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    UCSF Hospitalist Handbook

    Uploaded by

    niharjhatn
    The document provides formulas and abbreviations used in clinical medicine. It includes formulas for calculating corrected electrolyte levels, fluid deficits, osmolality, anion gaps, renal function, hemodynamics, and pulmonary function. It also lists common medical abbreviations from A-H such as AAA, ABG, AIDS, BNP, BUN, CAD, CHF, CPR, CrCl, CXR, DKA, ECG, ED, EEG, and HIV.

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    © All Rights Reserved
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    UCSF Hospitalist Handbook

    Uploaded by

    niharjhatn
    3K views58 pages
    The document provides formulas and abbreviations used in clinical medicine. It includes formulas for calculating corrected electrolyte levels, fluid deficits, osmolality, anion gaps, renal function, hemodynamics, and pulmonary function. It also lists common medical abbreviations from A-H such as AAA, ABG, AIDS, BNP, BUN, CAD, CHF, CPR, CrCl, CXR, DKA, ECG, ED, EEG, and HIV.

    Original Description:

    Good book for hospitals

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    The document provides formulas and abbreviations used in clinical medicine. It includes formulas for calculating corrected electrolyte levels, fluid deficits, osmolality, anion gaps, renal function, hemodynamics, and pulmonary function. It also lists common medical abbreviations from A-H such as AAA, ABG, AIDS, BNP, BUN, CAD, CHF, CPR, CrCl, CXR, DKA, ECG, ED, EEG, and HIV.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    3K views58 pages

    UCSF Hospitalist Handbook

    Uploaded by

    niharjhatn
    The document provides formulas and abbreviations used in clinical medicine. It includes formulas for calculating corrected electrolyte levels, fluid deficits, osmolality, anion gaps, renal function, hemodynamics, and pulmonary function. It also lists common medical abbreviations from A-H such as AAA, ABG, AIDS, BNP, BUN, CAD, CHF, CPR, CrCl, CXR, DKA, ECG, ED, EEG, and HIV.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 58
    At a glance
    Powered by AI
    The document discusses various medical formulas, equations, IV fluid compositions and strategies for managing hypertensive emergencies.

    Formulas are provided for electrolyte and acid-base corrections, calculating fluid deficits, osmolality, anion gaps, creatinine clearance, and more.

    Common IV fluids discussed include normal saline, D5W, half-normal saline, sodium bicarbonate, potassium chloride solutions, and their compositions.

    Appendix and

    Acknowledgements
    Appendix A: Formulas
    Electrolytes
    +

    Na (corrected for hyperglycemia):


    Corrected Na+ = measured Na+ + [(glucose 100) x 0.024]
    Ca2+ (corrected for hypoalbuminemia):
    Corrected Ca2+ = [(4 serum albumin) x 0.8] + measured Ca2+
    Free Water Deficit:
    Water deficit = wt (kg) x k x [(plasma Na+ / 140) 1]; where k = 0.5 for males and 0.4 for females
    Osmolality:
    Calculated Osm = (2 x Na+) + (glucose / 18) + (BUN / 2.8) + (EtOH / 4.6)
    normal: 270290
    Osm gap = measured Osm calculated Osm {normal < 10}
    >10 is abnormal: caused by renal failure, methanol, ethylene glycol, sorbitol, mannitol, isopropanol,
    radiocontrast dye
    Anion Gaps:
    Serum AG = [Na+] [Cl-] [HCO3] {normal 10-14}
    Corrected AG (for hypoalbuminemia)
    Corrected AG = serum AG + [(4 serum albumin) x 2.5]
    AG = (AG 12) + HCO3 {normal 2330}.
    AG >30: concomitant metabolic alkalosis (excessively high HCO3).
    AG <23: concomitant non-AG metabolic acidosis (excessively low HCO3).
    Urine AG = U[Na+] + U[K+] U[Cl-]
    NH4+ is the major unmeasured cation, so a strongly negative UAG suggests high urine NH4+.
    Urine AG <0: GI HCO3 loss.
    Urine AG >0: Renal HCO3loss (RTA).
    Body Fluid / IV Fluids
    Body fluid composition:
    Total Body Water = 0.6 x wt (kg) for males 0.5 x wt (kg) for females
    Extracellular fluid (ECF) = 0.2 x wt (kg)
    Intravascular: 1/3 ECF
    Interstitial: 2/3 ECF
    Intracellular fluid (ICF) = 0.4 x wt (kg)
    IVF and tonicity:
    Fluid

    Na+ (mEq/
    L)

    K+ (mEq/
    L)

    Cl- (mE
    q/L)

    HCO3 (mEq/
    L)

    Other
    (mEq/L
    )

    Osmolalit
    y
    (mOsm/L
    )

    Plasm
    a

    142

    104

    27

    29

    306

    NS

    154

    154

    308

    D5W

    278

    D5
    12NS

    77

    77

    421

    1 amp
    NaHC
    O3

    50

    50

    100

    20 mEq
    KCl

    20

    20

    40

    e.g. 14NS + 20 mEq KCl + 12 amp NaHCO3 = (308/4) + 40 + (100/2) = 167 mOsm/L, or roughly
    equivalent in tonicity to 12NS
    IVF effect on plasma Na:
    Na per liter IVF given = [NaIVF(mEq/l) + KIVF(mEq/l) Naserum (mmol/l)] / [Total Body Water + 1]
    Renal
    Creatinine Clearance:
    Estimated CrCl (Cockcroft-Gault Equation)* = [(140 age) x (wt in kg)] / [serum Cr x 72]
    *multiply by 0.85 for females
    {normal 100125 ml/min (M) or 85105 ml/min (F)}
    Measured CrCl = [urine Cr x urine volume (ml/24hr)] / [serum Cr x 1440 (min/24hr)]
    Fraction Na excretion:
    FENa = [(urine Na+ / serum Na+) x 100] / [(urine Cr / serum Cr)]
    <1% suggests pre-renal
    FENa interpretable only in oliguric states (UOP < 400 cc/day)
    Transtubular Potassium Gradient:
    TTKG = (urine K+ / serum K+) / (urine Osm / serum Osm)
    With hyperkalemia:
    < 7 suggestive decreased aldosterone activity.
    > 7 suggestive effective volume depletion with normal aldosterone activity.
    Hemodynamics
    Cardiac Output:
    CO = HR x stroke volume
    CI = CO / BSA (in m2); where BSA= ([ht (cm) x wt (kg)] / 3600)
    Fick Technique: CO = estimated O2 consumption or VO2 (ml/min)* / arteriovenous O2 difference**
    Resistance:
    SVR = [(MAP CVP) / CO] x 80
    {normal 7001600 dynes*s/cm5}
    PVR = [(MPAP PCWP) / CO] x 80
    {normal 20120 dynes*s/cm5}
    Pressure:
    Pulse Pressure = SBP DBP
    MAP = [SBP + (DBP x 2)] / 3
    Pulmonary
    Alveolar-arterial O2 gradient:

    Aa O2 gradient = [FiO2 x (pAtm pH2O)] (pCO2 / R) pO2


    o
    = [FiO2 x (760 47)] (pCO2 / 0.8) pO2

    = 150 (pCO2 / 0.8) pO2

    {normal 525 or age/3} *at sea level on RA

    Statistics
    Disease (+)

    Disease ()

    Test (+)

    A
    True Positive

    B
    False Positive

    Test ()

    C
    False Negative

    D
    True Negative

    Sensitivity = A / (A + C)
    Specificity = D / (D + B)
    Positive Predictive Value = A/ (A + B)
    Negative Predictive Value = D / (C + D)
    Positive Likelihood Ratio = sensitivity / (1 specificity)
    Negative Likelihood Ratio = (1 sensitivity) / specificity
    Number needed to treat (NNT) = 1 / (absolute risk reduction)
    References
    Hillier TA, Abbott RD, Barrett EJ. Hyponatremia: evaluating the correction factor for hyperglycemia. Am J
    Med. 1999 Apr;106(4):399-403.
    Appendix B: Abbreviations
    ACE - Angiotensin
    converting enzyme
    A
    A-a - Arterial-alveolar
    AAA - Abdominal aortic
    aneurysm
    ABC - Airway, breathing,
    circulation
    ABG - Arterial blood gas
    ABX - Antibiotics
    AC - Assist-control
    ventilation
    ACA - Anterior cerebral
    artery
    ACC - American College
    of Cardiology

    ACE-I -Angiotensin
    converting enzyme inhibitor
    ACLS - Advanced
    cardiac life support

    AF - Atrial fibrillation
    AFB - Acid-fast bacilli
    A-fib - Atrial fibrillation
    AG - Anion gap

    ACS - Acute coronary


    syndrome
    ACTH
    - Adrenocorticotropic
    hormone

    AHA - American Heart


    Association
    AI - Aortic insufficiency

    ACV - Assist-control
    ventilation
    ADC - AIDS dementia
    complex
    ADH - Anti-diuretic
    hormone

    AI - Adrenal insufficiency
    AICD - Automated
    implantable cardiac
    defibrillator

    AIDS - Acquired
    immunodeficiency syndrome

    ASA - American Society


    of Anesthesiologists

    BMJ - British Medical


    Journal

    AIN - Acute interstitial


    nephritis

    ASA - Aspirin

    BMT - Bone marrow


    transplant

    ALL - Acute lymphoblastic


    leukemia
    ALS - Amyotrophic
    lateral sclerosis
    ALT - Alanine
    aminotransferase
    AML - Acute myeloblastic
    leukemia

    AMS - Altered mental


    status
    ANA - Anti-nuclear
    antibody
    ANCA - Anti-nuclear
    cytoplasmic antibody
    APACHE - Acute
    physiology and chronic health
    evaluation
    APC - Activated protein C
    ARB - Angiotensin
    receptor blocker

    AST - Aspartate
    aminotransferase
    AT - Atrial tachycardia
    A-thal - Alpha
    thalassemia

    BNP - B-natriuretic
    peptide
    BP - Blood pressure
    BPM - Beats per minute
    BRBPR - Bright red blood
    per rectum

