1. Hospitalist Bootcamp Dr Scott Samis Hospitalist at PLC Dr Henry Lo Hospitalist SHC Dr Bhavini Gohel Hospitalist at SHC

2. Disclosures None

3. Objectives Overview of the hospitalist program Tips to succeed during the rotation Expectations of the residents and Evaluations Clinical Pearls on common medical problems

4. Why? Requests from residents as no formal teaching during rotations Ensure you are prepared Change in the curriculum fewer acute care rotations We want you to get the best out of the rotation We want you to succeed

5. A role of Hospitalist Family doctors that provide inpatient care Unique to North America in that done by GP’s as well as Internists In the major cities hospitalists do not have a previous relationship with their inpatients (exception) Patients are general, complex medical and ALC patients Often co-managed with other sub specialities Paid via ARP

6. Criteria for admission Can be rounded on once per day. Cannot be unstable There is no other speciality that the patient would be better cared under Often a grey area Our scope of practice has changed over time Conditions we will not manage by us: Bacterial meningitis, endocarditis, complicated biliary obstruction, IBD (except at SHC), DKA, Hepatic encephalopathy, High risk GIB, Severe HONKS, severe metabolic derangements………

7. Expectations of a Resident Call your preceptor before hand arrange a meeting time and place Arrive on time Have goals and objectives Expect to carry 5-6 patients on your first day this will increase to 8-10 Introduce yourself to charge nurse and touch base daily regarding issues for your patients Give each unit your pager and patients you will be looking after Expected to fully manage patients- including family meetings and updates, consultations etc Should be seeing 3 patients an hour Handover to on call if you need to

8. Histories/Progress notes/Plans some Pearls Histories-Call family and facilities for collateral, Comprehensive past medical history including names of consultants, ensure patients BADLS and IADLs are covered. Use Netcare and SCM Progress notes- ensure notes are written in way that the on call can reasonably manage the patient without having to go through the entire chart. If pt is sick ensure a good written plan is in place Plans- Ensure issues and plan outlined clearly and with all conversations with family and consultants documented

9. Discharge summaries Typed or dictated Ensure a clear plan outlined, relevant consultants copied, dates of appointments listed Details regarding primary dx and other diagnosis affects length of stay

10. Presentation- admission Brief ID Presenting complaint Overview of relevant medical conditions Summary of HPI Summary of relevant physical exam findings Summary of relevant investigations Your issues and then plan

11. Presentation post admission Summarize reason for admission Relevant PMH Course in hospital and treatment so far Your current plan Disposition

12. Medication Reconciliation

14. The Evidence: on Admission Errors in medications: 54%, 40% potential serious harm. Etchells et al.

15. The Evidence: Acute Care Canadian Adverse Events Study 1 in 9 patients are potentially given the wrong medication or wrong dose. Norton et al.

16. The Solution: Med Rec is where we take this…

17. and turn it into this… (for now…)

18. 1.Document Sources 2.List medications, dosage, route and frequency 3.Prescriber reconciliation where medications are indicated to continue, discontinue, hold, or change. Also indicate the reason for why 1 2 3

20. Med Rec at Discharge Compare discharge medications with admission medications Explain to next care provider the reasons for the changes Ie reason for new medications, changed meds, stopped medications

21. SCM order sets

22. Allied Health services Team consists of PT, OT, Transition services, SW Services each team offer MDM Rounds Will help with disposition planning

23. Disposition Home- Home care, Palliative home care, C3 program Lodge/retirement residence Supportive living- SL4 vs SL4D Long term care Hospice

24. Clinical Pearls

25. Acute Stroke

26. Case 1 You get the following page at 8am from the ward nurse: Mrs Brain is 62 yo female admitted for an unrelated reason. This morning she has a weak left arm and left leg. She is also speaking “funny.” Can you please come assess? Profile: HTN, smoker

27. What are your thoughts? Stroke Mimics Seizures with accompanying neurologic deficit Todd’s Paresis Systemic infection Brain tumor Toxic-metabolic disorders Hyponatremia Hypoglycemia Conversion disorder

28. Priorities Stabilize the patient Establishing the diagnosis by history and physical examination Obtaining blood tests, an ECG Obtaining a head CT

29. Stabilize the patient Bedside What is the patient’s level of consciousness? Airway and Vital Signs Is the patient in respiratory distress? What is the blood pressure? What is the heart rate? What is the temperature?

