surgery; and that hospitalists should be versed in the latest recommendations regarding restricted blood transfusion criteria. TH

Sally Wang MD, FHM, director of procedure education at Brigham and Women’s Hospital in Boston, and Brad Rosen, MD, MBA, FHM, medical director of the Inpatient Specialty Program (ISP) at Cedars-Sinai Hospital in Los Angeles, led another rapid-fire pre-course in ultrasound-guided procedures for the hospitalist at HM13.

Drs. Wang, Rosen, and a veteran group of faculty and trainers brought hands-on training in core bedside procedures, plus training in relatively new procedures to hospitalists such as intraosseous lines and skin biopsies. All attendees received close interaction with faculty and trainers, and participated in training exercises on tissue models, training models, and live models.

Additional discussion was focused on developing a proceduralist program. Experts explained the required commitment to proficiency and ongoing data collection, quality improvement, and “customer service” to stakeholders. But the basics of ongoing experiential learning are invaluable, they said, and often begin with simulation exercises.

Hospitalists thinking of becoming a proceduralist should start by making sure that they are proficient and experienced, and have invested the time necessary to maintain that experience. Beyond personal interest in procedures, administering an HM program that encourages and fosters procedural experience requires input from multiple stakeholders, as well as ongoing efforts to promote a climate of safety surrounding bedside procedures. TH

Dr. Chang is med-peds hospitalist at Univeristy of California San Diego, and a Team Hospitalist member.

Sally Wang MD, FHM, director of procedure education at Brigham and Women’s Hospital in Boston, and Brad Rosen, MD, MBA, FHM, medical director of the Inpatient Specialty Program (ISP) at Cedars-Sinai Hospital in Los Angeles, led another rapid-fire pre-course in ultrasound-guided procedures for the hospitalist at HM13.

Drs. Wang, Rosen, and a veteran group of faculty and trainers brought hands-on training in core bedside procedures, plus training in relatively new procedures to hospitalists such as intraosseous lines and skin biopsies. All attendees received close interaction with faculty and trainers, and participated in training exercises on tissue models, training models, and live models.

Additional discussion was focused on developing a proceduralist program. Experts explained the required commitment to proficiency and ongoing data collection, quality improvement, and “customer service” to stakeholders. But the basics of ongoing experiential learning are invaluable, they said, and often begin with simulation exercises.

Hospitalists thinking of becoming a proceduralist should start by making sure that they are proficient and experienced, and have invested the time necessary to maintain that experience. Beyond personal interest in procedures, administering an HM program that encourages and fosters procedural experience requires input from multiple stakeholders, as well as ongoing efforts to promote a climate of safety surrounding bedside procedures. TH

Dr. Chang is med-peds hospitalist at Univeristy of California San Diego, and a Team Hospitalist member.

Sally Wang MD, FHM, director of procedure education at Brigham and Women’s Hospital in Boston, and Brad Rosen, MD, MBA, FHM, medical director of the Inpatient Specialty Program (ISP) at Cedars-Sinai Hospital in Los Angeles, led another rapid-fire pre-course in ultrasound-guided procedures for the hospitalist at HM13.

Drs. Wang, Rosen, and a veteran group of faculty and trainers brought hands-on training in core bedside procedures, plus training in relatively new procedures to hospitalists such as intraosseous lines and skin biopsies. All attendees received close interaction with faculty and trainers, and participated in training exercises on tissue models, training models, and live models.

Additional discussion was focused on developing a proceduralist program. Experts explained the required commitment to proficiency and ongoing data collection, quality improvement, and “customer service” to stakeholders. But the basics of ongoing experiential learning are invaluable, they said, and often begin with simulation exercises.

Hospitalists thinking of becoming a proceduralist should start by making sure that they are proficient and experienced, and have invested the time necessary to maintain that experience. Beyond personal interest in procedures, administering an HM program that encourages and fosters procedural experience requires input from multiple stakeholders, as well as ongoing efforts to promote a climate of safety surrounding bedside procedures. TH

Dr. Chang is med-peds hospitalist at Univeristy of California San Diego, and a Team Hospitalist member.

This ID focused pre-course was a jam-packed, practical, and high-yield review of relevant ID topics encountered by practicing hospitalists. Here are some of the key takeaways:

HIV and the Hospitalist in 2013

John Flaherty, MD, prof. of medicine at Northwestern University Feinberg School of Medicine

• Lower the threshold for HIV testing; don’t limit to “high-risk” behaviors, 20% of those living with HIV/AID are unaware—so TEST!

• Recognize clinical clues to HIV infection: acute mono-like syndrome, unexplained chronic illness, comm.-acquired pneumonia.

Thomas Fraser, MD, FACP, FSHEA, vice chairman, Dept. of Infectious Disease, Medical Director for Infection Prevention, Cleveland Clinic

• Risk Factors for CDI: disease severity (sicker patients=higher risk), antibiotics, PPI use, NG tubes and tube feeds, stool softeners and enemas, GI surgery, increasing age.

• Treatment: stop abx if possible, no antiperistaltics, metronidazole 500mg po tid x 10d- 1st line, alt. vancomycin 125-150mg po qid x 10d, vancomycin preferred rx for seriously ill (wbc>20k, ARF, abd.distention, hemodynamic instability).

• Do not treat asymptomatic patient with stool sample + for C. diff.

Emerging Antimicrobial Resistance Issues

COL Glenn Wortmann, MD Chief of integrated Infectious Diseases Services Walter Reed army Medical Center and Bethesda Naval National Naval Center, Program Director of National Capital Consortium Infectious Diseases Fellowship Program, Assoc. Prof. of Medicine Uniformed Services University of the Health Sciences

• Global trends in rising antimicrobial resistance suggest that the antibiotic era may be ending.

• Emphasis shifting from infection treatment to prevention.

• Maximize hand washing: Wash in, wash out and lead by example.

• Consider chlorhexidine washes in high-risk patients as well as environmental decontamination devices.

• Judicious Use of Antimicrobial Agents: use narrow spectrum agents for shortest duration of therapy feasible, formulary restriction, mandatory ID or pharmacy consultation.

How to be a Leader in Antimicrobial Stewardship in Your Hospital

Arjun Srinivasan, MD FSHEA Assoc. Dir. for Healthcare Associated Infection Prevention Programs in the Div. of Healthcare Quality Promotion at the Centers for Disease Control and Prevention (CDC)

• Hospitalists have the greatest influence over how abx are used in hospitals.

• Hospitalists have the background, experience and strong interest in QI work to affect change; know that up to 50% of all antibiotic use is inappropriate.

• Hospitalists can help tackle issues of abx misuse with signouts, handoffs, and care transitions.

•

ID Emergencies: Diagnoses you can’t afford to miss

James Pile, MD FACP SFHM practicing hospitalist and ID specialist at Cleveland Clinic

• Acute Bacterial Meningitis: LP and Brain Imaging, subset of low-risk patients appears not to require imaging prior to LP, even pts with mild mass effects can probably be safely tapped, herniation may occur even with normal CT-if clinical evidence suggests increasing icp, consider deferring lp or using small gauge needle

• Rx: all adults-cover pneumococcus and meningococcus, empiric coverage of resistant S. pneumoniae is standard of care; cover for listeria for age >50, immunocompromised, alcoholic, pregnant, diabetic; recent head trauma or neurosurgery cover S. aureus and GNB (including pseudomonas).

