Kudos to our residents Sophie Cannon, Ibrahim Selevany and Diego Vargas for successfully launching a communication aid tool at the VA based off a QIPS case presented by Nandi Shah. Look out for these signs at the bedside to indicate communication deficits and improve the patient experience.
Today our amazing future chief Dr. Averie Tigges discussed a case of a young man with SCI admitted for UTI, but used the case to discuss the greater concept of malnutrition. Averie walked us through some of the prior rationale for using pre-albumin and then discussed why it is actually not a useful bio-marker for malnutrition (its a negative acute phase reactant!) . She then discussed the different clinical scores available to assess malnutrition and highlighted the choosing wisely recommendation to utilize one of these scores over pre-albumin for assessment of malnutrition.
Intern Victoria Wu created a best practice tool to help facilitate information exchange for patients being transferred to our hospitals. Find EPIC tips for starting orders and note early to transmit vital information and a helpful list of phone numbers of common transferring hospitals in the area.
This document has been added to the CVC and MICU rotation pages!
Today at Jacobs, we discussed two common practices in hospital medicine which, current evidence suggests, should be done away with: the use of docusate for prevention and treatment of constipation and assumption of a historical penicillin allergy without further investigation. Our residents digested the “Things We Do For No Reason” articles on these subjects, and then presented the information to each other in quick, 5-minute chalk talks! The “Things We Do For No Reason” series is a quick and easy tool to highlight both high value care, as well as quick, relevant topics to teach about on wards (you only need 20 minutes of prep time!). Check out our residents in action!
Today at Jacobs, we worked on some RACE track concepts through a hospital medicine lens! The residents paired up to discuss 2 articles from SHM’s Choosing Wisely campaign, “Things We Do For No Reason.” They then prepared a 5 minute chalk talk based on the articles to present to our small group! The teams learned just how easy it can be to quickly synthesize some high yield topics into a deliverable for wards!
Procalcitonin: Does It Really Change Management at UCSD Our stellar residents and interns on VIQ questioned the practical use of procalcitonin in our hospitals. Great job Nagambika Munaganuru, Bianca Palushaj, Alexander Tong, Alexandra Sykes, Jacob Kaiser, W. Kenneth Winter, Nandi Shah, Lester Tsai, Cynthia Hsu, Katarina Vasiljevic, Yan Xing, Praneet Mylavarapu, and Janna Raphelson!!
Procalcitonin is an emerging biomarker that can be used to predict the likelihood of bacterial infection. Multiple studies have looked at its role in guiding abx therapy with patients admitted for respiratory tract infections, as well as those admitted with sepsis to the ICU. Typically, for PCL < 0.1 mcg/L, antibiotics strongly discouraged; if it is >0.25 mcg/L, antibiotics are recommended.
Our study was to determine whether PCL levels resulted in fewer days of antibiotic therapy for patients with uncomplicated pneumonia. Charts for 57 patients hospitalized at UCSD with a diagnosis of CAP between 2/2019-8/2019 were reviewed. We found no clinically significant difference in average antibiotic duration between patients with elevated PCL vs normal PCL’s (5.1 vs 5.7 days, respectively).
Even in cases when RPNA was positive for virus and PCL was low, the median antibiotic duration was 7 days, suggesting that we do not rely on results from either diagnostic test for clinical decision making. This raises the question of why we order these tests at all.
There are several reasons that may explain this. There may be a discordance between a patient’s clinical presentation and their PCL level. Since many PCL’s are ordered by the ED, they may be accidentally or deliberately ignored by the primary team. Except for rare cases, it does not appear that PCL was trended (it should be to determine response to antibiotic treatment). Lastly, given that it is a relatively new biomarker, clinicians may not yet feel comfortable using it as part of their routine practice.
We conclude that there remain opportunities to improve our use of diagnostic testing by either reducing the use of irrelevant testing or increasing the extent to which we incorporate the test results in our antibiotic decision making.
Today one of our wonderful hospitalists, Dr. Gregory Seymann, spoke on the topic of procalcitonin and its utility in antibiotic stewardship. He reminded us that antibiotic overuse and growing bacterial resistance is an ongoing problem in medicine that we need to actively combat.
He walked us through several studies that showed shorter antibiotic courses were shown to be equivalent to longer courses in terms of efficacy of treatment of pneumonia, reduced antibiotic-related adverse events and reduced utilization costs for institutions. In particular, several studies demonstrated that excess therapy use was driven by discharge prescriptions for patients for antibiotic course prolonged beyond what was clinically indicated for treatment.
Dr. Seymann then introduced procalcitonin as a biomarker that could be utilized for treatment of bacterial infections in guiding initiation and discontinuation of antibiotics. He discussed the PROHOSP study and several meta-analyses, which showed that in the inpatient setting for both ward level and ICU level patients, using procalcitonin to guide early discontinuation of antibiotics (in regards to initiation and duration of treatment) did not lead to increased patient mortality and decreased risk of adverse effects.
He went on to address some common arguments against the use of procalcitonin. Dr. Seymann addressed the pitfalls of the 2018 PROACT study that had been published in NEJM and showed no difference in mean antibiotic days and no difference in adverse outcomes. In regards to relying instead on identification of a bacterial source of infection, he highlighted that often the yield from culture data is low. He noted that using an antibiotic time out does not appear to be sufficient as it may not be utilized as often as required, and therefore many antibiotics might be continued needlessly. As for relying on clinical judgment, there is evidence that about 50% of patient deemed by their provider as having low likelihood of having a bacterial infection will still get antibiotics. Therefore, there is a need for an additional tool like procalcitonin to guide usage of antibiotics.
Dr. Seymann then also highlighted the work of our residents recently on the Value Improves Quality (VIQ) rotation. They had looked at the utilization of procalcitonin within our hospitals and showed that providers at UCSD were not using procalcitonin appropriately. Some patients with low procalcitonins were still given antibiotics and some with high procalcitonin did not receive treatment. He reminded us to be thoughtful about only ordering tests the we would act upon and actively incorporate into our clinical decision-making, including procalcitonin.
Dr. Seymann concluded with a request to the audience to take on the responsibility of antibiotic stewardship together and to work actively combat antibiotic resistance.
Thank you for a thought-provoking talk, Dr. Seymann!
Congratulations to Dr. Jack Temple, outgoing QI chief, and his team on winning 1st place at the VA Performance Improvement Fair! They won the System Redesign Award!! Most impressive! Congratulations again, Jack! We will miss you!
At UCSD, we strive to provide the highest value, evidence-based care. Fortunately, there are great resources available to help hone our skills. Today’s LLL post focuses on Order Wisely®, an initiative from the High Value Practice Academic Alliance (HVPAA). It is a series of short lectures that outline the highest-value approach to many conditions–everything from headache to shoulder pain, pulmonary embolism to transfusions. They have many videos focused specifically on hospital-medicine-relevant topics. Here’s to high value care! Link here.