    ATN - Acute tubular


    necrosis

    BSA - Body surface area

    ATP - Adenosine
    triphosphate

    BUN - Blood urea


    nitrogen

    AV - Atrioventricular

    BZD - Benzodiazepine
    C
    C&S - Culture and
    specificity

    AV - Arteriovenous
    AVM - Arteriovenous
    malformation
    AVNRT - AV nodal
    reentrant tachycardia
    AVRT - AV reentrant
    tachycardia
    B
    BAL - Bronchoalveolar
    lavage

    Ca - Calcium
    CA - Cancer
    CABG - Coronary artery
    bypass grafting
    CaCl2 - Calcium chloride
    CaCO3 - Calcium
    carbonate

    BCx - Blood culture

    ARDS - Acute respiratory


    distress syndrome

    BG - Blood glucose

    CAD - Coronary artery


    disease

    ARF - Acute renal failure

    BID - Twice a day

    CaO2 - Oxygen content

    ARRD - Acute reversible


    renal dysfunction

    BiPAP - Bi-level positive


    airway pressure

    CAPD - Continuous
    ambulatory peritoneal dialysis

    AS - Aortic stenosis

    BMI - Body mass index

    CCB - Calcium-channel
    blocker

    CCPD - Continuous
    cycling peritoneal dialysis
    CCU - Coronary care unit
    CFU - Colony-forming
    unit
    CHF - Congestive heart
    failure

    COPD - Chronic
    obstructive pulmonary
    disease
    CP - Chest pain
    CPAP - Continuous
    positive airway pressure
    CPK - Creatine kinase

    CVVHDF - Continuous
    venovenous
    hemodiafiltration
    Cx - Culture
    CXR - Chest x-ray
    D
    DBP - Diastolic blood
    pressure

    CPP - Cerebral perfusion


    pressure

    DDAVP - Vasopressin

    CPPD - Calcium
    pyrophosphate dihydrate

    DDx - Differential
    diagnosis

    CK - Creatine kinase

    CPR - Cardiopulmonary
    resuscitation

    DI - Diabetes insipidus

    CKD - Chronic kidney


    disease

    Cr - Creatinine

    CI - Cardiac index
    CIWA - Clinical institute
    withdrawal assessment

    CK-MB - Creatine kinase


    (myocardial fraction)
    CLL - Chronic
    lymphocytic leukemia
    CML - Chronic myelocytic
    leukemia
    CMV - Cytomegalovirus
    CN - Contrast
    nephropathy
    CNS - Central nervous
    system
    CO - Carbon monoxide
    CO - Cardiac output
    CO2 - Carbon dioxide
    Cocci
    - Coccidioidomycosis

    CrAg - Cryptococcal
    antigen
    CrCl - Creatinine
    clearance
    CRRT - Continuous renal
    replacement therapy
    Crypto - Cryptococcosis
    CSF - Cerebrospinal fluid
    CT - Computed
    tomography
    CVA- Cerebrovascular
    accident
    CVP - Central venous
    pressure
    CVVH - Continuous
    venovenous hemofiltration
    CVVHD - Continuous
    venovenous hemodialysis

    DIC - Disseminated
    intravascular coagulation
    Diff - Differential
    DKA - Diabetic
    ketoacidosis
    DLCO - Diffusing
    capacity of carbon monoxide
    DM - Diabetes mellitus
    DM - Dermatomyositis
    DMV - Department of
    motor vehicles
    DOT - Directly observed
    therapy
    DS - Double strength
    DT - Delirium tremens
    DTR - Deep tendon
    reflex
    DVT - Deep venous
    thrombosis

    Dz - Disease
    E
    EBV - Epstein-Barr virus
    ECASA - Enteric-coated
    aspirin
    ECG - Electrocardiogram
    ED - Emergency
    department
    EEG
    - Electroencephalogram
    EGD
    - Esophogastroduodenosco
    py
    EKG - Electrocardiogram
    ELISA - Enzyme-linked
    immunosorbent assay
    EMG - Electromyogram
    ER - Emergency room
    ERCP - Endoscopic
    retrograde
    cholangiopancreatography
    ESR - Erythrocyte
    sedimentation rate
    ESRD - End-stage renal
    disease
    ESWL - Extracorporeal
    shock-wave lithotripsy
    EtOH - Alcohol
    ETT - Exercise treadmill
    test
    F
    FENa - Fractional
    excretion of sodium

    FEV1 - Forced expiratory


    capacity in one second
    FFP - Fresh frozen
    plasma
    FH - Family history
    FIO2 - Fractional inspired
    oxygen
    FNA - Fine needle biopsy
    FQ - Fluoroquinolone

    GU - Genitourinary
    GVHD - Graft versus
    host disease
    H
    H&P - History and
    physical
    HA - Headache
    HAART - Highly active
    antiretroviral therapy
    HAV - Hepatitis Avirus

    FRC - Functional residual


    capacity

    HBV - Hepatitis B virus

    FSGS - Focal segmental


    glomerulosclerosis

    HCG - Human chorionic


    gonadotropin

    FUO - Fever of unknown


    origin

    HCO3 - Bicarbonate

    FVC - Forced vital


    capacity
    G
    GBM - Glomerular
    basement membrane

    Hct - Hematocrit
    HCTZ
    - Hydrochlorothiazide
    HCV - Hepatitis C virus

    GCA - Giant cell arteritis


    HD - Hemodialysis
    GCS - Glasgow coma
    scale
    GERD
    - Gastroesophageal reflux
    disease
    GFR - Glomerular
    filtration rate
    GI - Gastrointestinal
    GIB - Gastrointestinal
    bleed

    HDL - High-density
    lipoprotein
    He - Helium
    Hgb - Hemoglobin
    HgbA1c - Hemoglobin
    A1c
    Histo - Histoplasmosis

    GN - Glomerulonephritis

    HIT - Heparin-induced
    thrombocytopenia

    GSH - Glutathione

    HIV - Human

    immunodeficiency virus
    INR - International
    normalized ratio

    LDL - Low-density
    lipoprotein

    HOB - Head of bed

    IPAP - Inspiratory positive


    airway pressure

    LDUH - Low-dose
    unfractionated heparin

    HOCM - Hypertrophic
    obstructive cardiomyopathy

    IR - Interventional
    radiology

    LFTs - Liver function tests

    HONKC - Hyperosmolar
    non-ketotic coma

    IV - Intravenous

    LGIB - Lower
    gastrointestinal bleed

    IVC - Inferior vena cava

    LLQ - Left lower quadrant

    IVDU - Intravenous drug


    use

    LMWH - Low molecular


    weight heparin

    IVF - Intravenous fluids

    LP - Lumbar puncture

    IVP - Intravenous push


    J
    JAMA - Journal of the
    American Medical
    Association

    LR - Lactated Ringers

    HME - Heat moisture


    exchanger

    HPF - High powered field


    HR - Heart rate
    HSP - Henoch-Schonlein
    purpura
    HSV - Herpes simplex
    virus
    HTN - Hypertension
    HUS - Hemolytic-uremic
    syndrome
    I
    IBD - Inflammatory bowel
    disease
    IBW - Ideal body weight
    ICP - Intracranial
    pressure
    ICU - Intensive care unit
    IE - Infective endocarditis

    JVP - Jugular venous


    pulsation
    K
    K - Potassium
    KCl - Potassium chloride
    KI - Potassium iodide

    IMI - Inferior myocardial


    infraction
    INH - Isoniazid

    LTRA - Leukotriene
    receptor antagonist
    LUQ - Left upper
    quadrant
    LV - Left ventricle
    LVEDP - Left ventricular
    end-diastolic pressure

    KS - Kaposi sarcoma
    KUB - Kidneys ureters
    bladder (abdominal film)
    L
    LAD - Left anterior
    descending artery

    IJ - Internal jugular
    IM - Intramuscular

    LR - Likelihood ratio

    LBBB - Left bundle


    branch block

    LVEF - Left ventricular


    ejection fraction
    LVH - Left ventricular
    hypertrophy
    M
    MAC - Mycobacterium
    avium complex
    Mag - Magnesium

    LCx - Left circumflex


    artery
    LDH - Lactate
    dehydrogenase

    MAHA - Microangiopathic
    hemolytic anemia
    MAO - Monoamine

    oxidase

    resistant staph epidermis

    MAP - Mean arterial


    pressure

    MS - Mental status

    MAR - Medication
    administration record
    MCA - Middle cerebral
    artery
    MCP
    - Metacarpophalangeal
    MCV - Mean corpuscular
    volume
    MDI - Metered dose
    inhaler
    MELD - Model for Endstage Liver Disease
    Mg - Magnesium
    MgSO4 - Magnesium
    sulfate
    MI - Myocardial infarction
    MIF - Maximal inspiratory
    force
    MOM - Milk of magnesia
    MPO - Myeloperoxidase
    MR - Mitral regurgitation
    MRA - Magnetic
    resonance angiography
    MRI - Magnetic
    resonance imaging
    MRSA - Methicillinresistant staph aureus
    MRSE - Methicillin-

    NG - Nasogastric
    NH4+ - Ammonium
    NIPPV - Noninvasive
    positive pressure ventilation
    Nl - Normal

    MS - Mitral stenosis

    MTX - Methotrexate

    NNT - Number needed to


    treat
    NPO - Nothing per mouth
    NQWMI - Non-Q-wave
    myocardial infarction
    NRB - Non-rebreather
    NS - Normal saline
    NSAIDs - Non-steroidal
    anti-inflammatory drugs
    NSTEMI - Non-ST
    elevation myocardial
    infarction
    NTE - Not to exceed
    NTG - Nitroglycerin
    O
    OA - Osteoarthritis
    OR - Operating room
    Osm - Osmolality
    OTC - Over the counter
    P
    PAline - Pulmonary artery
    catheter
    PAN - Polyarteritis
    nodosa
    PAP - Pulmonary artery
    pressure