• Steroids are recommended for suspected BM give dexamethasone with or before antibiotics.

• Spinal Epidural Abscess: It’s easy to miss!

• Necrotizing Fasciitis/Necrotizing Soft Tissue Infections (NSTI): Pain out of proportion to physical findings, systemic findings (delirium, fever, diaphoresis, tachycardia) out of proportion to physical findings; consider Dx to make Dx, easy to miss or delay diagnosis→worsening outcomes. Have low threshold for surgical consultation and/or CT in patients with what appears to be severe cellulitis; include clindamycin (with other abx) for empiric coverage

ID Pearls Every Hospitalist Should Know

John Flaherty, MD

• Re: Perioperative Abx, “Better late than never” does NOT apply. Ensure appropriate timing of peri-op abx.

• Fever ≠ Infection, No Fever ≠ No Infection.

• Sepsis and Hypotension: start broad-spectrum abx NOW.

• Persistent pna despite empiric rx and neg cx, think TB and blastomycoses.

• Fatigue, low-grade fever, and anemia- r/o infective endocarditis.

• Single+blood cx is not always a contaminant; is IS a source of prolonged hospitalization and further testing, so choose wisely when ordering blood cx.

Implementing Socio-Adaptive Change: The role of leaders, followers and bundles in preventing infection

Sanjay Saint, MD MPH Prof. of Int. Medicine University of Michigan, Dir. of the VA/Univeristy of Michigan Patient Safety Enhancement Program, Assoc. Chief of Medicine Ann Arbor VAMC

• Successful implementation of change requires recognition of both the technical and socio-adaptive barriers.

• The key to good leadership is good followership—very little written on subject of followership.

Infective Endocarditis and Intravascular Device Infections

Thomas Fraser, MD FACP FSHEA

• Management Highlights: If patient is sick, pull the line out. If patient has a bad bug, pull the line out. Most people with lines are health care experienced—start broad-spectrum abx and tailor rx once cx available. If you do not pull the line, follow very closely, have low threshold to call ID consult, S. aureus is in a class all its own.

• When can line be replaced? Timing depends on clinical need ultimately, clinically well with resolving syndrome, receiving effective rx, blood cx neg for 72 hrs; maybe longer for Candida species.

• Who should get a TEE for HCA S. aureus bacteremia? Patients with prolonged bacteremia; >4 days; presence of an intracardiac device (valve, icd, ppm); metastatic complication; vertebral or other osteomyelitis, etc. TH

Dr. Lindsey is a COO at Strategist Synergy Surgicalists, lead consultant at Asynd Consulting, and a Team Hospitalist member.

This ID focused pre-course was a jam-packed, practical, and high-yield review of relevant ID topics encountered by practicing hospitalists. Here are some of the key takeaways:

HIV and the Hospitalist in 2013

John Flaherty, MD, prof. of medicine at Northwestern University Feinberg School of Medicine

• Lower the threshold for HIV testing; don’t limit to “high-risk” behaviors, 20% of those living with HIV/AID are unaware—so TEST!

• Recognize clinical clues to HIV infection: acute mono-like syndrome, unexplained chronic illness, comm.-acquired pneumonia.

Thomas Fraser, MD, FACP, FSHEA, vice chairman, Dept. of Infectious Disease, Medical Director for Infection Prevention, Cleveland Clinic

• Risk Factors for CDI: disease severity (sicker patients=higher risk), antibiotics, PPI use, NG tubes and tube feeds, stool softeners and enemas, GI surgery, increasing age.

• Treatment: stop abx if possible, no antiperistaltics, metronidazole 500mg po tid x 10d- 1st line, alt. vancomycin 125-150mg po qid x 10d, vancomycin preferred rx for seriously ill (wbc>20k, ARF, abd.distention, hemodynamic instability).

• Do not treat asymptomatic patient with stool sample + for C. diff.

Emerging Antimicrobial Resistance Issues

COL Glenn Wortmann, MD Chief of integrated Infectious Diseases Services Walter Reed army Medical Center and Bethesda Naval National Naval Center, Program Director of National Capital Consortium Infectious Diseases Fellowship Program, Assoc. Prof. of Medicine Uniformed Services University of the Health Sciences

• Global trends in rising antimicrobial resistance suggest that the antibiotic era may be ending.

• Emphasis shifting from infection treatment to prevention.

• Maximize hand washing: Wash in, wash out and lead by example.

• Consider chlorhexidine washes in high-risk patients as well as environmental decontamination devices.

• Judicious Use of Antimicrobial Agents: use narrow spectrum agents for shortest duration of therapy feasible, formulary restriction, mandatory ID or pharmacy consultation.

How to be a Leader in Antimicrobial Stewardship in Your Hospital

Arjun Srinivasan, MD FSHEA Assoc. Dir. for Healthcare Associated Infection Prevention Programs in the Div. of Healthcare Quality Promotion at the Centers for Disease Control and Prevention (CDC)

• Hospitalists have the greatest influence over how abx are used in hospitals.

• Hospitalists have the background, experience and strong interest in QI work to affect change; know that up to 50% of all antibiotic use is inappropriate.

• Hospitalists can help tackle issues of abx misuse with signouts, handoffs, and care transitions.

•

ID Emergencies: Diagnoses you can’t afford to miss

James Pile, MD FACP SFHM practicing hospitalist and ID specialist at Cleveland Clinic

• Acute Bacterial Meningitis: LP and Brain Imaging, subset of low-risk patients appears not to require imaging prior to LP, even pts with mild mass effects can probably be safely tapped, herniation may occur even with normal CT-if clinical evidence suggests increasing icp, consider deferring lp or using small gauge needle

• Rx: all adults-cover pneumococcus and meningococcus, empiric coverage of resistant S. pneumoniae is standard of care; cover for listeria for age >50, immunocompromised, alcoholic, pregnant, diabetic; recent head trauma or neurosurgery cover S. aureus and GNB (including pseudomonas).

• Steroids are recommended for suspected BM give dexamethasone with or before antibiotics.

• Spinal Epidural Abscess: It’s easy to miss!

• Necrotizing Fasciitis/Necrotizing Soft Tissue Infections (NSTI): Pain out of proportion to physical findings, systemic findings (delirium, fever, diaphoresis, tachycardia) out of proportion to physical findings; consider Dx to make Dx, easy to miss or delay diagnosis→worsening outcomes. Have low threshold for surgical consultation and/or CT in patients with what appears to be severe cellulitis; include clindamycin (with other abx) for empiric coverage

ID Pearls Every Hospitalist Should Know

John Flaherty, MD

• Re: Perioperative Abx, “Better late than never” does NOT apply. Ensure appropriate timing of peri-op abx.

• Fever ≠ Infection, No Fever ≠ No Infection.

• Sepsis and Hypotension: start broad-spectrum abx NOW.

• Persistent pna despite empiric rx and neg cx, think TB and blastomycoses.

• Fatigue, low-grade fever, and anemia- r/o infective endocarditis.

• Single+blood cx is not always a contaminant; is IS a source of prolonged hospitalization and further testing, so choose wisely when ordering blood cx.

Implementing Socio-Adaptive Change: The role of leaders, followers and bundles in preventing infection

Sanjay Saint, MD MPH Prof. of Int. Medicine University of Michigan, Dir. of the VA/Univeristy of Michigan Patient Safety Enhancement Program, Assoc. Chief of Medicine Ann Arbor VAMC

• Successful implementation of change requires recognition of both the technical and socio-adaptive barriers.