30. Establishing the diagnosis by history and physical examination History **Establish when the patient was LAST SEEN WELL What are symptoms? Antecedent TIAs? Medical history and medication history Physical Examination National Institutes of Health Stroke Scale or NIH Stroke Scale (NIHSS)

32. Investigations CBC, Electrolytes, Creatinine, glucose, INR/PTT, ECG Cerebral infarction cannot be disginuished with certainty from intracerebral hemorrhage on Hx and PE CT Scan MRI

33. Treatment If within the timeframe for thrombolysis Collaborate with stroke neurologist for thrombolysis Outside timeframe for thrombolysis Antiplatelets

34. Thrombolysis Onset of symptoms < 4.5 hours before beginning treatment Exclusion Criteria Historical Significant stroke or head trauma in the previous 3 months Previous intracranial hemorrhage Intracranial neoplasm, AV malformation, or aneurysm Recent intracranial or intraspinal surgery Arterial puncture at a non-compressible site in previous 7 days Clinical Subarachnoid hemorrhage Persistent blood pressure elevation (systolic >/= 185 or diastolic >/= 110) Serum glucose < 2.8 Active internal bleeding

35. Hematologic Platelet count < 100 Current anticoagulant use INR > 1.7 or PT > 15 sec Current use of direct thrombin inhibitor or direct factor Xa inhibitor Head CT scan Evidence of hemorrhage Relative exclusion criteria Only minor and isolated neurological signs Rapidly improving stroke symptoms Major surgery or serious trauma in prior 14 days GI bleeding or Urinary tract bleeding in previous 21 days MI in prior 3 months Pregnancy

36. A few points Acute Strokes are infrequently encountered on hospitalist service If you are at any site other than FMC, contact the stroke neurologist early if index of suspicion high for acute ischemic stroke (even prior to CT scan) if still within the window for thrombolysis Involve neurology with care plan

37. Secondary Investigations What are the investigations for secondary prevention of ischemic stroke? fasting lipid panel and liver enzymes: for consideration of starting statin therapy echo heart : assess for cardiac source of emboli holter moniter: assess for atrial fibrillation Anticoagulate if atrial fibrillation found carotid dopplers (if CTA not done): assess extent of carotid stenosis and consideration of carotid endarterectomy referral to stroke prevention clinic

38. Common in hospital Complications post stroke repeat stroke hemorrhagic conversion seizures aspiration pneumonia PEG tube placement delirium depression

39. DVT and PE

40. Case 2 62 yo man presented with 5 day history of worsening dyspnea and orthopnea after returning from a 3 day business trip to Russia. On exam: HR 102; BP 110/60; O2 Sat 86% RA Diagnostic approach?

41. NEJM, 2008 D-dimer - For admitted patients many will fall to high risk category - Much less useful in older patients >80, patients with cancer, or pregnant women

42. Imaging US of legs detects about 20% of patients with pulmonary embolism Positive test essentially establishes diagnosis of PE CT Requires IV contrast VQ Alternative when contrast dye is a concern Less available: M to F business hours

43. Predictor of Severity Prognostic Factors Shock and right ventricular dysfunction Clinical – clinical evidence of shock Radiologic – by echo or CT Labs – BNP and/or troponin elevation RV thrombus Coexisting DVT

44. PE Severity Index (PESI)

45. Simplified PE Severity Index (sPESI) Low risk = 0 High Risk > 1 Arch Intern Med. 2010; 170(15):1383-1389

46. Therapy Hemodynamically unstable patients Thrombolytic therapy Embolectomy Hemodynamically stable patients Anticoagulation in patients with low risk of bleeding IVC filter if contraindication to anticoagulation or an unacceptably high bleeding risk