    MUGA - Multiple gated


    acquisition

    PBS - Peripheral blood


    smear

    MVI - Multivitamin

    PCI - Percutaneous
    coronary intervention

    MS - Multiple sclerosis
    MSH - Melanocyte
    stimulating hormone
    MSSA - Methicillinsensitive staph aureus
    MSSE - Methicillinsensitive staph epidermis
    MTHFR
    - Methylenetetrahydrofolate
    Reductase
    MTP
    - Metatarsophalangeal

    MVP - Mitral valve


    prolapse
    N
    N/V - Nausea/vomiting
    N/V/D
    - Nausea/vomiting/diarrhea

    PCKD - Polycystic kidney


    disease
    pCO2 - Partial pressure
    of carbon dioxide
    PCP - Pneumocystis
    pneumonia

    Na - Sodium

    PCR - Polymerase chain


    reaction

    NaHCO3 - Sodium
    bicarbonate

    PCV - Pressure control


    ventilation

    Nebs - Nebulizers

    PCW - Pulmonary
    capillary wedge

    NEJM - New England


    Journal of Medicine

    PCWP - Pulmonary
    capillary wedge pressure

    PD - Peritoneal dialysis
    PE - Pulmonary
    embolism
    PEA - Pulseless electrical
    activity
    PEEP - Positive endexpiratory pressure
    PEG tube
    - Percutaneous endoscopic
    gastrostomy tube
    PEX - Physical exam
    PF - Peak flow
    PICC - Peripherally
    inserted central catheter
    PID - Pelvic inflammatory
    disease
    PIP joint - Proximal
    interphalangeal joint
    PLT - Platelets
    PM - Polymyositis
    PMH - Past medical
    history
    P-MIBI - Persantine-MIBI
    PML - Progressive
    multifocal
    leukoencephalopathy
    PMNs - Neutrophils
    PMR - Polymyalgia
    rheumatica
    PNA - Pneumonia
    PNH - Paroxysmal
    nocturnal hemoglobinuria
    PO - By mouth
    pO2 - Partial pressure of
    oxygen
    PO4 - Phosphorous
    PPL - Plateau pressure
    PR - Per rectum
    PRBC - Packed red
    blood cells
    PRN - As needed
    PRSP - Penicillinresistant streptococcus
    pneumoniae
    PS - Pressure support
    PSVT -Paroxysmal
    supraventricular tachycardia
    PT - Physical therapy
    PT - Prothrombin time
    Pt. - Patient
    PTCA -Percutaneous
    transluminal coronary
    angioplasty
    PTH - Parathyroid
    hormone

    P-Thal - Persantine
    thallium
    PTHrP -Parathyroid
    related protein
    PTT - Partial
    thromboplastin time

    glomerulonephritis
    RR - Respiratory rate
    RSI - Rapid sequence
    intubation

    PTX - Pneumothorax
    RT - Respiratory therapy
    PUD - Peptic ulcer
    disease
    PVR - Post-void residual
    Q
    QD - Once a day
    QHS - Once a night
    QID - Four times a day
    QOD - Once every other
    day
    QTc - Corrected QT
    interval
    R
    R/O MI- Rule out
    myocardial infarction
    RA - Rheumatoid arthritis
    RA - Right atrium
    RBBB - Right bundle
    branch block
    RBC - Red blood cell
    RCA - Right coronary
    artery
    RCT - Randomized
    controlled trial
    RDW - Red cell
    distribution width

    RTA- Renal tubular


    acidosis
    RUQ - Right upper
    quadrant
    RV - Right ventricle
    RVH - Right ventricular
    hypertrophy
    RVMI - Right ventricular
    myocardial infarction
    S
    S/P - Status-post
    SAH - Subarachnoid
    hemorrhage
    SaO2 - Oxygen
    saturation
    SBE - Subacute bacterial
    endocarditis
    SBP - Spontaneous
    bacterial peritonitis

    RF - Risk factor

    SBP - Systolic blood


    pressure

    RI - Reticulocyte index

    SC - Subcutaneous

    RLQ - Right lower


    quadrant

    SCD - Sequential
    compression devices

    ROS - Review of
    systems

    ScvO2 - Central venous


    oxygen saturation

    RPGN - Rapidly
    progressive

    SES - Sick euthyroid


    syndrome

    SFGH - San Francisco


    General Hospital
    SH - Social history
    SIMV - Synchronized
    intermittent mandatory
    ventilation
    SIRS - Systemic
    inflammatory
    response syndrome
    SL - Sublingual
    SLE - Systemic lupus
    erythematosus
    SOB - Shortness of
    breath
    Sosm - Serum osmolality
    SPEP - Serum protein
    electrophoresis
    SQ - Subcutaneous
    SSRI - Selective
    serotonin reuptake inhibitor
    STEMI - ST segment
    elevation myocardial
    infarction
    SV - Stroke volume
    SVC - Superior vena
    cava
    SVR - Systemic vascular
    resistance
    SVT - Supraventricular
    tachycardia
    T
    T.bili - Total bilirubin
    TB - Tuberculosis

    TBW - Total body water


    TCA - Tricyclic
    antidepressant
    TEE - Transesophageal
    echocardiogram
    TFT - Thyroid function
    tests

    TTE - Transthoracic
    echocardiogram
    TTP - Thrombotic
    thrombocytopenic purpura
    TV - Tidal volume
    U
    UA - Urinalysis
    UAG - Urine anion gap

    TIA - Transient ischemic


    attack

    UCl - Urine chloride

    TIBC - Total iron binding


    capacity

    UGIB - Upper
    gastrointestinal bleed

    TID - Three times a day

    UK - Urine potassium

    TLC - Triple lumen


    catheter

    UNa - Urine sodium

    TLSO
    - Thoracolumbosacral
    orthotic

    UO - Urine output
    UOP - Urine output

    TM - Tympanic
    membrane

    UPEP - Urine protein


    electrophoresis

    TMP/SMX
    - Trimethoprimsulfamethoxazole

    UTI - Urinary tract


    infection

    Toxo - Toxoplasmosis
    t-PA- Tissue
    plasminogen activator
    TPN - Total parenteral
    nutrition
    TRALI - Transfusion
    related acute lung injury
    TSH - Thyroid
    stimulating hormone
    TSI - Thyroid stimulating
    immunoglobulin

    Utox - Urine toxicology


    screen
    V
    V/Q - Ventilation/perfusion
    scan
    VC - Vital capacity
    VDRL - Venereal disease
    research laboratory
    VF - Ventricular fibrillation
    VRE - Vancomycinresistant enterococcus
    VT - Ventricular

    tachycardia
    VZV - Varicella zoster

    virus
    W
    WBC - White blood cells

    WPW - Wolff-ParkinsonWhitesyndrome

    Appendix C: Sliding Scales


    Heparin
    Bolus and initial maintenance rate are determined by underlying disease state (higher initial bolus for pulmonary embolism
    than acute coronary syndrome). Always check with your local hospital pharmacy for correct initial bolus and maintenance
    rate.

    Acute coronary syndrome: initial bolus = 60 U/kg, initial maintenance rate = 12 U/kg/hr.

    Pulmonary embolism: initial bolus = 80 U/kg, initial maintenance rate = 18 U/kg/hr


    Check PTT and adjust infusion at 6, 12, and 24 hours after the initiation of heparin and QD thereafter. Check PTT 4 to 6
    hours after any dose adjustment.
    PTT (sec)

    Change

    IV infusion

    < 35

    70 U/kg bolus

    Increase by 3 U/kg/hr

    35 49

    35 U/kg bolus

    Increase by 2 U/kg/hr

    50 70

    no change

    no change

    71 90

    no change

    Decrease by 2 U/kg/hr

    > 90

    Hold infusion for 30 minutes

    Decrease by 3 U/kg/hr

    Insulin
    For updated insulin sliding scales and regimens that take into account differences between
    type 1 and type 2 diabetics, see Endocrine: Insulin sliding scale. Included here is the more traditional
    sliding scale (most hospitals are transitioning toward pre-printed insulin sliding scale order
    sheets and away from arbitrary insulin sliding scales):

    FBS

    Action

    < 50

    1 amp D50 IV and call MD

    51 80

    Give juice and repeat in 12 hour

    81 200

    No coverage

    201 250

    3 U regular insulin SQ

    251 300

    6 U regular insulin SQ

    301 350

    8 U regular insulin SQ

    351 400

    10 U regular insulin SQ

    > 400

    12 U regular insulin SQ, call MD

    Nitropaste
    Apply to chest wall q 6 hours according to sliding scale and after 24 hours, wipe off nightly from 12
    a.m. to 6 a.m. to avoid development of tolerance.

    SBP

    Action

    < 100

    wipe off

    100120

    121140

    >140

    Potassium
    Caution in renal failure or ESRD. Always check the creatinine prior to replacing potassium.

    Serum K+

    KCl (mEq) to give IV or PO

    3.7 3.8

    20

    3.5 3.6

    40

    3.3 3.4

    60

    3.1 3.2

    80

    3.0

    100

    Magnesium
    Caution in renal failure or ESRD. Always check the creatinine prior to replacing magnesium.

    Serum Mg2+

    MgSO4 (g) to give IV

    1.8 1.9

    1.6 1.7

    1.4 1.5

    1.2 1.3

    < 1.2

    References
    Becker RC, et al. A randomized, multicenter trial of weight-adjusted intravenous heparin dose titration
    and point-of-care coagulation monitoring in hospitalized patients with active thromboembolic disease.
    Am Heart J. 1999;137:59-71.

    Handbook Editors

    Editors
    Somnath Mookherjee, MD
    Cindy Lai, MD
    Stephanie Rennke, MD
    Chapter Editors
    1.

    2.

    3.

    4.

    5.

    6.

    7.

    8.

    9.

    10.

    11.

    12.

    13.

    14.