• The key to good leadership is good followership—very little written on subject of followership.

Infective Endocarditis and Intravascular Device Infections

Thomas Fraser, MD FACP FSHEA

• Management Highlights: If patient is sick, pull the line out. If patient has a bad bug, pull the line out. Most people with lines are health care experienced—start broad-spectrum abx and tailor rx once cx available. If you do not pull the line, follow very closely, have low threshold to call ID consult, S. aureus is in a class all its own.

• When can line be replaced? Timing depends on clinical need ultimately, clinically well with resolving syndrome, receiving effective rx, blood cx neg for 72 hrs; maybe longer for Candida species.

• Who should get a TEE for HCA S. aureus bacteremia? Patients with prolonged bacteremia; >4 days; presence of an intracardiac device (valve, icd, ppm); metastatic complication; vertebral or other osteomyelitis, etc. TH

Dr. Lindsey is a COO at Strategist Synergy Surgicalists, lead consultant at Asynd Consulting, and a Team Hospitalist member.

This ID focused pre-course was a jam-packed, practical, and high-yield review of relevant ID topics encountered by practicing hospitalists. Here are some of the key takeaways:

HIV and the Hospitalist in 2013

John Flaherty, MD, prof. of medicine at Northwestern University Feinberg School of Medicine

• Lower the threshold for HIV testing; don’t limit to “high-risk” behaviors, 20% of those living with HIV/AID are unaware—so TEST!

• Recognize clinical clues to HIV infection: acute mono-like syndrome, unexplained chronic illness, comm.-acquired pneumonia.

Thomas Fraser, MD, FACP, FSHEA, vice chairman, Dept. of Infectious Disease, Medical Director for Infection Prevention, Cleveland Clinic

• Risk Factors for CDI: disease severity (sicker patients=higher risk), antibiotics, PPI use, NG tubes and tube feeds, stool softeners and enemas, GI surgery, increasing age.

• Treatment: stop abx if possible, no antiperistaltics, metronidazole 500mg po tid x 10d- 1st line, alt. vancomycin 125-150mg po qid x 10d, vancomycin preferred rx for seriously ill (wbc>20k, ARF, abd.distention, hemodynamic instability).

• Do not treat asymptomatic patient with stool sample + for C. diff.

Emerging Antimicrobial Resistance Issues

COL Glenn Wortmann, MD Chief of integrated Infectious Diseases Services Walter Reed army Medical Center and Bethesda Naval National Naval Center, Program Director of National Capital Consortium Infectious Diseases Fellowship Program, Assoc. Prof. of Medicine Uniformed Services University of the Health Sciences

• Global trends in rising antimicrobial resistance suggest that the antibiotic era may be ending.

• Emphasis shifting from infection treatment to prevention.

• Maximize hand washing: Wash in, wash out and lead by example.

• Consider chlorhexidine washes in high-risk patients as well as environmental decontamination devices.

• Judicious Use of Antimicrobial Agents: use narrow spectrum agents for shortest duration of therapy feasible, formulary restriction, mandatory ID or pharmacy consultation.

How to be a Leader in Antimicrobial Stewardship in Your Hospital

Arjun Srinivasan, MD FSHEA Assoc. Dir. for Healthcare Associated Infection Prevention Programs in the Div. of Healthcare Quality Promotion at the Centers for Disease Control and Prevention (CDC)

• Hospitalists have the greatest influence over how abx are used in hospitals.

• Hospitalists have the background, experience and strong interest in QI work to affect change; know that up to 50% of all antibiotic use is inappropriate.

• Hospitalists can help tackle issues of abx misuse with signouts, handoffs, and care transitions.

•

ID Emergencies: Diagnoses you can’t afford to miss

James Pile, MD FACP SFHM practicing hospitalist and ID specialist at Cleveland Clinic

• Acute Bacterial Meningitis: LP and Brain Imaging, subset of low-risk patients appears not to require imaging prior to LP, even pts with mild mass effects can probably be safely tapped, herniation may occur even with normal CT-if clinical evidence suggests increasing icp, consider deferring lp or using small gauge needle

• Rx: all adults-cover pneumococcus and meningococcus, empiric coverage of resistant S. pneumoniae is standard of care; cover for listeria for age >50, immunocompromised, alcoholic, pregnant, diabetic; recent head trauma or neurosurgery cover S. aureus and GNB (including pseudomonas).

• Steroids are recommended for suspected BM give dexamethasone with or before antibiotics.

• Spinal Epidural Abscess: It’s easy to miss!

• Necrotizing Fasciitis/Necrotizing Soft Tissue Infections (NSTI): Pain out of proportion to physical findings, systemic findings (delirium, fever, diaphoresis, tachycardia) out of proportion to physical findings; consider Dx to make Dx, easy to miss or delay diagnosis→worsening outcomes. Have low threshold for surgical consultation and/or CT in patients with what appears to be severe cellulitis; include clindamycin (with other abx) for empiric coverage

ID Pearls Every Hospitalist Should Know

John Flaherty, MD

• Re: Perioperative Abx, “Better late than never” does NOT apply. Ensure appropriate timing of peri-op abx.

• Fever ≠ Infection, No Fever ≠ No Infection.

• Sepsis and Hypotension: start broad-spectrum abx NOW.

• Persistent pna despite empiric rx and neg cx, think TB and blastomycoses.

• Fatigue, low-grade fever, and anemia- r/o infective endocarditis.

• Single+blood cx is not always a contaminant; is IS a source of prolonged hospitalization and further testing, so choose wisely when ordering blood cx.

Implementing Socio-Adaptive Change: The role of leaders, followers and bundles in preventing infection

Sanjay Saint, MD MPH Prof. of Int. Medicine University of Michigan, Dir. of the VA/Univeristy of Michigan Patient Safety Enhancement Program, Assoc. Chief of Medicine Ann Arbor VAMC

• Successful implementation of change requires recognition of both the technical and socio-adaptive barriers.

• The key to good leadership is good followership—very little written on subject of followership.

Infective Endocarditis and Intravascular Device Infections

Thomas Fraser, MD FACP FSHEA

• Management Highlights: If patient is sick, pull the line out. If patient has a bad bug, pull the line out. Most people with lines are health care experienced—start broad-spectrum abx and tailor rx once cx available. If you do not pull the line, follow very closely, have low threshold to call ID consult, S. aureus is in a class all its own.

• When can line be replaced? Timing depends on clinical need ultimately, clinically well with resolving syndrome, receiving effective rx, blood cx neg for 72 hrs; maybe longer for Candida species.

• Who should get a TEE for HCA S. aureus bacteremia? Patients with prolonged bacteremia; >4 days; presence of an intracardiac device (valve, icd, ppm); metastatic complication; vertebral or other osteomyelitis, etc. TH

Dr. Lindsey is a COO at Strategist Synergy Surgicalists, lead consultant at Asynd Consulting, and a Team Hospitalist member.

Clinical question

What are the most effective strategies in improving patient safety?

Bottom line

This group of experts, commissioned by the Agency for Healthcare Research and Quality (AHRQ), outlined the top 10 strategies for improved patient safety. These strategies, which are "strongly encouraged" for adoption in all health care systems, consist primarily of interventions that help prevent health care-associated infections and avoid medical errors. LOE = 5

Reference

Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med 2013;158(5 Pt 2):365-368.

