Prevention of venous thromboembolism in the hospitalized medical patient.

Hospitalized acutely ill medical patients are at high risk for venous thromboembolism (VTE), and clinical trials clearly demonstrate that pharmacologic prophylaxis of VTE for up to 14 days significantly reduces the incidence of VTE in this population. Guidelines recommend use of low-molecular-weight heparin (LMWH) or unfractionated heparin (5,000 U three times daily) for VTE prophylaxis in hospitalized medical patients with risk factors for VTE; in patients with contraindications to anticoagulants, mechanical prophylaxis is recommended. All hospitalized medical patients should be assessed for their risk of VTE at admission and daily thereafter, and those with reduced mobility and one or more other VTE risk factors are candidates for aggressive VTE prophylaxis. Based on results from the recently reported EXCLAIM trial, extended postdischarge prophylaxis with LMWH for 28 days should be considered for hospitalized medical patients with reduced mobility who are older than age 75 or have a cancer diagnosis or a history of VTE.

Prevention of venous thromboembolism in the orthopedic surgery patient.

Patients undergoing major orthopedic surgery--hip or knee arthroplasty, or hip fracture repair--are in the highest risk category for venous thromboembolism (VTE) solely on the basis of the orthopedic procedure itself. Despite this, nearly half of patients undergoing these procedures do not receive appropriate prophylaxis against VTE, often due to a disproportionate fear of bleeding complications in this population. Guidelines from the American College of Chest Physicians (ACCP) provide evidence-based recommendations for many aspects of VTE risk reduction in the setting of orthopedic surgery, as detailed in this review. The ACCP recommends the use of either low-molecular-weight heparin (LMWH), fondaparinux, or adjusted-dose warfarin as preferred VTE prophylaxis in patients undergoing either hip or knee arthroplasty. Fondaparinux is the preferred recommendation for patients undergoing hip fracture repair, followed by LMWH, unfractionated heparin, and adjusted-dose warfarin as alternative options. Extended-duration prophylaxis (for 4 to 5 weeks) is now recommended for patients undergoing hip arthroplasty or hip fracture repair. Patients undergoing knee arthroscopy do not require routine pharmacologic VTE prophylaxis.

Prevention of venous thromboembolism in the cancer surgery patient.

Cancer patients, especially those undergoing surgery for cancer, are at extremely high risk for developing venous thromboembolism (VTE), even with appropriate thromboprophylaxis. Anticoagulant prophylaxis in cancer surgery patients has reduced the incidence of VTE events by approximately one-half in placebo-controlled trials, and extended prophylaxis (for up to 1 month) has also significantly reduced out-of-hospital VTE events in clinical trials in this population. Clinical trials show no difference between low-molecular-weight heparin (LMWH) and unfractionated heparin in VTE prophylaxis efficacy or bleeding risk in this population, although the incidence of heparin-induced thrombocytopenia is lower with LMWH. The risk-benefit profile of low-dose anticoagulant prophylaxis appears to be favorable even in many cancer patients undergoing neurosurgery, for whom pharmacologic VTE prophylaxis has been controversial because of bleeding risks.

Role of pharmacist counseling in preventing adverse drug events after hospitalization.

BACKGROUND: Hospitalization and subsequent discharge home often involve discontinuity of care, multiple changes in medication regimens, and inadequate patient education, which can lead to adverse drug events (ADEs) and avoidable health care utilization. Our objectives were to identify drug-related problems during and after hospitalization and to determine the effect of patient counseling and follow-up by pharmacists on preventable ADEs. METHODS: We conducted a randomized trial of 178 patients being discharged home from the general medicine service at a large teaching hospital. Patients in the intervention group received pharmacist counseling at discharge and a follow-up telephone call 3 to 5 days later. Interventions focused on clarifying medication regimens; reviewing indications, directions, and potential side effects of medications; screening for barriers to adherence and early side effects; and providing patient counseling and/or physician feedback when appropriate. The primary outcome was rate of preventable ADEs. RESULTS: Pharmacists observed the following drug-related problems in the intervention group: unexplained discrepancies between patients' preadmission medication regimens and discharge medication orders in 49% of patients, unexplained discrepancies between discharge medication lists and postdischarge regimens in 29% of patients, and medication nonadherence in 23%. Comparing trial outcomes 30 days after discharge, preventable ADEs were detected in 11% of patients in the control group and 1% of patients in the intervention group (P = .01). No differences were found between groups in total ADEs or total health care utilization. CONCLUSIONS: Pharmacist medication review, patient counseling, and telephone follow-up were associated with a lower rate of preventable ADEs 30 days after hospital discharge. Medication discrepancies before and after discharge were common targets of intervention.

Comparison of a single end point to determine optimal initial warfarin dosing (5 mg versus 10 mg) for venous thromboembolism.

There remains considerable controversy regarding optimal initial warfarin dosing in patients with acute venous thromboembolism. Therefore, an open-label, randomized trial comparing 2 warfarin initiation nomograms (5 vs 10 mg) was conducted in patients with acute venous thromboembolism. All participants received fondaparinux for > or = 5 days as a "bridge" to warfarin. The primary end point was defined as the number of days necessary to achieve 2 consecutive international normalized ratio laboratory test values > 1.9. A total of 50 patients were enrolled and randomly assigned to each of the treatment arms. The median time to 2 consecutive international normalized ratios was 5 days in the 2 groups. There was no statistical difference in achieving the primary end point using either the 5- or the 10-mg nomogram (p = 0.69). These results should provide clinicians with increased warfarin dosing options in patients presenting with acute venous thromboembolism.