    Hospitalist 101
    o
    Elizabeth Le, MD, Karimi Gituma, MD
    o
    Faculty: Sumana Kesh, MD, Saraswat Iobst, MD
    Night Calls
    o
    Abigail Eastburn, MD, Jared Herr, MD
    o
    Faculty: Henry Crevensten, MD
    Cardiology
    o
    Sahael Stapleton, MD, Sanket Dhruva, MD
    o
    Faculty: Rajni Rao, MD, Dana McGlothin, MD
    o
    Fellow: MD, Brian Moyers, MD
    Critical Care
    o
    Carolyn Hendrickson, MD, MPH, Ailinh Tran, MD
    o
    Faculty: Jon Matthew Aldrich, MD, Kristina Sullivan, MD
    Pulmonary
    o
    Robert Bronwell, MD, Michael Guarnieri, MD
    o
    Faculty: Herbert Chen, MD, MPH
    o
    Fellow: Charles Everett, MD
    Acid-Base
    o
    Cason Pierce, MD, MA, Alvin Rajkomar, MD
    o
    Faculty: Kerry Cho, MD, Delphine Tuot, MD
    Renal
    o
    Christopher Moriates, MD, Elizabeth Stewart, MD
    o
    Faculty: Kerry Cho, MD, Delphine Tuot, MD
    Hematology & Oncology
    o
    John Gordan, MD, PhD, Gabriel Mannis, MD
    o
    Faculty: Andrew Ko, MD
    o
    Fellow: Matt Wieduwilt, MD, PhD
    Gastroenterology & Hepatology
    o
    Andrew Nett, MD, Susie Ng, MD
    o
    Faculty: Oren Fix, MD
    o
    Fellow: Jennifer Lai, MD
    Endocrine
    o
    Colleen Lynch, MD. Jason Mansoori, MD
    o
    Faculty: Robert Rushakoff, MD, MS, Anne Schafer, MD
    Infectious Disease
    o
    Seth Cohen, MD, Sanjiv Baxi, MD, MS
    o
    Faculty: Brian Schwartz, MD, Gabriel Oritz, MD, PhD
    o
    Additional Faculty: Monica Gandhi, MD, MPH
    Rheumatology
    o
    James Andrews, MD, Uchenna Agbim, MD
    o
    Faculty: Julie Zikherman, MD
    o
    Fellow: Laura Tarter, MD
    Neurology
    o
    Laura Rosow, MD, Shobha Sadasivaiah, MD
    o
    Faculty: S. Andrew Josephson, MD, Hooman Kamel, MD
    Toxicology
    o
    Karen Wong, MD, MPH, Larissa Thomas, MD, MPH
    o
    Faculty: Paul Blanc, MD

    15.

    16.

    17.

    18.

    19.

    20.

    o
    Additional Faculty: Thomas Kearney, PharmD
    Medicine Consultation
    o
    Jie Zheng, MD, Anna Chodos, MD, MPH
    o
    Faculty: Bradley Monash, MD
    Procedures
    o
    Ajay Dharia, MD, Aparna Goel, MD
    o
    Faculty: Andrew Lai, MD, MPH
    Evidence Based Medicine
    o
    Jennifer Ross, MD, MPH, Catherine Koss, MD
    o
    Faculty: Sumant Ranji, MD, Lawrence Haber, MD
    Geriatrics
    o
    Dandan Liu, MD, Erika Mak, MD
    o
    Faculty: Stephanie Rennke, MD
    Palliative Care
    o
    Sunita Puri, MD, MS, Kristen Adams, MD
    o
    Faculty: Meredith Heller, MD, Matt Gonzales, MD
    ACLS
    o
    Ravi Garg, MD, Elizabeth Hardin, MD
    o
    Faculty: Catherine Lau, MD

    Preface and Acknowledgements


    The Hospitalist Handbook represents the culmination of several years of effort on behalf of the
    Internal Medicine housestaff at the University of California, San Francisco to make a thorough, yet
    concise, bedside guide to inpatient clinical medicine. The Hospitalist Handbook began as the
    Housestaff Handbook several years ago and has served as both an educational tool for its authors as
    well as a valuable resource for students, housestaff, and attending physicians.
    The fourth edition of the Hospitalist Handbook continues in the process of updating the handbook to
    reflect the most recent advances in hospital medicine. We hope that with the fourth edition, anyone
    engaged in inpatient medicinemedical students, residents of all specialties, hospitalist physicians,
    nurse practioners, physician assistants, and otherswill continue to find the handbook easy to read
    and practical in its approach to common problems in inpatient medicine.
    We are indebted to the UCSF staff who have assisted with this book, especially Sue Sheehan.
    As stated earlier, the Hospitalist Handbook is a result of the efforts of many past and present
    housestaff in the Department of Medicine at UCSF. The following physicians have all been past
    contributors to the handbook: Lexmi Acharya, Susan Alt, Garth Beinart, Anna Bloxham, Carolyn
    Calfee, Paul Campbell, Ethan Canin, Larry Chang, Sumitra Chari, Tom Chen, Victor Cheng, Peter
    Chin-Hong, Molly Conroy, Sarah Cooley, Ethan Corcoran, Ian de Boer, Fiona Dulbecco, Darryl
    Elmouchi, Sara Erickson, Monica Gandhi, Anil Gehi, Leslie Gillum, Andrei Goga, Antonio Gomez,
    Nathan Gunn, Samir Gupta, Jennifer Guy, Steve Harr, Mary Beth Humphrey, Jimee Hwang, Andy
    Josephson, Todd Kim, Ajay Kirtane, Kiran Khush, Drew Klein, Katy Lease, Natalie Lee, Sei Lee, Josh
    Lehrer-Graiwer, Adam Lauring, Amy Levin, Debbie Lindes, Pam Ling, Raymond Liu, Taylor Liu, Annie
    Luetkemeyer, Kamyar Madani, David McManus, Denise Marciano, Deepu Nair, Anisa Nayeem, Justin
    Ortiz, Daniel Perlov, Samantha Pitts, Josefa Rangel, Mike Ren, Anne Rosenthal, Kiki Rutkowski,
    Urmimala Sarkar, Sanjiv Shah, Brad Sharpe, Robin Shaw, Mike Shiloh, Eddie Siew, Jacek
    Skarbinski, Michael Steinman, Jack Tsao, Elizabeth Turner, Jim Uyeki, Doug White, Ed Vasilevskis,
    and Roni Zeiger.
    The Hospitalist Handbook is a continual work in progress. We are always looking for ways to
    improve the handbooks content in order to make it more accurate, practical, and coherent, as
    well as concise. If you have any comments, suggestions, or corrections, please email ssheehan@medicine.ucsf.edu so that we can continue to enhance the value of this
    resource.

    HOSPITALIST 101
    The Hospitalist
    Definition
    First described in the 1990s, the term hospitalist describes a physician who assumes the generalized care of a hospitalized
    patient, and transfers care of the patient back to a primary care physician at discharge.
    Context
    Advantages to the hospitalist model of medicine include greater inpatient physician availability, increased emphasis on
    hospital-wide safety and quality improvements, and potential increased participation in medical training and education.
    Studies have shown increasing differences between hospitalist and non-hospitalist-driven patient care, including length of
    stay, cost of hospitalization and performance with respect to certain quality of care measures.
    Common communication issues

    Who is my doctor?
    o
    Patients may not understand the hospitalist model or who is responsible for their medical
    care.
    o
    Explain to patients the hospitalist model of care, especially the role of the team, primary care
    provider (PCP) and specialists in decision-making.
    o
    Inform the patient that their PCP will be contacted and made aware of major
    decisions/results.

    The Voltage Drop.


    o
    The concept that there may be a loss of information as a patient is transferred from one
    provider to another.
    o
    Contact PCPs when their patient is admitted (preferably within 24 hours). PCPs are
    invaluable resources for background information on patients and can help make major
    decisions, including decisions regarding code status and transitions to higher levels of care.
    o
    Contact the PCP and inform them of an impending discharge. Important things to relay are
    a discharge summary with follow-up, pending tests and changes in medications.

    Hospitalist vs. PCP


    o
    Though the hospitalist should be recognized as the expert on inpatient care, disagreements
    may arise with the PCP concerning a variety of issues.
    o
    Collegiality is essential. The PCP and hospitalist should communicate openly and provide
    a consistent message to the patient, which they consider to be in the patients best
    interests.
    Acknowledgements to Cason Pierce, MD and Amy Clouse, MS4 for their contributions to this chapter.
    References

    Alpers A. Key legal principles for hospitalists. Am J Med 2001;111:5S-9S.


    Lindenauer PK, Rothberg MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AA. Outcomes of Care
    by Hospitalists, General Internists, and Family Physicians 2007; 357: 2589-2600.
    Vasilevskis EE, Knebel RJ, Dudley RA, Wachter RM, Auerbach AD. Cross-sectional Analysis of Hospitalist
    Prevalence and Quality of Care in California 2010; 5: 200-207.
    Wachter RM and Goldman L. The Emerging Role of Hospitalists in the American Health Care System. N
    Engl J Med 1996; 335: 514-517.

    Admission Checklist

    Contact family for all patients, but especially for those who are altered or demented.
    o
    Obtain pertinent phone numbers for contacts, and establish a decision maker within the family.
    Contact the patients primary care provider.
    o
    Contact with PCPs has been shown to decrease rates of urgent readmissions.
    o
    All PCPs should be contacted, preferably within 24 hours of admission.
    Medication reconciliation.
    o
    Use the resources around you: past discharge summaries, computerized medications, patient pill
    bottles, and a patients pharmacy.
    o
    Check in with the patient:

    Make sure he or she is taking the listed meds.

    Regarding allergies and the specific reaction to each listed medication.