Study design

Systematic review

Funding source

Government

Allocation

Uncertain

Setting

Various (guideline)

Synopsis

Previous publications by the Institute of Medicine and the AHRQ have highlighted the importance of patient safety practices. A group of researchers, supported by the AHRQ, evaluated the data on current strategies to improve patient safety. The group assessed the quality of existing systematic reviews on these topics and performed new literature searches when needed. The focus was on data that reported on implementation and adoption of these strategies, as well as on the context in which they have been used. Individual studies on safety interventions were examined for quality and risk of bias. The authors rated the strength of evidence of the effectiveness of each intervention, reported evidence on possible harmful consequences, assessed difficulty in implementation, and estimated costs. Of the 41 safety strategies that were evaluated, the following 10 were chosen as strategies that are "strongly encouraged" for adoption now: 1. Preoperative and anesthesia checklists to prevent perioperative events 2. Bundles that include checklists to prevent central line-associated bloodstream infections 3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders , or nurse-initiated removal protocols 4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes to prevent ventilator-associated pneumonia 5. Hand hygiene 6. The do-not-use list for hazardous abbreviations 7. Multicomponent interventions to reduce pressure ulcers 8. Barrier precautions to prevent health care-associated infections 9. Use of real-time ultrasonography for central line placement 10. Interventions to improve prophylaxis for venous thromboembolism.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

What are the most effective strategies in improving patient safety?

Bottom line

This group of experts, commissioned by the Agency for Healthcare Research and Quality (AHRQ), outlined the top 10 strategies for improved patient safety. These strategies, which are "strongly encouraged" for adoption in all health care systems, consist primarily of interventions that help prevent health care-associated infections and avoid medical errors. LOE = 5

Reference

Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med 2013;158(5 Pt 2):365-368.

Study design

Systematic review

Funding source

Government

Allocation

Uncertain

Setting

Various (guideline)

Synopsis

Previous publications by the Institute of Medicine and the AHRQ have highlighted the importance of patient safety practices. A group of researchers, supported by the AHRQ, evaluated the data on current strategies to improve patient safety. The group assessed the quality of existing systematic reviews on these topics and performed new literature searches when needed. The focus was on data that reported on implementation and adoption of these strategies, as well as on the context in which they have been used. Individual studies on safety interventions were examined for quality and risk of bias. The authors rated the strength of evidence of the effectiveness of each intervention, reported evidence on possible harmful consequences, assessed difficulty in implementation, and estimated costs. Of the 41 safety strategies that were evaluated, the following 10 were chosen as strategies that are "strongly encouraged" for adoption now: 1. Preoperative and anesthesia checklists to prevent perioperative events 2. Bundles that include checklists to prevent central line-associated bloodstream infections 3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders , or nurse-initiated removal protocols 4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes to prevent ventilator-associated pneumonia 5. Hand hygiene 6. The do-not-use list for hazardous abbreviations 7. Multicomponent interventions to reduce pressure ulcers 8. Barrier precautions to prevent health care-associated infections 9. Use of real-time ultrasonography for central line placement 10. Interventions to improve prophylaxis for venous thromboembolism.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

What are the most effective strategies in improving patient safety?

Bottom line

This group of experts, commissioned by the Agency for Healthcare Research and Quality (AHRQ), outlined the top 10 strategies for improved patient safety. These strategies, which are "strongly encouraged" for adoption in all health care systems, consist primarily of interventions that help prevent health care-associated infections and avoid medical errors. LOE = 5

Reference

Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med 2013;158(5 Pt 2):365-368.

Study design

Systematic review

Funding source

Government

Allocation

Uncertain

Setting

Various (guideline)

Synopsis

Previous publications by the Institute of Medicine and the AHRQ have highlighted the importance of patient safety practices. A group of researchers, supported by the AHRQ, evaluated the data on current strategies to improve patient safety. The group assessed the quality of existing systematic reviews on these topics and performed new literature searches when needed. The focus was on data that reported on implementation and adoption of these strategies, as well as on the context in which they have been used. Individual studies on safety interventions were examined for quality and risk of bias. The authors rated the strength of evidence of the effectiveness of each intervention, reported evidence on possible harmful consequences, assessed difficulty in implementation, and estimated costs. Of the 41 safety strategies that were evaluated, the following 10 were chosen as strategies that are "strongly encouraged" for adoption now: 1. Preoperative and anesthesia checklists to prevent perioperative events 2. Bundles that include checklists to prevent central line-associated bloodstream infections 3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders , or nurse-initiated removal protocols 4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes to prevent ventilator-associated pneumonia 5. Hand hygiene 6. The do-not-use list for hazardous abbreviations 7. Multicomponent interventions to reduce pressure ulcers 8. Barrier precautions to prevent health care-associated infections 9. Use of real-time ultrasonography for central line placement 10. Interventions to improve prophylaxis for venous thromboembolism.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does the addition of aliskiren, a direct renin inhibitor, to standard therapy decrease mortality and readmission in patients hospitalized for worsening heart failure?

Bottom line

The addition of aliskiren to standard therapy in patients hospitalized with heart failure (HF) does not reduce cardiovascular mortality or HF readmission rates. LOE = 1b

Reference

Gheorghiade M, Böhm M, Greene SJ, et al, for the ASTRONAUT Investigators and Coordinators. Effect of aliskiren on postdischarge mortality and heart failure readmissions among patients hospitalized for heart failure. JAMA 2013;309(11):1125-1135.

Study design

Randomized controlled trial (double-blinded)

Funding source

Industry

Allocation

Uncertain

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Despite current standard therapy, postdischarge mortality and rehospitalizations remain high for patients hospitalized for HF. To study the effect of direct renin inhibitors on these outcomes, investigators enrolled adults hospitalized for worsening HF with a left ventricular ejection fraction (LVEF) of 40% or less. Once these patients were clinically and hemodynamically stable, they were randomized to receive aliskiren 150 mg daily or placebo. Study patients were followed up at regular intervals and the aliskiren dose was increased to 300 mg daily as long as the initial dose was tolerated. Aliskiren, either 150 mg or 300 mg, was then continued up to a maximum follow-up time of 12 months. All patients also received standard HF therapy at the discretion of their treating physicians. The 2 groups had similar baseline characteristics. The patients' mean age was 65 years, mean LVEF was 28%, and the majority were New York Heart Association Class III-IV at randomization. For the primary end point of either cardiovascular death or HF rehospitalization at 6 months, there was no significant difference between the aliskiren and placebo groups. Events rates between the 2 groups were also similar at 12 months. The aliskiren group was more likely to experience hyperkalemia, hypotension, and renal impairment or renal failure. Additionally, a subgroup analysis showed that patients with diabetes fared worse with aliskiren, with a greater risk of all-cause mortality at 12 months, than those who took placebo.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does the addition of aliskiren, a direct renin inhibitor, to standard therapy decrease mortality and readmission in patients hospitalized for worsening heart failure?

Bottom line

The addition of aliskiren to standard therapy in patients hospitalized with heart failure (HF) does not reduce cardiovascular mortality or HF readmission rates. LOE = 1b

Reference

Gheorghiade M, Böhm M, Greene SJ, et al, for the ASTRONAUT Investigators and Coordinators. Effect of aliskiren on postdischarge mortality and heart failure readmissions among patients hospitalized for heart failure. JAMA 2013;309(11):1125-1135.