Once daily enoxaparin for outpatient treatment of acute venous thromboembolism: a case-control study.

We studied the efficacy and safety of an investigational enoxaparin regimen, 1.5 mg/kg once daily, as a bridge to warfarin for the outpatient treatment of acute venous thromboembolism. We undertook a case-control design. We enrolled 40 acute venous thromboembolism cases prospectively and matched them by age, gender, and location of venous thromboembolism to 80 previously treated controls. All controls had received enoxaparin 1 mg/kg twice daily. The primary end point was recurrent venous thromboembolism. We followed the cases for 30 days. We discontinued enoxaparin after we achieved the target international normalized ratio between 2.0 and 3.0. One case (2.9%) and three controls (3.8%) had recurrent venous thromboembolic events (P = 1.00). There were no major bleeding complications in the case group, compared to 3 (3.8%) in the control group (P = .55). Once daily enoxaparin, 1.5 mg/kg, as a bridge to warfarin was as effective with a similar safety profile as twice daily enoxaparin, 1mg/kg, for initial treatment of acute venous thromboembolism in the outpatient setting. This case-control study provides the rationale for undertaking a randomized controlled trial comparing enoxaparin 1.5 mg/kg once daily versus enoxaparin 1.0 mg/kg twice daily as a bridge to warfarin in outpatients with acute venous thromboembolism.

Core competencies in hospital medicine: development and methodology.

BACKGROUND: The hospitalist model of inpatient care has been rapidly expanding over the last decade, with significant growth related to the quality and efficiency of care provision. This growth and development have stimulated a need to better define and characterize the field of hospital medicine. Training and developing curricula specific to hospital medicine are the next step in the evolution of the field. METHODS: The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (the Core Competencies), by the Society of Hospital Medicine, introduces the expectations of hospitalists and provides an initial structural framework to guide medical educators in developing curricula that incorporate these competencies into the training and evaluation of students, clinicians-in-training, and practicing hospitalists. This article outlines the process that was undertaken to develop the Core Competencies, which included formation of a task force and editorial board, development of a topic list, the solicitation for and writing of chapters, and the execution of multiple reviews by the editorial board and both internal and external reviewers. RESULTS: This process culminated in the Core Competencies document, which is divided into three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in each section delineate the core knowledge, skills, and attitudes necessary for effective inpatient practice while also incorporating a systems organization and improvement approach to care coordination and optimization. CONCLUSIONS: These competencies should be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve inpatient training practices.

How to use The Core Competencies in Hospital Medicine: a framework for curriculum development.

BACKGROUND: The seminal article that coined the term hospitalist, published in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital. Since that time the role of the hospitalist has evolved, and hospitalists are being called upon to demonstrate that they actually improve quality of care and the education of the next generation of physicians. A companion article in this issue describes in detail the rationale for the development of the Core Competencies document and the methods by which it was created. METHODS: Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development. The cases illustrate 1) a specific problem and the need for improvement; 2) a needs assessment of the targeted learners (hospitalists and clinicians in training); 3) goals and specific measurable objectives; 4) educational strategies using the competencies to provide structure and guidance; 5) implementation (applying competencies to a variety of training opportunities and curricula); 6) evaluation and feedback; and 7) remaining questions and the need for additional research. RESULTS: This article illustrates how to utilize The Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients. CONCLUSIONS: Medical educators should compare their learning objectives to the Core Competencies to ensure that their trainees have achieved competency to practice hospital medicine and improve the hospital setting.

Core competencies in hospital medicine: development and methodology.

BACKGROUND: The hospitalist model of inpatient care has been rapidly expanding over the last decade, with significant growth related to the quality and efficiency of care provision. This growth and development have stimulated a need to better define and characterize the field of hospital medicine. Training and developing curricula specific to hospital medicine are the next step in the evolution of the field. METHODS: The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (the Core Competencies), by the Society of Hospital Medicine, introduces the expectations of hospitalists and provides an initial structural framework to guide medical educators in developing curricula that incorporate these competencies into the training and evaluation of students, clinicians-in-training, and practicing hospitalists. This article outlines the process that was undertaken to develop the Core Competencies, which included formation of a task force and editorial board, development of a topic list, the solicitation for and writing of chapters, and the execution of multiple reviews by the editorial board and both internal and external reviewers. RESULTS: This process culminated in the Core Competencies document, which is divided into three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in each section delineate the core knowledge, skills, and attitudes necessary for effective inpatient practice while also incorporating a systems organization and improvement approach to care coordination and optimization. CONCLUSIONS: These competencies should be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve inpatient training practices.

How to use the core competencies in hospital medicine: a framework for curriculum development.

BACKGROUND: The seminal article that coined the term hospitalist, published in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital. Since that time the role of the hospitalist has evolved, and hospitalists are being called upon to demonstrate that they actually improve quality of care and the education of the next generation of physicians. A companion article in this issue describes in detail the rationale for the development of the Core Competencies document and the methods by which it was created. METHODS: Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development. The cases illustrate 1) a specific problem and the need for improvement; 2) a needs assessment of the targeted learners (hospitalists and clinicians in training); 3) goals and specific measurable objectives; 4) educational strategies using the competencies to provide structure and guidance; 5) implementation (applying competencies to a variety of training opportunities and curricula); 6) evaluation and feedback; and 7) remaining questions and the need for additional research. RESULTS: This article illustrates how to utilize The Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients. CONCLUSIONS: Medical educators should compare their learning objectives to the Core Competencies to ensure that their trainees have achieved competency to practice hospital medicine and improve the hospital setting.