    Ask about any supplements, herbal medications, or over the counter medication
    use.
    Limits on all blood pressure meds, opiates, and laxatives.
    o
    For example Hold for BP < 100, HR < 60 or Hold for Sedation, RR < 8.
    IV Access.
    o
    Consider whether your patient needs an IV, how many and what sizes. Remember that for
    resuscitation, several large bore (16 and 18 gauge) IVs are superior to a triple lumen catheter.
    o
    Order PICCs early for patients who will need long term IV antibiotics. If a patient may need future
    dialysis, check-in with Renal consultant before ordering a PICC.
    o
    For patients with difficult access, attempt EJs or deep brachial IVs instead of central lines.
    Pneumovax.
    o
    Not everyone needs a pneumovax. The guidelines for pneumovax are as follows:

    Immunocompetent patients > 65 years of age. If pneumovax was given


    previously, revaccinate only if the last dose was > 5 years ago AND the patient
    was < 65 years old at the time of previous vaccination.

    Immunocompetent patients aged 19-64 with chronic cardiovascular, pulmonary,


    renal or liver disease, alcoholism, cochlear implants or CSF leaks/shunts, as
    well as patients aged 19-64 who are living in chronic care facilities should get
    vaccinated once.

    Immunocompromised patients > 19, including patients with HIV, malignancy,


    chronic renal disease, nephrotic syndrome, asplenia (including sickle cell disease),
    post-transplant patients or those on chronic immunosuppression.
    Influenza shot in appropriate seasons.
    Indications for gastric ulcer prophylaxis.
    o
    Not all patients admitted to the hospital need a proton pump inhibitor. Patients who should be
    considered for ulcer prophylaxis include:

    Patients in the ICU with: mechanical ventilation > 48hrs, coagulopathy, shock,
    sepsis, burns, head trauma, hepatic failure, renal failure, organ transplant
    recipients, spinal cord injury.

    Patients with 2+ of the following: in the ICU > 1 week, occult bleed > 5 days, on
    steroids.

    Patients with previous history of PUD or UGIB within one year of hospital
    admission.

    Relative indications: patients on high dose or chronic steroids. Contraindications:


    use of atazanavir.
    Foley vs. condom catheter vs. urinal. Keep track of which patients have a foley catheter and remove
    ASAP.
    o
    Accepted indications for long-term catheterization include: uncorrectable bladder outlet obstruction,
    intractable skin breakdown due to urinary incontinence, neurogenic bladder, and palliative care.
    o
    Short-term catheterization is acceptable in patients undergoing urologic surgery, critically ill patients
    requiring accurate urine output, patients receiving high dose diuretics and for acute urinary retention.
    o
    Condom catheters can be useful for those who have difficulty using a urinal, or cannot tolerate foley
    catheters, but keep in mind the infection risk is similar to that of foley catheters.
    Smoking cessation counseling. Assess patient readiness to quit and provide appropriate
    counseling. Respiratory therapy provides counseling and education for smoking cessation.
    Involve PT/OT, social work and case management early (see discharge planning).

    Check final reads of all studies.


    o
    Many initial or overnight reads change upon attending physicians read. As these studies may have
    been done while the patient was in the emergency department, radiologists may not know who to
    contact for final reads.
    Establish patients surrogate decision-maker, and goals of care for resuscitation in the case of an
    emergency.

    Discharge Planning
    Context: The transition immediately following a hospitalization is a vulnerable period for patients, often resulting in adverse
    events and subsequent readmissions.
    Risk factors for hospital readmission include:
    Depression: 73% increase in hospital utilization (ED or readmission) within 30 days post-discharge.
    Lack of post-discharge PCP follow-up.
    Lack of hospital based discharge teaching.
    Errors in medications.
    Discharge Planning Checklist
    1. At the time of admission (things to get rolling early)

    Social work: discuss socially complicated patients with your social worker. Consider
    that the patient may already have a caseworker who should be notified of the
    admission.

    Home vs. placement: consider the stability of the patients living situation. Is he or she
    likely able to return home after this hospital admission? Consider referral to acute
    rehab, skilled nursing facility, board and care or permanent placement. Discuss patients
    who will have home needs with case management early. Start the Patient Discharge
    Plan (PDP) early case managers cannot refer patients for any services until the PDP
    is completed.

    Physical therapy/occupational therapy: involve physical therapy and occupational


    therapy early. Early rehabilitation can prevent need for placement.

    High utilizer: if the patient is an ED high utilizer, consider coordinating with an ED


    representative, the patient, and PMD on a developing care plan to guide future ED,
    home, and inpatient care.

    Conservatorship: if your patient is not felt to be competent to make medical decisions,


    consider medical conservatorship. If your patient already has a conservator, contact
    them early in the discharge. (See Decision Making Capacity and Involuntary Holds)

    2. Preparing for discharge (24-48 hours before discharge)

    Home safety: consider a home social worker evaluation and a home safety evaluation,
    even for patients who have family members caring for them at home.

    Home health: consider a referral to home services. Available services include: skilled
    nursing needs (BP monitoring, medication education, insulin education), home safety
    evaluation, social services, occupational/physical therapy, rehabilitation services,
    speech therapy, infusion therapy.

    Preparing meds: consider new medications, oxygen, and equipment patient will need
    on discharge. Contact your social worker or case manager to ascertain the tests or
    consults a patient needs to qualify for service (e.g., some insurance companies require
    an ABG for home O2, others require a room air oxygen saturation < 88%).

    Arrange follow-up: obtain dates and times of all follow up appointments your patient
    will need following discharge. Many patients do not have a stable address, and will not
    receive mail/telephone reminders. For patients who do not have a primary care
    physician, consider appointments in Bridge Clinic (SFGH), Screening and Acute Care

    Center (UCSF), referrals to MP Clinic (VAMC) or a referral to Healthy San Francisco for
    follow up care.

    Remove foley

    3. 12-24 Hours Before Discharge

    Patient education:
    o

    Use patient-friendly language and avoid medical jargon.

    Closing the Loop or use the Teach-back Method: Confirm


    comprehension, for example, by asking patients in a nonjudgmental
    way: I want to make sure Im being clear. Could you explain to me how
    youre going to take your medications? Invite questions from patients and
    their families by asking, What questions do you have? rather than Do
    you have any questions? which may prompt a No response.

    Have the pharmacists or nurse educators see your patient. Many


    hospitals have diabetes, COPD, and CHF educators who can see the
    patient and discuss medication changes.

    Check on pending tests: Follow up on tests ordered during the admission that may
    still be pending to avoid last minute surprises. Any outstanding tests should be
    conveyed to the PCP.

    Contact the PCP: Phone or email the PCP about new diagnoses, medication changes,
    pending tests and appointment dates. Follow up appts with PCPs should be made
    within 2-3 wks.

    Order medications early: For hospitals that provide discharge meds, preparation of
    these medications can delay discharges by hours. Have the medication list prepared
    the day prior to discharge, so small changes can easily be made on the day of d/c.

    Transport: Ensure that the patient has a ride home by bus if appropriate, by taxi
    voucher or family member. Make sure patients have keys to their living facilities when
    appropriate.

    4. Discharge Summary

    Should be completed within 24-48hrs of discharge

    Should include:
    o

    Diagnoses, abnormal physical findings, diet, activity level, important test


    results, discharge medications, follow-up arrangements and appointments
    that still need to be made, counseling provided to patient and family and
    tests still pending at discharge.

    Make sure to highlight changes in discharge medications which are


    often the main cause of adverse events following hospital discharge.

    5. Discharge Checklist - Summary

    Follow up appointment requested

    Medication reconciliation completed


    o

    Includes: phone call or email with communication of key elements of


    discharge summary (as above) securely send actual discharge summary
    if possible.

    Communication with multi-disciplinary team completed


    o

    Includes: ensuring patients understand their hospital findings, discharge


    diagnoses and follow up plans/tests

    Communication with PCP completed


    o

    Includes: principal diagnosis, concise hospital course by problem,


    discharge meds and doses, follow-up plan and appt date(s), pending
    tests

    Discharge discussion/education with patient completed


    o

    Also includes: assess how pts will pick up their medications on discharge
    and pharmacy consult for high risk meds.

    Discharge summary completed


    o

    Includes: appointment within two weeks for routine home discharge, four
    weeks for SNF discharge.

    Includes: discussion of discharge plan (as applicable) with SW, CM, PT,
    OT, Pharmacy for high risk meds, and ancillary services.

    Discharge timeout completed


    o

    Includes: Face-to-face conversation with the nurse about: Discharge


    diagnosis Follow up plans RN teaching to patient (e.g. ostomy care,
    lovenox injections) Home care or equipment (e.g. home 02) ordered
    Review key med changes (meds started/stopped)

    References

    Balaban R, Williams M. Improving Care Transitions: Hospitalists Partnering with


    Primary Care. J Hosp Med 2010; 5: 375-377.

    Kripalani S, Jackson A, Schnipper J, Coleman E. Promoting Effective Transitions of


    Care at Hospital Discharge: A Review of Key Issues for Hospitalists. Journal of Hospital
    Medicine 2010; 2: 314-320.

    Van Walraven C, Taljaard M, Etchells E, Bell CM, Stiell IG, Zarnke K, Forster AJ. The
    independent association of provider and information continuity on outcomes after
    hospital discharge: implications for hospitalists. J Hosp Med 2010; 7:398-405.

    Care of Vulnerable Patients


    Definition: Medically vulnerable populations are those at specific risk for poor health status as a result of social forces.
    Immigrants

    Communicable diseases (TB, parasitic illnesses, rheumatic heart disease, malaria, hepatitis, HIV), elevated
    lead levels among children and pregnant women, violence and trauma exposure (particularly among
    refugees).
    Application:
    o
    Obtain history about immigration status (country of origin, reasons for immigration,
    hardships endured, length of time in the U.S., social/family situation).
    o
    Consider screening for medical conditions listed above.
    o
    Review vaccination history; remember to provide appropriate prophylaxis if patient plans to
    visit country of origin.
    o
    Conduct culturally competent patient education.

    Limited English proficiency patients (LEP)

    All hospitals are federally regulated to provide language services through CMS regulations.

    Receive lower quality of care than those who speak English fluently; using interpreters has been shown to
    narrow this gap (both in-person and telephonic interpreters).