Study design

Randomized controlled trial (double-blinded)

Funding source

Industry

Allocation

Uncertain

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Despite current standard therapy, postdischarge mortality and rehospitalizations remain high for patients hospitalized for HF. To study the effect of direct renin inhibitors on these outcomes, investigators enrolled adults hospitalized for worsening HF with a left ventricular ejection fraction (LVEF) of 40% or less. Once these patients were clinically and hemodynamically stable, they were randomized to receive aliskiren 150 mg daily or placebo. Study patients were followed up at regular intervals and the aliskiren dose was increased to 300 mg daily as long as the initial dose was tolerated. Aliskiren, either 150 mg or 300 mg, was then continued up to a maximum follow-up time of 12 months. All patients also received standard HF therapy at the discretion of their treating physicians. The 2 groups had similar baseline characteristics. The patients' mean age was 65 years, mean LVEF was 28%, and the majority were New York Heart Association Class III-IV at randomization. For the primary end point of either cardiovascular death or HF rehospitalization at 6 months, there was no significant difference between the aliskiren and placebo groups. Events rates between the 2 groups were also similar at 12 months. The aliskiren group was more likely to experience hyperkalemia, hypotension, and renal impairment or renal failure. Additionally, a subgroup analysis showed that patients with diabetes fared worse with aliskiren, with a greater risk of all-cause mortality at 12 months, than those who took placebo.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does the addition of aliskiren, a direct renin inhibitor, to standard therapy decrease mortality and readmission in patients hospitalized for worsening heart failure?

Bottom line

The addition of aliskiren to standard therapy in patients hospitalized with heart failure (HF) does not reduce cardiovascular mortality or HF readmission rates. LOE = 1b

Reference

Gheorghiade M, Böhm M, Greene SJ, et al, for the ASTRONAUT Investigators and Coordinators. Effect of aliskiren on postdischarge mortality and heart failure readmissions among patients hospitalized for heart failure. JAMA 2013;309(11):1125-1135.

Study design

Randomized controlled trial (double-blinded)

Funding source

Industry

Allocation

Uncertain

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Despite current standard therapy, postdischarge mortality and rehospitalizations remain high for patients hospitalized for HF. To study the effect of direct renin inhibitors on these outcomes, investigators enrolled adults hospitalized for worsening HF with a left ventricular ejection fraction (LVEF) of 40% or less. Once these patients were clinically and hemodynamically stable, they were randomized to receive aliskiren 150 mg daily or placebo. Study patients were followed up at regular intervals and the aliskiren dose was increased to 300 mg daily as long as the initial dose was tolerated. Aliskiren, either 150 mg or 300 mg, was then continued up to a maximum follow-up time of 12 months. All patients also received standard HF therapy at the discretion of their treating physicians. The 2 groups had similar baseline characteristics. The patients' mean age was 65 years, mean LVEF was 28%, and the majority were New York Heart Association Class III-IV at randomization. For the primary end point of either cardiovascular death or HF rehospitalization at 6 months, there was no significant difference between the aliskiren and placebo groups. Events rates between the 2 groups were also similar at 12 months. The aliskiren group was more likely to experience hyperkalemia, hypotension, and renal impairment or renal failure. Additionally, a subgroup analysis showed that patients with diabetes fared worse with aliskiren, with a greater risk of all-cause mortality at 12 months, than those who took placebo.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

The approval of the biologic drug golimumab has been expanded to include the treatment of adults with moderate to severe ulcerative colitis that is refractory to prior treatment or requires continuous steroid therapy, the Food and Drug Administration announced on May 15.

Golimumab (Simponi), a tumor necrosis factor–blocker, was approved in 2009 for treatment of moderate to severe active rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, all in adults. Simponi is marketed by Janssen Ortho Biotech.

The approval for ulcerative colitis was based on two studies of patients with moderate to severe ulcerative colitis, according to the FDA statement announcing the approval. In one study, which enrolled 513 patients who could not tolerate or had not responded to other treatments, "a greater proportion of Simponi-treated patients achieved clinical response, clinical remission and, as seen during endoscopy, had improved appearance of the colon after 6 weeks," compared with those on placebo, the statement said.

In a study of 310 patients who had responded to golimumab and were then randomized to continue treatment with golimumab or were switched to placebo, "a greater proportion of Simponi-treated patients maintained clinical response through week 54, had clinical remission at both weeks 30 and 54 and, as seen during endoscopy, had improved appearance of the colon at both weeks 30 and 54 compared with the placebo group," the FDA said. The most common adverse effects associated with golimumab are upper respiratory infection and redness at the injection site.

The risks of serious infections, invasive fungal infections, reactivation of hepatitis B infection, lymphoma, heart failure, nervous system disorders, and allergic reactions are increased with treatment.

Serious adverse events associated with golimumab should be reported to the FDA at 800-332-1088 or www.fda.gov/medwatch/.

emechcatie@frontlinemedcom.com

The approval of the biologic drug golimumab has been expanded to include the treatment of adults with moderate to severe ulcerative colitis that is refractory to prior treatment or requires continuous steroid therapy, the Food and Drug Administration announced on May 15.

Golimumab (Simponi), a tumor necrosis factor–blocker, was approved in 2009 for treatment of moderate to severe active rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, all in adults. Simponi is marketed by Janssen Ortho Biotech.

The approval for ulcerative colitis was based on two studies of patients with moderate to severe ulcerative colitis, according to the FDA statement announcing the approval. In one study, which enrolled 513 patients who could not tolerate or had not responded to other treatments, "a greater proportion of Simponi-treated patients achieved clinical response, clinical remission and, as seen during endoscopy, had improved appearance of the colon after 6 weeks," compared with those on placebo, the statement said.

In a study of 310 patients who had responded to golimumab and were then randomized to continue treatment with golimumab or were switched to placebo, "a greater proportion of Simponi-treated patients maintained clinical response through week 54, had clinical remission at both weeks 30 and 54 and, as seen during endoscopy, had improved appearance of the colon at both weeks 30 and 54 compared with the placebo group," the FDA said. The most common adverse effects associated with golimumab are upper respiratory infection and redness at the injection site.

The risks of serious infections, invasive fungal infections, reactivation of hepatitis B infection, lymphoma, heart failure, nervous system disorders, and allergic reactions are increased with treatment.

Serious adverse events associated with golimumab should be reported to the FDA at 800-332-1088 or www.fda.gov/medwatch/.

emechcatie@frontlinemedcom.com

The approval of the biologic drug golimumab has been expanded to include the treatment of adults with moderate to severe ulcerative colitis that is refractory to prior treatment or requires continuous steroid therapy, the Food and Drug Administration announced on May 15.

Golimumab (Simponi), a tumor necrosis factor–blocker, was approved in 2009 for treatment of moderate to severe active rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, all in adults. Simponi is marketed by Janssen Ortho Biotech.

The approval for ulcerative colitis was based on two studies of patients with moderate to severe ulcerative colitis, according to the FDA statement announcing the approval. In one study, which enrolled 513 patients who could not tolerate or had not responded to other treatments, "a greater proportion of Simponi-treated patients achieved clinical response, clinical remission and, as seen during endoscopy, had improved appearance of the colon after 6 weeks," compared with those on placebo, the statement said.