47. Anticoagulation

48. Key Players Unfractionated heparin - Potentiates the action of antithrombin III and thereby inactivates thrombin and prevents the conversion of fibrinogen to fibrin Low molecular weight heparin Warfarin – blocks a vitamin K dependent step in clotting factor production Dabigatran (Pradaxa) – direct thrombin inhibitor Rivaroxaban (Xarelto) – Factor Xa inhibitor Apixaban (Eliquis) – Factor Xa inhibitor

49. Unfractionated heparain – IV drip Severe renal failure (CrCl < 30) High likelihood of acute reversal of anticoagulation Low molecular weight heparin Active cancer Pregnancy Bridging to warfarin or (transitioning to dabigatran) Warfain Requires bridging with heparin Renal failure Requires following INR

50. Direct factor Xa and thrombin inhibitors

51. Oral factor Xa inhibitors: rivaroxaban, apixaban Evaluated as monotherapy Thrombin inhibitors: dabigatran In studies all patients treated with heparin prior to their administration Exclusions CrCl < 30 pregnant

52. Bridging LMWH  LMWH  warfarin Initiate LMWH and warfarin on day 1 Stop LMWH after no less than 5 days and when INR is stable at 2.0 or more for 2 days LMWH  dabigatran Initiate 5 days of LMWH Start dabigatran 0 to 2 hours prior to time of LMWH would be due

53. Direct factor Xa inhibitors Were evaluated without prior administration of heparin (monotherapy) No bridging required to initiate anticoagulation

55. Case 3 Bridging Peri-operatively Mrs Fast Heart is 80 yo female who has a history of atrial fibrillation and is on warfarin. She has been complaining of weakness and fatigue. She is found to be anemic at her GP’s office but no signs of overt bleeding. She is admitted to hospital for investigation of her anemia. GI plans to complete an upper and lower endoscopy as an inpatient. How should her anti-coagulation be managed peri-operatively for GI investigations?

56. Risk of thromboembolism vs risk of bleeding Estimating thromboembolic Risk Atrial fibrillation: CHADS2 score Prosthetic heart valve Recent Thromboembolism Risk of bleeding Discuss with GI or surgeon and depends on the procedure Some endoscopists will tolerate an elevated INR

57. Bridging Anticoagulation Typically interrupting warfarin and administration of a short acting anticoagulant such as LMWH or unfractionated heparin Examples when appropriate: Embolic stroke or systemic embolic event within the previous 12 weeks Mechanical mitral valve Mechanical aortic valve Atrial fibrillation and very high risk of stroke (CHADS2 score 5 or 6, stroke within the previous 12 weeks) VTE within 12 weeks Recent coronary stenting Previous thromboembolism during interruption of chronic anticoagulation

58. Case 3 Bridging Peri-operatively Mrs Fast Heart is 80 yo female who has a history of atrial fibrillation and is on warfarin. She has been complaining of weakness and fatigue. She is found to be anemic at her GP’s office but no signs of overt bleeding. She is admitted to hospital for investigation of her anemia. GI plans to complete an upper and lower endoscopy as an inpatient. How should her anti-coagulation be managed peri-operatively for GI investigations?

59. Example If otherwise healthy  CHADS2 score 1 for age. Can likely avoid bridging If Mrs Fast Heart more comorbidites Congestive heart failure Hypertension > Age 75 Diabetic Prior stroke Will likely require bridging if wait is prolonged in hospital Will likely require bridging if waiting as an outpatient

60. BUT WHAT HAPPENS for ADMITTED PATIENTS Typically in hospital: Warfarin is held once decision for endoscopy made INR is monitored every day If patient is low risk for thromboembolism, consider reversal with vitamin K GI investigations completed once INR is at target for the GI doctor If patient high risk for thromboembolism and procedure is delayed, consider LWMH/unfractionated heparin to bridge Post procedure started on LMWH/Unfractionated heparin and then bridged back to warfarin

61. Case 4 67 yo male on warfarin and has an acute upper GI bleed. He is dizzy and pre-syncope. INR is 7. How do you reverse the anticoagulation?