    Application: Use trained interpreters, either in person or by video monitor (preferred over telephone
    interpreters).
    o
    Trained interpreters translate words, but also provide cultural interpretation and are
    preferable to ad hoc (or untrained) interpreters.
    o
    Ad hoc (untrained) interpreters (e.g., non-trained staff, family, friends):

    Except in emergencies, children should never be used as interpreters.

    Remind ad hoc interpreters: Thank you for your help. Please try to
    translate our conversation word for word, and even when you know the
    answer to the questions I ask, please tell me what she says. If you have
    something to say, we can talk separately.
    o
    Bilingual physicians: If you have doubts about your language ability, it is probably best to
    call for an interpreter. Physicians often overestimate their own language skills.
    Persons with limited health literacy

    25% of American adults have limited functional health literacy (FHL). At public hospitals, as many as 50% of
    patients have been estimated to have low FHL.

    These Americans can have higher rates of hospitalization, fewer preventive services, increased risk of
    poorly controlled chronic disease.

    Application:
    o
    Assess patient understanding of and beliefs about their illnesses.
    o
    Be specific and avoid medical jargon.
    o
    Use Closing the Loop or the Teach-back method: For instance, confirm
    comprehension by asking in a non-judgmental way, I want to make sure that Im being
    clear here. Can you tell me how youre going to take the medicines?
    Homeless persons

    Increased prevalence of mental illness, both acute and chronic medical illness, communicable diseases
    (TB, HIV, HBV/HCV), substance abuse, and violence exposure.

    Application:
    o
    Obtain history of current and prior housing status at every visit. Consider screening for
    medical conditions as above (i.e. yearly PPD).
    o
    Screen for history of physical of sexual abuse, substance abuse, mental illness, and refer to
    appropriate services; address foot care; refer to dental services.
    o
    Coordinate care with other members of the health care team (case managers, social
    workers, vocational trainers, visiting nurses).
    o
    Consider referral to appropriate housing: shelters, respite, board and care or other solutions
    that are available in your area.
    Persons with a history of incarceration:

    Increased prevalence of communicable diseases (HIV, STDs, HBV/HCV, TB, Staphylococcus infection),
    mental illness, substance abuse and violence exposure.

    Application:
    o
    o
    o
    o

    o
    References

    Screen for history of physical or sexual abuse, substance abuse, mental illness, gang
    involvement and refer to appropriate services. Screen for medical diseases above.
    Obtain an incarceration history in a non-judgmental way.
    Refer to social work for assistance with housing, insurance, vocational training, reunification
    with children and social support.
    Harm reduction: Recently released patients are at especially high risk of mortality from:

    Drug overdose

    Cardiovascular disease

    Violence

    Suicide

    Cancer
    Primary care: It is essential that recently released patients be connected with primary care
    physicians. Ninety percent are uninsured and high users of emergency departments.

    Binswanger IA, Stern MF, Deyo RA, et al. Release from prison Ahigh risk of death for former inmates. N
    Engl J Med 2007;356:157.
    Chen AH, Jacobs EA. Providing Care to Patients Who Speak Limited English. In: King TE and Wheeler
    MB, eds. Medical Management of Vulnerable and Underserved Populations. McGraw-Hill, New York,
    2007:265-274.
    Kushel M, Jain S. Care of the Homeless Patient. In: King TE and Wheeler MB, eds. Medical Management
    of Vulnerable and Underserved Populations. McGraw-Hill, New York, 2007:245-254.
    Morales S. Immigrant Health Issues. In: King TE and Wheeler MB, eds. Medical Management of
    Vulnerable and Underserved Populations. McGraw-Hill, New York, 2007:255-264.
    Paasche-Orlow MK, Parker RM. Improving the Effectiveness of Patient Education: A Focus on Limited
    Health Literacy. In: King TE and Wheeler MB, eds. Medical Management of Vulnerable and Underserved
    Populations. McGraw-Hill, New York, 2007:101-110.
    Wang EA, Tulsky JP, White MC. Clinical Care for Persons with a History of Incarceration. In: King TE and
    Wheeler MB, eds. Medical Management of Vulnerable and Underserved Populations. McGraw-Hill, New
    York, 2007:235-244.

    Decision Making Capacity


    Definitions
    1.
    2.

    Competency: A legal term regarding an individuals ability to make their own decisions. Assessment of
    competence requires a judge and hearing (but in practice is determined de facto by physicians).
    Decision-making capacity: A medical assessment by health care providers regarding the ability of a
    patient to make informed decisions.
    o
    Decision-making capacity is both decision and time specific. Patients may have
    capacity for certain decisions but not others, and this may fluctuate over time.
    o
    Psychiatric evaluation is not always necessary but can be helpful in making and
    documenting this determination.
    Context
    Assessment of a patients decision-making capacity frequently takes place during the routine
    patient-physician interaction, often without either party aware. However, whenever a patients
    decision-making capacity is disputed, thorough assessment and potentially surrogate decisionmaking are required. Most often, questions of patient decision-making ability arise in the geriatric
    population with dementia or in individuals with co-morbid psychiatric disease.
    Application
    Assessing decision-making capacity: See algorithm below.
    Surrogate decision-making: When a patient lacks decision-making capacity, look for guidance in an
    advance directive, DPOA, next of kin or court ordered guardian. Informed consent applies to surrogates.
    Standards for decisions include:
    o
    Substituted judgment: What decision would the patient make if he/she were capable?
    o
    Best interests: What decision is in the best interests of the patient?
    Medical Probate:
    o
    If there is no surrogate decision-maker available and a patient lacks capacity, a court may
    order a medical probate for authorizing treatment. If a patient regains capacity to give
    informed consent, this court order becomes invalid.
    o
    Until a probate is in place, the patient can be held against their will until treatment can be
    provided.
    Medical Conservatorship:
    o
    A conservator is a court-appointed surrogate who is responsible for consent for medical
    treatment in patients with sustained loss of capacity to give informed consent. Informed
    consent still applies, and the conservator is obliged to act in the patients best interests,
    taking into account patient preferences.
    o
    A temporary conservatorship, or T-Con, may be granted for 30 days upon the
    recommendation of a conservatorship investigator to expedite this process
    (see Involuntary Holds).
    For information regarding psychiatric loss of decision making capacity, see Involuntary Holds

    Approach to Determining Decision Making Capacity

    References

    Lo B. Resolving Ethical Dilemmas: A Guide for Clinician, 2nd Editions. Lippincott Williams & Wilkins,
    2000:80-93.
    Critchfield JM, Williams MV. Care of Ill Socially Complicated Patients in the Hospital Medical Management of
    Vulnerable and Underserved Populations. McGraw-Hill, New York, 2007:407-418.

    Informed Consent and Refusal

    Definition

    Informed consent is a shared decision-making process between the patient and physician. It is
    required for invasive or complex procedures and for treatments with significant risk. On the medical
    ward, this includes blood transfusion or any procedure, including paracentesis, thoracentesis, or
    lumbar puncture.
    Context
    Informed consent is a legal and ethical responsibility that protects patient safety and autonomy. In
    situations in which it is difficult to obtain informed consent (emergencies, low health literacy) or
    informed refusal (pts leaving AMA, refusing procedures), thorough assessments of capacity,
    multidisciplinary assistance and clear documentation are key.
    Application
    Critical steps of informed consent:
    Assess patients capacity for decision-making and communication.
    o
    Use professional interpreters as available. Document use of interpreters.
    o
    Patients with low health literacy, limited English proficiency, or significant illness have more
    documented difficulties with informed consent.
    Explain intervention and risks and benefits. Use plain language and concrete details.
    Discuss reasonable alternatives (as well as no intervention), along with their risks & benefits.
    Assess patient understanding. Have the patient teach-back to you their understanding.
    Patient consent and documentation:
    o
    Ask patient to sign a consent form, but consent can be verbal if documented.
    o
    Remember, simply obtaining a patients signature on a consent form does not equate to the
    patient having given informed consent.
    o
    Document informed consent in the procedure note. Below is an example:
    Date
    Procedure Note
    Mr./Ms. ______ was explained the major risks and benefits associated with ______
    procedure, and I answered his/her questions. I obtained informed consent directly
    from the patient in his/her language/through a professional interpreter/through
    nurse/staff/family member as interpreter. The patient signed a consent form. The
    patient was then prepped in the usual manner. A time-out check was performed.
    Signature

    Emergency consent

    Consent may be presumed in emergencies. However, if the situation permits, it is better to take the time to
    obtain informed consent, collect collaborative information or use a surrogate decision-maker (see Decision
    Making Capacity). These circumstances must be documented.

    Informed consent may be obtained by phone. These telephone discussions should be witnessed by a
    hospital employee and well documented.
    Informed refusal

    Informed refusal is often as important as informed consent, particularly with patients who may be leaving
    AMA or placing themselves at danger. Assess capacity to make decisions (see Decision Making
    Capacity) and go through the usual steps of obtaining informed consent.

    Patients may refuse information if they so choose. Documentation of this event is advisable.

    Exceptions to informed refusal may include communicable diseases, pregnancy or attempted suicide
    during hospitalization.
    Leaving against medical advice (AMA)
    These patients often have a high rate of readmission, longer subsequent hospitalizations and worse
    overall outcomes. Use the following checklist below to assess patients requesting to leave AMA
    (adapted from Berger et al):

    Capacity: Does the patient have decision-making capacity? (see Decision Making Capacity) Consider a
    STAT psychiatry consult if you are unsure. Does the patient understand the risks?

    Voluntariness: Assess for physical, social, emotional, psychiatric or cultural controlling influences. What are
    the patients reasons for leaving (e.g. withdrawal? family or social issues?)