In a study of 310 patients who had responded to golimumab and were then randomized to continue treatment with golimumab or were switched to placebo, "a greater proportion of Simponi-treated patients maintained clinical response through week 54, had clinical remission at both weeks 30 and 54 and, as seen during endoscopy, had improved appearance of the colon at both weeks 30 and 54 compared with the placebo group," the FDA said. The most common adverse effects associated with golimumab are upper respiratory infection and redness at the injection site.

The risks of serious infections, invasive fungal infections, reactivation of hepatitis B infection, lymphoma, heart failure, nervous system disorders, and allergic reactions are increased with treatment.

Serious adverse events associated with golimumab should be reported to the FDA at 800-332-1088 or www.fda.gov/medwatch/.

emechcatie@frontlinemedcom.com

EDITOR'S NOTE: August 26, 2013: This article has been amended since it was first published to make it clear that Dr. Kelley Pagliai Redbord's description of the pulley stitch procedure was taken directly from an article published by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg.2011;37:1503-5). In her presentation, Dr. Redbord credited Dr. Yag-Howard and her article. However, this credit and attribution to Dr. Yag-Howard was not included in the article published.

WASHINGTON – The pulley stitch "is my go-to stitch for defects under tension," said Dr. Kelley Pagliai Redbord.

The pulley stitch allows for considerable reduction in the surface area of a large defect that can’t be closed by side-to-side stitches alone, making it an excellent choice for use on the scalp and legs, Dr. Redbord said at the Atlantic Dermatological Conference.

"When the tension across the wound is decreased, buried dermal sutures can be placed more easily and accurately," she said. "I use it a lot as an intraoperative tissue expander."

Dr. Redbord said that her description of the pulley stitch was taken from an article by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg. 2011; 37:1503-5).* 

The pulley stitch can serve as a temporary suture that can be left in place or removed, said Dr. Redbord, a dermatologist in group practice in Rockville, Md.

Courtesy of Dr. Kelley Pagliani Redbord

The technique follows a far-near-near-far pattern, starting the stitch 8 mm from the wound edge (far), then bringing it to the opposite side just 4 mm from the wound edge (near). Dr. Redbord then reenters the stitch 4 mm from the wound edge on the initial side (near), and makes another pass to the opposite side 8 mm from the wound edge (far).

Multiple passes through the tissue create resistance that keeps the suture from slipping. "The loops of the stitch are placed at an oblique angle so that the inner and outer loops are offset and do not override each other," she noted. This technique minimizes potential skin damage from pressure necrosis caused by overriding loop sutures. The pulley stitch has a 2:1 mechanical advantage over an interrupted suture, and the additional friction of a second loop prevents the knot from slipping.

A modification of the pulley stitch is to loop the suture through an external loop on the opposite side of the incision, and pull across. "This new loop functions as a pulley and directs the tension away from the other strands," she said.

Another stitch with excellent eversion, in which the pulley stitch plays a key role, is the subcutaneous inverted cross mattress stitch (SICM). The SCIM is entirely subcutaneous, and combines the buried vertical mattress stitch and the buried pulley stitch.

The SCIM "uses the buried vertical mattress’s ability to evert wound edges and combines it with the pulley stitch’s ability to decrease tension at the wound edge," she said.

The four-step process is as follows:

• 1. Insert the needle into the dermis 3-5 mm lateral to the wound edge. Advance the needle into the upper reticular dermis, and then curve down to exit through the lower reticular dermis.

• 2. Insert the needle into the opposite edge of the wound at the lower reticular dermis and advance into the upper reticular dermis, then curve down and exit intradermally.

• 3. Insert the needle across the defect using an intradermal approach 1-2 mm lateral to the initial needle insertion point. Then, create a second buried vertical mattress stitch.

• 4. Pull the two stitches to close, which "creates a pulley effect with minimal recoil, and tie off," Dr. Redbord said.

"The pulley system locks the wound edges so that a knot can be tied without slipping," she added.

Dr. Redbord said she had no relevant financial disclosures.

hsplete@frontlinemedcom.com

EDITOR'S NOTE: August 26, 2013: This article has been amended since it was first published to make it clear that Dr. Kelley Pagliai Redbord's description of the pulley stitch procedure was taken directly from an article published by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg.2011;37:1503-5). In her presentation, Dr. Redbord credited Dr. Yag-Howard and her article. However, this credit and attribution to Dr. Yag-Howard was not included in the article published.

WASHINGTON – The pulley stitch "is my go-to stitch for defects under tension," said Dr. Kelley Pagliai Redbord.

The pulley stitch allows for considerable reduction in the surface area of a large defect that can’t be closed by side-to-side stitches alone, making it an excellent choice for use on the scalp and legs, Dr. Redbord said at the Atlantic Dermatological Conference.

"When the tension across the wound is decreased, buried dermal sutures can be placed more easily and accurately," she said. "I use it a lot as an intraoperative tissue expander."

Dr. Redbord said that her description of the pulley stitch was taken from an article by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg. 2011; 37:1503-5).* 

The pulley stitch can serve as a temporary suture that can be left in place or removed, said Dr. Redbord, a dermatologist in group practice in Rockville, Md.

Courtesy of Dr. Kelley Pagliani Redbord

The technique follows a far-near-near-far pattern, starting the stitch 8 mm from the wound edge (far), then bringing it to the opposite side just 4 mm from the wound edge (near). Dr. Redbord then reenters the stitch 4 mm from the wound edge on the initial side (near), and makes another pass to the opposite side 8 mm from the wound edge (far).

Multiple passes through the tissue create resistance that keeps the suture from slipping. "The loops of the stitch are placed at an oblique angle so that the inner and outer loops are offset and do not override each other," she noted. This technique minimizes potential skin damage from pressure necrosis caused by overriding loop sutures. The pulley stitch has a 2:1 mechanical advantage over an interrupted suture, and the additional friction of a second loop prevents the knot from slipping.

A modification of the pulley stitch is to loop the suture through an external loop on the opposite side of the incision, and pull across. "This new loop functions as a pulley and directs the tension away from the other strands," she said.

Another stitch with excellent eversion, in which the pulley stitch plays a key role, is the subcutaneous inverted cross mattress stitch (SICM). The SCIM is entirely subcutaneous, and combines the buried vertical mattress stitch and the buried pulley stitch.

The SCIM "uses the buried vertical mattress’s ability to evert wound edges and combines it with the pulley stitch’s ability to decrease tension at the wound edge," she said.

The four-step process is as follows:

• 1. Insert the needle into the dermis 3-5 mm lateral to the wound edge. Advance the needle into the upper reticular dermis, and then curve down to exit through the lower reticular dermis.

• 2. Insert the needle into the opposite edge of the wound at the lower reticular dermis and advance into the upper reticular dermis, then curve down and exit intradermally.

• 3. Insert the needle across the defect using an intradermal approach 1-2 mm lateral to the initial needle insertion point. Then, create a second buried vertical mattress stitch.

• 4. Pull the two stitches to close, which "creates a pulley effect with minimal recoil, and tie off," Dr. Redbord said.

"The pulley system locks the wound edges so that a knot can be tied without slipping," she added.