62. Management of Life-Threatening Bleed on Warfarin Warfarin Stop warfarin Vitamin K – 10 mg IV fresh frozen plasma or Octaplex: for serious bleeding and INR > 2 Dosing depends on weight and INR

63. What about reversal of the other anticoagulatants? Rivaroxaban and apixaban – no antidote Interval since last dose. Anticoagulation to have resolved after 5 half-lives Drug removal from GI tract: ie activated charcoal Antifibrinolytics: tranexamic acid Prothrombin complex Dabigatran As above but antidote idarucizumab

64. Alcohol withdrawal

65. CIWA-subjective scoring system to determine presence/severity of withdrawal-includes things like headache, hallucinations, nausea Ativan-shorter acting; can be given sl/po/IV/IVP Valium-longer acting; can only be given po/IVPB Antipsychotics-adjuvant to Benzos for more severe Withdrawal, Delirium Tremens Beta Blockers(Propranolol),Clonidine-used to blunt adrenergic overdrive if Tachycardic, Hypertense, Febrile in more severe withdrawal Withdrawal can develop 1-7 days after last alcohol intake Keep in mind if delirium develops after admission for another reason

66. Electrolytes

67. Hyponatremia-Hypovolemic,Isovolemic,Hypervolemic useful labs:Lytes,BUN,Cr,Serum and Urine Osmol,Urine Lytes,TSH,Cortisol,U/A At what level do symptoms occur? Don’t overcorrect too fast-risk of Central Pontine Myelinolysis Hypernatremia-usually volume related,also Diabetes Insipidus again don’t overcorrect too fast

68. Electrolytes Hyperkalemia-what level is problematic how to determine if level is needing emergent therapy therapies:shifting vs elimination Hypokalemia-arrhythmias,muscle weakness replacement-po vs IV

69. Pneumonia

70. Antibiotic treatment-multiple options, tailor according to clinical scenario,comorbidities,suspected organisms start broad,narrow as more information available po vs IV Duration of therapy-5 vs 7 vs 10 days vs longer Parapneumonic effusions-reactive,layer out,exudative and not purulent on thoracentesis tend to not make people ill

71. Pneumonia Empyema-fluid is infected Tend to be loculated,don’t layer out,enhancing rim on CT Scan On thoracentesis are exudative,purulent,may or may not grow organisms,high protein,low glucose Need to be drained Abscesses-Drainage,prolonged antibiotics keep TB,cancer in mind Hospital Acquired (HAP) vs Community Acquired (CAP) Different organisms therefore different antibiotics

72. Pancreatitis

73. Bloodwork: CBC,Lytes,BUN,Cr, Liver Enzymes,Lipase,Calcium,Alb Blood Gases if sicker Radiologic-CXR,Ultrasound,CT Scan,MRI,Alcohol,others Causes:Gallstones if evidence of Gallstones-ERCP vs Cholecystectomy+/-ERCP IV Fluid,NPO,Analgesics Scoring Systems:Ranson’s Criteria,BISAP Score for Pancreatitis Mortality (BUN,Impaired Mental Status,SIRS Criteria,Age,Pleural Effusion),APACHE 2 To feed or not to feed- when to worry about feeding

74. Congestive heart failure

75. Congestive heart failure and Atrial fibrillation A-fib-rate vs rhythm management -what HR to aim for -what drugs-choices,pitfall A-fib with RVR+CHF often “chicken or egg” situation CHF-Left CHF vs Right CHF vs HF of Preserved Ejection Fraction(Diastolic Dysfunction) Diagnosis-Hx,Physical,CXR,EKG,Bloodwork-NT proBNP

76. Congestive heart failure Treatment-acute is Diuresis +/-Nitrates -BIPAP -ACEI vs ARB Echo-determine cause of CHF-treatments will vary New drugs-Entresto (Angiotensin Receptor Neprilysin Inhibitor- Sacubitril/Valsartan);Ivabradine (If Channel Blocker) Other useful classes of drugs: Aldosterone Antagonists,Hydralazine,Nitrates Digoxin