    Mitigation: Attempt multidisciplinary efforts to mitigate controlling influences (e.g. social work, case
    management, community partners).
    Treatment alternatives: Assess medically appropriate outpatient treatment alternatives.
    Aftercare: Encourage and facilitate aftercare and harm reduction strategies (e.g. schedule follow up,
    prescribe medications).
    Documentation: Ask the patient to sign an AMA form when possible. Clearly document the event and the
    AMA discussion with the patient.
    References
    Applebaum PS, Grisso T.Assessing patients capacities to consent to treatment. N Engl J M
    1988;319:1635-1638.
    Berger JT. Discharge against medical advice: ethical considerations and professional obligations. J Hosp
    Med 2008; 5: 403-408.
    Cassileth BR, Zupkis RV, Sutton-Smith K, et al. Informed consent why are its goals imperfectly realized? N
    Engl J M 1980;302:896-900.
    National Quality Forum. Implementing a national voluntary consensus standard for informed consent. 2005.
    Meise A, Kuczewski M. Legal and ethical myths about informed consent. Arch Int Med 1996;156:25212526.
    Rajput V, Bekes CE. Ethical issues in hospitalist medicine. Med Clin N Am 2002;86:869-886.
    San Francisco General Hospital Medical Center, Policy and Procedures. Consent to Medical and Surgical
    Procedures. Section 3.9. 2006.
    Sudore RL, Landefeld CS, Williams BA, et al. Use of a modified informed consent process among
    vulnerable patients: a descriptive study. J Gen Intern Med 2006;21:867-73.

    Involuntary Holds

    Context

    References

    Patients admitted for psychiatric reasons often require further medical attention prior to initiating inpatient
    psychiatric care.
    Application
    The Medical Hold: Officially, this entity does not exist. If there is a medical emergency, a patient can be
    held with appropriate documentation if he or she lacks decision making capacity.
    o
    Call psychiatry to help clarify and corroborate the incident. (see Decision Making
    Capacity)
    For non-emergencies, seek out surrogate decision makers or medical probate conservatorship. Aprobate
    conservatorship is a court proceeding wherein a judge appoints a responsible person (conservator) to make
    decisions on behalf of an adult for cannot care for themselves or their finances.72-hour hold (e.g., in
    California termed a 5150):
    o
    Involuntary hold for one of the following three reasons.

    Danger to self.

    Danger to others.

    Grave disability (unable to provide food, clothing, shelter).


    o
    Usually done by police or mental health professionals. Patients with Alzheimers, brain
    injuries, or other organic brain disorders or intoxication may be held under a psychiatric hold
    (5150). However, it does not confer permission for medical interventions in which case you
    must consult a surrogate decision maker or seek conservatorship. The exception to this is
    in cases of medical emergency.
    14-day hold (e.g., in California 5250): Involuntary hold for 14 days after a 5150. This extends a 72 hour
    hold if the patient still requires treatment for the above reasons (see 72-hour hold). Requires a judicial
    hearing and one of the same three criteria must be met.
    Temporary Conservatorship (T-Con): A temporary 30-day psychiatric conservatorship for patients who
    remain gravely disabled and require additional treatment after the initiation of a 5150 and 5250.
    o
    Placed by Psychiatry.
    o
    Does not allow for the involuntary administration of psychotropic medications, except in
    urgent situations.
    o
    Riese hearings are the process by which a judge determines if the patient is able to provide
    informed consent or refuse medications.
    LPS (Lanterman Petris Short) Conservatorship: A conservator is appointed, via a court process, to
    make decisions in the best interest of a mentally ill adult, such as consent to mental health treatment,
    placement in a facility and financial decisions (e.g. paying bills, collecting income).
    o
    The most common illnesses for which LPS conservatorship is pursued include
    schizophrenia, bipolar disorder, schizoaffective disorder, clinical depression and obsessive
    compulsive disorder.
    o
    LPS conservatorship does not apply to patients with organic brain disorders, brain trauma,
    addiction, developmental delay or dementia unless there is also a con-current DSM
    psychiatric disorder.
    When in doubt, consult with psychiatry, ethics committee, or risk management.
    Felker B, Yazel JJ, Short D: Mortality and medical comorbidity among psychiatric patients: a review.
    Psychiatr Serv 1996; 47:1356-1363.
    USCF Psychiatry Residents. Psychiatry Resident Handbook. 2010-2011 Version.

    Approach to Inpatient Death


    Context

    As an inpatient physician, you will be called to pronounce a patients death. It is important to make sure that
    there is notification to the appropriate parties and clear documentation.
    Application
    Things to think about before entering the room:
    o
    Was the death expected or unexpected.
    o
    Are there unusual family dynamics that you should address with the attending prior to
    entering the room.
    o
    If the family is present, inform them of what you are doing and ask if they would like to be
    present for the examination.
    o
    Ask the family if they would like to request or decline an autopsy.
    How to pronounce a death:
    o
    Identify the patient by ID tag.
    o
    Assess for response to tactile or verbal stimuli (avoid overtly painful stimuli, particularly in the
    presence of family).
    o
    Listen for absence of heart sounds and feel for the absence of a carotid pulse for a
    minimum of 60 seconds.
    o
    Look and listen for the absence of spontaneous respirations for a minimum of 30 seconds.
    o
    Record the position of the pupils and the absence of a pupillary light reflex.
    Who to notify: the phone numbers and appropriate forms for the Organ Donor Network and Medical
    Examiner are part of the death packet to be filled for each patient.
    o
    The attending physician
    o
    Organ Donor Network
    o
    Medical Examiner
    A death note must be documented in the chart. Below is a sample of information that should be included:
    Called at _____ by _____ to pronounce _____. On exam, no heart sounds or breath
    sounds were noted after 1 minute of auscultation. Pupils were fixed and dilated
    without pupillary light reflex. Patient was pronounced dead on --/--/---- at --:--.
    Attending Dr._____ was notified. Family _____ was present/notified by phone and
    condolences were offered. The organ donor network was notified and the case was
    accepted/declined. The case was/was not reportable to medical examiner. Autopsy
    was requested/declined.

    References
    Marchand LR, Kushner KP. Death Pronouncement: survival tips for residents. American Family Physician.
    July 1998.
    Marshall SA, Ruedy J. On Call: Principles and protocols. 4th Ed. Philadelphia, PA: Saunders; 2004.

    Patient Safety and Errors


    Definitions

    Medical error: An act or omission that leads to an unanticipated, undesirable outcome or to substantial
    potential for such an outcome
    Adverse event: An undesirable clinical outcome related to diagnosis or therapy while in the hospital, which
    may or may not result from a medical error

    Context
    Creating a culture of safety to reduce errors includes embracing the following ideas:

    Moving from the paradigm of errors as individual failures to system failures

    Moving from a punitive environment to a just culture

    Trading secrecy for transparency

    Moving care from being provider-centered to patient-centered

    Moving from models reliant on individual performance to collaborative teamwork

    Embracing the idea that accountability is universal and reciprocal


    Application

    Reporting of medical errors: Many hospitals use online Incident Reporting to alert the appropriate people
    of systems that have broken down, and to promote change without individual blame.
    o
    Reporting medical errors is essential to optimal patient care and promoting positive change.
    o
    If you believe a medical error occurred, check online for your institutions Incident Reporting
    mechanism. If you are unclear about what needs to be reported or how to report an
    incident, consider involving your attending or even risk management.
    o
    Even a close call i.e. when no adverse event resulted from the error, should be reported.
    o
    Write down and report errors ASAP as often errors or their details are forgotten.

    Disclosure of medical errors: There is generally a large discrepancy in the percentage of patients
    desiring error disclosure and the percentage of physicians actually disclosing error. Disclosure of a medical
    error is not only an ethical obligation to the patient, but can also provide a cathartic and educational benefit to
    the health care providers involved.
    o
    Involve your attending physician and consider involving risk management prior to
    discussion with the patient.
    o
    Keys to disclosure of medical error include:

    Disclosure: full and immediate disclosure to the patient. Less than full
    disclosure can often lead to patient mistrust of the care provider. However,
    if unsure about the reason behind the error, it is acceptable to immediately
    disclose that an error occurred and that we will be looking into what
    happened. Reassure the patient that the team will continue to openly
    discuss the issue as more information is discovered.

    Repentance: apology with sincere remorse and discussion of what will


    be done to prevent future errors (systems changes, root cause analysis,
    etc). This often allows patients a sense that recognition of their error can
    help other patients avoid error.

    Forgiveness: in addition to seeking forgiveness from the patient, the


    physician must be able to forgive him or herself in order to learn from the
    incident and start healing.

    Tips: choose an appropriate setting (private, interruption-free), give the


    patient the option to have support present, use laymans terms, allow for
    silent moments, have time for questions.
    o
    Reducing medical errors: The reduction of medical errors involves defining and
    implementing Patient Safety Practices, processes meant to reduce the probability of
    adverse events resulting from exposure to the health care system. Common patient safety
    practices include, but are not limited to:

    Adverse drug events: computerized order entry, protocols for high-risk


    drugs.

    Infection control: hand washing practices, prevention of catheter


    associated infections and nosocomial UTIs, contact precautions for C.
    difficile.

    Perioperativemedicine: cardiac risk stratification, perioperative glycemic


    control.

    Geriatricmedicine: fall precautions, delirium prevention.

    Nosocomialcomplications: GI bleed, DVTs, contrast nephropathy,

    References

    pressure ulcers.
    Pain control.
    Procedural safety: ultrasound guidance of central line placement or
    procedures.
    Increased patient participation: promoting hand hygiene to their care
    workers, medication familiarity.

    Berlinger N, Wu AW. Subtracting insult from injury: addressing cultural expectations in the disclosure of
    medical error. J Med Ethics 2005;32: 106-108.
    Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug event: a
    problem for quality improvement. Comm J Qual Improv 1995;21:541 548.
    Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Washington, DC:
    National Academic Press. 2000.
    Leap LL, Berwick DM. Five years after to err Is human: what have we learned? JAMA.2005;293:23842390.
    Longtin Y, Sax H, Leape LL, Sheridan SE, Donaldson L, Pittet D. Patient participation: current knowledge
    and applicability to patient safety 2010. Mayo Clin Proc; 85:53-62.
    Rosner F, Berger JT, Kark P, Potash K, Bennett AJ. Disclosure and prevention of medical errors. Committee
    on Bioethical Issues of the Medical Society of the State of New York. Arch Intern Med 2000; 160: 20892092.
    Shojania KG, Duncan BW, McDonald KM, et al, eds. Making Health Care Safer: A Critical Analysis of
    Patient Safety Practices. evidence Report/Technology Assessment No. 43, AHRQ Publication No. 01-e058;
    July 2001.