Dr. Redbord said she had no relevant financial disclosures.

hsplete@frontlinemedcom.com

EDITOR'S NOTE: August 26, 2013: This article has been amended since it was first published to make it clear that Dr. Kelley Pagliai Redbord's description of the pulley stitch procedure was taken directly from an article published by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg.2011;37:1503-5). In her presentation, Dr. Redbord credited Dr. Yag-Howard and her article. However, this credit and attribution to Dr. Yag-Howard was not included in the article published.

WASHINGTON – The pulley stitch "is my go-to stitch for defects under tension," said Dr. Kelley Pagliai Redbord.

The pulley stitch allows for considerable reduction in the surface area of a large defect that can’t be closed by side-to-side stitches alone, making it an excellent choice for use on the scalp and legs, Dr. Redbord said at the Atlantic Dermatological Conference.

"When the tension across the wound is decreased, buried dermal sutures can be placed more easily and accurately," she said. "I use it a lot as an intraoperative tissue expander."

Dr. Redbord said that her description of the pulley stitch was taken from an article by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg. 2011; 37:1503-5).* 

The pulley stitch can serve as a temporary suture that can be left in place or removed, said Dr. Redbord, a dermatologist in group practice in Rockville, Md.

Courtesy of Dr. Kelley Pagliani Redbord

The technique follows a far-near-near-far pattern, starting the stitch 8 mm from the wound edge (far), then bringing it to the opposite side just 4 mm from the wound edge (near). Dr. Redbord then reenters the stitch 4 mm from the wound edge on the initial side (near), and makes another pass to the opposite side 8 mm from the wound edge (far).

Multiple passes through the tissue create resistance that keeps the suture from slipping. "The loops of the stitch are placed at an oblique angle so that the inner and outer loops are offset and do not override each other," she noted. This technique minimizes potential skin damage from pressure necrosis caused by overriding loop sutures. The pulley stitch has a 2:1 mechanical advantage over an interrupted suture, and the additional friction of a second loop prevents the knot from slipping.

A modification of the pulley stitch is to loop the suture through an external loop on the opposite side of the incision, and pull across. "This new loop functions as a pulley and directs the tension away from the other strands," she said.

Another stitch with excellent eversion, in which the pulley stitch plays a key role, is the subcutaneous inverted cross mattress stitch (SICM). The SCIM is entirely subcutaneous, and combines the buried vertical mattress stitch and the buried pulley stitch.

The SCIM "uses the buried vertical mattress’s ability to evert wound edges and combines it with the pulley stitch’s ability to decrease tension at the wound edge," she said.

The four-step process is as follows:

• 1. Insert the needle into the dermis 3-5 mm lateral to the wound edge. Advance the needle into the upper reticular dermis, and then curve down to exit through the lower reticular dermis.

• 2. Insert the needle into the opposite edge of the wound at the lower reticular dermis and advance into the upper reticular dermis, then curve down and exit intradermally.

• 3. Insert the needle across the defect using an intradermal approach 1-2 mm lateral to the initial needle insertion point. Then, create a second buried vertical mattress stitch.

• 4. Pull the two stitches to close, which "creates a pulley effect with minimal recoil, and tie off," Dr. Redbord said.

"The pulley system locks the wound edges so that a knot can be tied without slipping," she added.

Dr. Redbord said she had no relevant financial disclosures.

hsplete@frontlinemedcom.com

You’ve heard it before: Social media is the new marketing. Chances are good that you’re already using social media to market your practice. The question is: Are you using it effectively?

Traditional marketing – buying ads through newspapers, magazines, radio, et cetera – is still alive. But more and more, companies, including medical practices, are turning to social media marketing or "media marketing." Why? Social marketing costs less, helps build your brand, is interactive, is less obtrusive, provides real-time results, and can be adjusted or tailored quickly to meet your current needs.

As health care providers, we know that the best form of advertising is positive word of mouth. Turns out the same is true online. A 2012 Nielsen Global Trust in Advertising report found that of 28,000 Internet respondents in 56 countries, 92% of consumers said they trusted earned media (media recommended by family and friends) above all other forms of advertising.

The same is true with health care. Health care consumers want more, not fewer, online reviews of doctors and medical centers because they trust word of mouth. According to a May 2011 report from the Pew Research Center, 16% of Internet users, or 12% of adults, have consulted online rankings or reviews of doctors or other health care providers. These numbers will only rise as more patients post reviews.

Despite its benefits, social marketing won’t work for your practice if you don’t use it correctly. Unlike traditional marketing, which relies on a one-way message from the company (you) to the consumer (your current and prospective patients), social marketing is a two-way message. You are connecting with and sharing information with others on different social media platforms on a regular basis.

Successful marketing is a multistep process. It’s not good enough to simply attract. You also need to convert. The online world is full of clutter, so to attract people’s attention, you need to provide value. You do this by creating compelling, credible content that can be easily shared on many social platforms, such as Twitter, Facebook, and Pinterest. The hub of your social media marketing content should be your website/blog.

Your practice website should include a blog that is continually updated with fresh, original material that can be shared on social platforms. That way, when people find you on Facebook or Twitter, they can click through to your practice website where conversion takes place. Keep in mind it often takes more than one visit to convert.

For social marketing to be effective, you need a strong brand and message. Are you the acne expert? The technologically tricked-out Mohs surgeon? The bilingual pediatrician?

Let’s look at an example: You’re a pediatric dermatologist who specializes in eczema. You write engaging, useful, medically accurate blog posts that you share on different social media platforms. A mom of a child with eczema finds a link to one of your posts on natural remedies for eczema. She clicks through to your practice website, where she posts a comment on the blog and shares the post on Pinterest.

Here’s what she should find while she’s on your practice’s website:

• A clean, updated site with information about you and your practice.

• More blog posts for visitors to read and comment on.

• An RSS feed to subscribe to your blog.

• The ability to sign up for your newsletter or do one-click shopping (if applicable).

• The ability to make an appointment by phone or by using an online booking service (such as ZocDoc.com).

• Links to your other social media platforms (Facebook page, twitter feed).

• Any details that make your practice stand out, such as when and whether you offer night or weekend appointments, descriptions of your latest technology, or the presence of multilingual staff.

She will likely start consuming your information. She might comment on a blog post, begin following you on Twitter, or sign up for your RSS feed that will provide her with updates every time you post new content. Over time, she will come to value your brand and see you as a trusted source of information. She may eventually schedule an appointment, refer you to a friend, or buy one of your products. Likely, she’ll share her positive experiences online, helping to spread the good word about you.

If you’ve tried social media marketing in the past and didn’t find it successful, then ask yourself these questions: Did you misuse your social media platforms by constantly promoting yourself or criticizing others? Did you spam people with unwanted ads or add people to your e-mail list without their permission? Ignore questions and comments? Forget to make it about them, not you?

Today, there is no successful marketing without successful social media. By following these steps, not only will you attract new clients, you will also convert them, leading to more satisfied patients and a more satisfied you.

Dr. Benabio is in private practice in San Diego. Visit his consumer health blog at http://thedermblog.com; connect with him on Twitter @Dermdoc, and on Facebook (DermDoc).

You’ve heard it before: Social media is the new marketing. Chances are good that you’re already using social media to market your practice. The question is: Are you using it effectively?

