NEW Communication Tool to the VA (VIQ/QIPS)

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.

GREAT WORK TEAM!!

VIQ: Procalcitonin: Does It Really Change Management at UCSD?

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.

Grand Rounds 9/11: Improving Antibiotic Stewardship: Can Procalcitonin Save Us?

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.

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Thank you for a thought-provoking talk, Dr. Seymann!

 

 

 

 

 

Lifelong Learning: WIHI

The Institute for Healthcare Improvement (IHI) is arguably the foremost organization for all things Quality and Patient Safety in the United States. They have created a new “online radio” (think podcast) channel called WIHI (click here for an explanation of how “W” and “K” became assigned to radio channels, in case you’re curious like me). WIHI covers a wide range of topics, some recent episodes include: What’s an Apology Worth? The Case for Communication and Resolution Women in Action: Paving the Way for Better Care  Building the Will and Skill to Be a Clinical Improver  Lowering Readmissions, Reducing Disparities And many more! Oh, and did I mention it’s free?? Happy listening!

Friday School: statistical process control charts, osteoporosis and transgender health

Today we had a perfect combination of sessions to round out the end of the Endo, Gender Health and QI block! We started with a hands-on session, creating our own SPC charts to learn how easy and useful these can be. This was lead by our very own Dr. Jack Temple. Remember these graphs/charts help you see visually how a process changes over time. This is easy to understand when you think about graphing someone’s blood pressure: you can see average ranges and when it goes high vs low. This was followed by a case-based session on osteoporosis with Dr. Kado. The groups went through various cases to discuss when and how to treat osteoporosis and when to stop. Take a look at this single slide for a nice guide:   The interns joined us for the rest of Friday school which consisted of a lecture on LGBT health by Dr. Jill Blumenthal and followed by a transgender panel. Below

read more Friday School: statistical process control charts, osteoporosis and transgender health

Demystifying the PDSA

Hey! It’s no secret, residents often dread PDSAs — many put them off until late into their training. I’m here to help! In this short video, I demystify the PDSA. I go over: the what (is a PDSA)? why (do we do them)? and how (do you do them)? Also, I throw a shout out to Chimpanzees, the original PDSA champions! As a reminder, six PDSAs are required of categorical residents in order to graduate, but hey, if a Chimpanzee can do it, it can’t be that hard! If you have any questions, email me at jltemple@ucsd.edu