77. Infections

78. Sepsis- Fluids fluids and fluids, Urine output, ensure blood cultures are done, Staphyl aureus bacteremia and continuous bacteremia think of endocarditis (indicates persistent endovascular infection) Wounds- Always look at your wounds and check to see if they probe to bone. Management- Vac dressing Osteomyelitis - When do you suspect Osteomyelitis? Investigation of choice, definitive diagnosis UTI- Urine analysis, Male- think of why they have a UTI Cellulitis- Very RARE to have bilateral cellulitis think of other diagnosis, If not healing feel peripheral pulses, Abx choices Aspiration pneumonia vs Aspiration pneumonitis

79. Delirium and Dementia

80. Delirium Delirium- what is it Hypoactive and hyperactive? History is KEY! Work up- CBC, lytes, Cr, Ur, TSH, Liver enzymes, Trop, ECG Urine culture, CXR, EEG and LP Management- Treat underlying causes, Antipsychotics is aggressive and WAIT! Prolonged delirium- Tough! Cognitive assessments in Delirium Bottom line need to recognise it EARLY and Prevent (Melatonin)

81. Dementia History History History Types of dementia- Alzheimer's, Vascular, Lewy Body dementia, Parkinson's disease Dementia, Frontol- Temporal dementia etc Usually come in due to caregiver burnout Testing- MOCA, ILS/Functional assessment, RUDAS- OT Ensure medical work up is complete Hospital will make them worse

82. Dementia Managing aggressive behaviours Why are they aggressive- Pain, infections, recent changes in medications other etiology Start pain and behavioural mapping see if there is pattern Behavioural interventions Antipsychotics- Risperidone, Olanzapine, Seroquel Other drugs- SSRI, Trazadone, Memantine, Donepezil Disposition- this is challenging

83. Falls History again is key- Loss of consciousness, Medication changes. History does tend to happen over time Ensure a full examination is done including MSK and Neuro exam Often multifactorial Invx- Basic labs, echo, holter, CT/MRI brain, EEG, ?cartoid dopplers, postural BP, if Diabetes check Blood sugars Treatment- Multi disciplinary approach

84. Pain in the elderly Use the pain ladder but avoid NSAIDS Pain management is very different in the elderly Use low doses in those that are opioid naive and titrate slowly Drugs that can be used in those with renal impairment- Hydromorphone, fentanyl Have a conversion chart remember they all vary slightly PCAs and Infusions Alternative ways to manage pain- Radiation, local injections, Kyphoplasty

85. Housekeeping Mental health forms PD and EPOA Medical assessment forms Capacity assessments Goals of care

86. Evaluations- How to succeed We want the skills you gain to be transferable to your practice Take ownership of your patients look over relevant past medical history You are detectives Be able to recognise sick patients and initiate basic work up and then call for help Devise a reasonable good plan with rationale Be able to consult and recognise relevant consult services

87. How are we going to help- Resident modules Case-Based Worksheet for Hospitalist Patients 1.What are the criteria for admitting this patient, as opposed to managing them as an outpatient? Why would they come to the hospitalist service (compared to a subspecialist or a transition bed)? 2.What is your differential diagnosis? Include at least three most likely, as well as at least one sinister hypothesis. 3.What investigations will you order? What ongoing follow-up should be done during the admission? 4.What will be the management principles for the most likely condition? Include both pharmacologic and non-pharmacologic management. What contra-indications could exist for these choices? Be ready to discuss these with your preceptor in detail 5.What complications could arise during this patient’s stay? How could you attempt to prevent these? 6. What other resources can you enlist to assist you in the management of this patient? 7. How will you know this patient is ready for discharge – what parameters will be your guide and what needs to be in place at their residence?

88. Questions?

89. Thank you Bhavini Gohel: bhavini.gohel@ahs.ca - SHC educational site lead Scott Samis Henry Lo