Traditional marketing – buying ads through newspapers, magazines, radio, et cetera – is still alive. But more and more, companies, including medical practices, are turning to social media marketing or "media marketing." Why? Social marketing costs less, helps build your brand, is interactive, is less obtrusive, provides real-time results, and can be adjusted or tailored quickly to meet your current needs.

As health care providers, we know that the best form of advertising is positive word of mouth. Turns out the same is true online. A 2012 Nielsen Global Trust in Advertising report found that of 28,000 Internet respondents in 56 countries, 92% of consumers said they trusted earned media (media recommended by family and friends) above all other forms of advertising.

The same is true with health care. Health care consumers want more, not fewer, online reviews of doctors and medical centers because they trust word of mouth. According to a May 2011 report from the Pew Research Center, 16% of Internet users, or 12% of adults, have consulted online rankings or reviews of doctors or other health care providers. These numbers will only rise as more patients post reviews.

Despite its benefits, social marketing won’t work for your practice if you don’t use it correctly. Unlike traditional marketing, which relies on a one-way message from the company (you) to the consumer (your current and prospective patients), social marketing is a two-way message. You are connecting with and sharing information with others on different social media platforms on a regular basis.

Successful marketing is a multistep process. It’s not good enough to simply attract. You also need to convert. The online world is full of clutter, so to attract people’s attention, you need to provide value. You do this by creating compelling, credible content that can be easily shared on many social platforms, such as Twitter, Facebook, and Pinterest. The hub of your social media marketing content should be your website/blog.

Your practice website should include a blog that is continually updated with fresh, original material that can be shared on social platforms. That way, when people find you on Facebook or Twitter, they can click through to your practice website where conversion takes place. Keep in mind it often takes more than one visit to convert.

For social marketing to be effective, you need a strong brand and message. Are you the acne expert? The technologically tricked-out Mohs surgeon? The bilingual pediatrician?

Let’s look at an example: You’re a pediatric dermatologist who specializes in eczema. You write engaging, useful, medically accurate blog posts that you share on different social media platforms. A mom of a child with eczema finds a link to one of your posts on natural remedies for eczema. She clicks through to your practice website, where she posts a comment on the blog and shares the post on Pinterest.

Here’s what she should find while she’s on your practice’s website:

• A clean, updated site with information about you and your practice.

• More blog posts for visitors to read and comment on.

• An RSS feed to subscribe to your blog.

• The ability to sign up for your newsletter or do one-click shopping (if applicable).

• The ability to make an appointment by phone or by using an online booking service (such as ZocDoc.com).

• Links to your other social media platforms (Facebook page, twitter feed).

• Any details that make your practice stand out, such as when and whether you offer night or weekend appointments, descriptions of your latest technology, or the presence of multilingual staff.

She will likely start consuming your information. She might comment on a blog post, begin following you on Twitter, or sign up for your RSS feed that will provide her with updates every time you post new content. Over time, she will come to value your brand and see you as a trusted source of information. She may eventually schedule an appointment, refer you to a friend, or buy one of your products. Likely, she’ll share her positive experiences online, helping to spread the good word about you.

If you’ve tried social media marketing in the past and didn’t find it successful, then ask yourself these questions: Did you misuse your social media platforms by constantly promoting yourself or criticizing others? Did you spam people with unwanted ads or add people to your e-mail list without their permission? Ignore questions and comments? Forget to make it about them, not you?

Today, there is no successful marketing without successful social media. By following these steps, not only will you attract new clients, you will also convert them, leading to more satisfied patients and a more satisfied you.

Dr. Benabio is in private practice in San Diego. Visit his consumer health blog at http://thedermblog.com; connect with him on Twitter @Dermdoc, and on Facebook (DermDoc).

You’ve heard it before: Social media is the new marketing. Chances are good that you’re already using social media to market your practice. The question is: Are you using it effectively?

Traditional marketing – buying ads through newspapers, magazines, radio, et cetera – is still alive. But more and more, companies, including medical practices, are turning to social media marketing or "media marketing." Why? Social marketing costs less, helps build your brand, is interactive, is less obtrusive, provides real-time results, and can be adjusted or tailored quickly to meet your current needs.

As health care providers, we know that the best form of advertising is positive word of mouth. Turns out the same is true online. A 2012 Nielsen Global Trust in Advertising report found that of 28,000 Internet respondents in 56 countries, 92% of consumers said they trusted earned media (media recommended by family and friends) above all other forms of advertising.

The same is true with health care. Health care consumers want more, not fewer, online reviews of doctors and medical centers because they trust word of mouth. According to a May 2011 report from the Pew Research Center, 16% of Internet users, or 12% of adults, have consulted online rankings or reviews of doctors or other health care providers. These numbers will only rise as more patients post reviews.

Despite its benefits, social marketing won’t work for your practice if you don’t use it correctly. Unlike traditional marketing, which relies on a one-way message from the company (you) to the consumer (your current and prospective patients), social marketing is a two-way message. You are connecting with and sharing information with others on different social media platforms on a regular basis.

Successful marketing is a multistep process. It’s not good enough to simply attract. You also need to convert. The online world is full of clutter, so to attract people’s attention, you need to provide value. You do this by creating compelling, credible content that can be easily shared on many social platforms, such as Twitter, Facebook, and Pinterest. The hub of your social media marketing content should be your website/blog.

Your practice website should include a blog that is continually updated with fresh, original material that can be shared on social platforms. That way, when people find you on Facebook or Twitter, they can click through to your practice website where conversion takes place. Keep in mind it often takes more than one visit to convert.

For social marketing to be effective, you need a strong brand and message. Are you the acne expert? The technologically tricked-out Mohs surgeon? The bilingual pediatrician?

Let’s look at an example: You’re a pediatric dermatologist who specializes in eczema. You write engaging, useful, medically accurate blog posts that you share on different social media platforms. A mom of a child with eczema finds a link to one of your posts on natural remedies for eczema. She clicks through to your practice website, where she posts a comment on the blog and shares the post on Pinterest.

Here’s what she should find while she’s on your practice’s website:

• A clean, updated site with information about you and your practice.

• More blog posts for visitors to read and comment on.

• An RSS feed to subscribe to your blog.

• The ability to sign up for your newsletter or do one-click shopping (if applicable).

• The ability to make an appointment by phone or by using an online booking service (such as ZocDoc.com).

• Links to your other social media platforms (Facebook page, twitter feed).

• Any details that make your practice stand out, such as when and whether you offer night or weekend appointments, descriptions of your latest technology, or the presence of multilingual staff.

She will likely start consuming your information. She might comment on a blog post, begin following you on Twitter, or sign up for your RSS feed that will provide her with updates every time you post new content. Over time, she will come to value your brand and see you as a trusted source of information. She may eventually schedule an appointment, refer you to a friend, or buy one of your products. Likely, she’ll share her positive experiences online, helping to spread the good word about you.

If you’ve tried social media marketing in the past and didn’t find it successful, then ask yourself these questions: Did you misuse your social media platforms by constantly promoting yourself or criticizing others? Did you spam people with unwanted ads or add people to your e-mail list without their permission? Ignore questions and comments? Forget to make it about them, not you?

Today, there is no successful marketing without successful social media. By following these steps, not only will you attract new clients, you will also convert them, leading to more satisfied patients and a more satisfied you.

Dr. Benabio is in private practice in San Diego. Visit his consumer health blog at http://thedermblog.com; connect with him on Twitter @Dermdoc, and on Facebook (DermDoc).