    Patient Handoffs
    Definition
    A patient handoff is generally defined as the exchange of information during transfer of primary medical responsibility from
    one provider to another provider.
    Context
    On average, 15 handoffs occur per patient during a 5 day hospitalization and interns are involved in approximately
    300 handoffs per month.

    Increasing handoffs have been associated with poor communication leading to adverse events, medication
    errors, and worsened educational outcomes for medical students.

    Safely done handoffs provide opportunity for increased volume of exposure to clinical cases and
    management styles, an opportunity for error-correction, (double checking medication lists, problems lists,
    clinical reasoning) and opportunities to improve communication skills.
    Application

    Information technology: Electronic Medical Records (EMR) with standardized electronic sign-out
    templates carry the benefits of improved legibility, reduction in omissions, decreased chance of missed
    patients on rounds and reduction in time spent pre-rounding or performing handoffs.

    Individual practices: Several mnemonics exist to describe key features of high quality handoffs
    o
    SBAR:

    Situation: describe the patients current situation and location

    Background: provide background information on the patient including


    reason for admission

    Anticipated Problems: provide a list of likely anticipated problems

    Recommendations: provide recommendations or contingency plans for


    any anticipated problems
    o
    SIGNOUT?: (closer to the practice at UCSF)

    Sick/DNR: prioritize patients who are most sick and clearly identify code
    status

    Identifying data: provide basic demographics as well as up-to-date patient


    location

    General hospital course: summarize major events of patients hospital


    course

    New events: identify any new events in the last 24-48h including
    procedures, changes in clinical status

    Overall health status/clinical condition: summarize current clinical status,


    trend (improving, worsening, stable), and provide baseline for vitals, mental
    status and pertinent physical exam findings

    Up-coming possibilities with plan/rationale: provide a concise and thorough


    list of the most-likely anticipated problems with contingency plan for each

    Tasks to complete overnight: clearly identify and keep up-to-date any


    tasks that need to be performed by the covering physician

    ?: Time for questions and clarification: provide the recipient time for
    questions, clarifications. Request the recipient to teach back any critical
    information or to-dos

    Commonly observed mistakes in sign-out:


    o
    Lack of clarity in plan for broadening antibiotics.
    o
    Missing baseline mental status, abdominal exam, joint exam, etc.
    o
    Patient location is not up-to-date.
    o
    Medication list is not up-to-date.
    o
    Nothing-to-do or NTD listed on the sign-out but patient has to-dos.
    o
    Poor feedback by all parties about quality (or lack of quality) surrounding patient handoffs.

    Tips:
    o
    Make sure one designated person is responsible for updating sign-out (resident vs. intern).
    o
    Sign out in a quiet location with minimal interruptions, this should occur in the same location
    and at the same time every day.
    o
    Both parties should have access to the electronic version of the handoff document.
    o
    Exchange of information should be face-to-face.
    o
    Prioritize the sickest patients first.
    References

    Arora, V., Kao, J., Lovinger, D., Seiden, S. C., & Meltzer, D. (2007). Medication discrepancies in resident

    sign-outs and their potential to harm. Journal of General Internal Medicine, 22(12), 1751-1755.
    Cohen, M. D., & Hilligoss, P. B. (2010). The published literature on handoffs in hospitals: Deficiencies
    identified in an extensive review. Quality & Safety in Health Care, doi:10.1136/qshc.2009.033480
    Bernstein, J., MacCourt, D. C., Jacob, D. M., & Mehta, S. (2010). Utilizing information technology to mitigate
    the handoff risks caused by resident work hour restrictions. Clinical Orthopaedics and Related Research,
    468(10), 2627-2632.
    Petersen, L. A., Brennan, T.A., ONeil, A. C., Cook, E. F., & Lee, T. H. (1994). Does housestaff discontinuity of
    care increase the risk for preventable adverse events? Annals of Internal Medicine, 121(11), 866-872.
    Sarkar, U., Carter, J. T., Omachi, T.A., Vidyarthi, A. R., Cucina, R., Bokser, S., van Eaton, E., & Blum, M.
    (2007). SynopSIS: Integrating physician sign-out with the electronic medical record. Journal of Hospital
    Medicine : An Official Publication of the Society of Hospital Medicine, 2(5), 336-342.
    Van Eaton, E. G., Horvath, K. D., Lober, W. B., & Pellegrini, C. A. (2004). Organizing the transfer of patient
    care information: The development of a computerized resident sign-out system. Surgery, 136(1), 5-13.
    Van Eaton, E. G., Horvath, K. D., Lober, W. B., Rossini, A. J., & Pellegrini, C. A. (2005). A randomized,
    controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care
    and resident work hours. Journal of the American College of Surgeons, 200(4), 538-545.
    Vidyarthi, A. R., Arora, V., Schnipper, J. L., Wall, S. D., & Wachter, R. M. (2006). Managing discontinuity in
    academic medical centers: Strategies for a safe and effective resident sign-out. Journal of Hospital
    Medicine : An Official Publication of the Society of Hospital Medicine, 1(4), 257-266.

    Health Care Quality and Improvement


    Context
    Quality improvement has been defined as the cumulative efforts of all parties involved in healthcare to make changes [to
    systems of care] that will lead to better patient outcomes (health), better system performance (care) and better professional
    development (learning) (Batalden. OSHF 2007). The quality movement has arisen from several concerning observations
    and areas of research in healthcare, including:

    Dramatic and often inexplicable variations in health care practices.

    Disparities in health and health care.

    Medical errors and the impact on patient safety.

    Escalating health care costs have prioritized maximizing value and clinical efficacy.
    Application

    How is quality measured? The Donabedian triad categorizes clinical variables as structure, process or
    outcome measures, each type with its own advantages and disadvantages.
    Measure

    Definition

    Advantages

    Disadvantages

    STRUCTUR
    E

    How care is
    organizedExamples: # of ICU
    beds EMR

    Easy to measure
    Quantifies otherwise
    complex systems

    Limited description of
    quality of care delivered
    Often no gold standard

    PROCESS

    What care is
    providedExamples: ASA for
    ACS Influenza Vaccination
    Medication Reconciliation

    Often from evidence or


    consensus-based
    guidelines Easier to
    measure and change
    than outcomes Direct
    measure of care

    Proxy for desired outcomes


    Gold standard not always
    agreed upon. May draw
    attention from unmeasured
    clinical care

    OUTCOME

    What happened to
    patient Examples:Inpatient
    mortalityVentilator-associated
    PNA Readmissions

    What we really care


    about

    Influenced by many factors


    besides clinical care Often
    long-term, less common
    events Comparisons
    require careful case-mix
    adjustment

    Who measures quality? Health care organizations (hospitals quality committees, health care networks,
    etc.).
    o
    Regulatory (e.g., Joint Commission on Accreditation of Healthcare Organizations).
    o
    Government (e.g., Center for Medicare and Medicaid Services, Agency for Healthcare
    Quality and Research)
    o
    Public-private partnerships (e.g., National Quality Forum).
    o
    Business coalitions (e.g., Leapfrog Group).
    o
    Foundations (e.g., California HealthCare Foundation).
    How can housestaff impact quality improvement?
    o
    Educational efforts: A dedicated quality improvement rotation for housestaff, participation in
    Root Cause Analysis (RCA) sessions, board recertification.
    o
    Feedback: Outpatient report cards or provider performance data compared to
    benchmarks, for example, percent of congestive heart failure patients who receive ACE-I.
    o
    Financial incentives/penalties: Housestaff incentive program, quality and safety initiatives
    and competitions.

    References

    What is continuous quality improvement?


    o
    Involves a team of clinical and non-clinical members in a continuous cycle of change and
    measurement.

    What are we trying to accomplish? Set measurable and time-specific


    goals.

    How will we know that a change is an improvement? Select practical


    quantitative measures.

    What changes can we make that will result in improvement?


    PDSA Cycles Plan, Do, Study, Act: Allows quality improvement teams to plan interventions, test whether
    they work, and modify the intervention.
    What is the Joint Commission?
    o
    The Joint Commission on Accreditation of Healthcare Organizations (aka Joint
    Commission or JCAHO) is the primary health care standards-setting and accrediting body.
    Its mission is to improve the safety and quality of care provided to the public through the
    provision of health care accreditation. Current JCAHO standards for accreditation include:

    Time Out: Patient identification and identification of surgical/procedure


    site.

    Policies surrounding verbal and telephone orders.

    Do Not Use abbreviations: Avoidance of misinterpretable abbreviations.

    Critical test read back and confirm procedures.

    Sentinel and adverse event reporting policy.


    Batalden PF, Davidoff F. What is quality improvement and how can it transform healthcare. Qual Saf
    Health Care. 2007 16:2-3.
    Batalden PF, Davidoff F. Teaching Quality Improvement: The Devil is in the Details. JAMA 2007: 10591061.
    Berwick D, Nolan T. Physicians as leaders in improving health care: a new series in Annals of Internal
    Medicine. Ann Intern Med 1998;128:289-292.
    Boonyasai RT, WIndish DM, Chakraborti C, Feldman LS, Rubin HR, Bass EB. Effectiveness of teaching
    quality improvement to clinicians: Asystematic review. JAMA 2007; 289: 1023-1037.
    Wachter RM, Goldman L, Hollander H. Hospital Medicine, Second Edition. 2005: Chapter 12: Assessment
    and Improvement of Quality and Value.

    Health Care Costs


    Context

    Over-utilization of diagnostic tests have contributed to the increasing costs of health care. The number of
    tests used per patient discharged at UCSF is higher than 15 other comparable academic hospitals
    (according to University Hospital Consortium data). The following is a list of costs incurred to the patient and
    healthcare system as a whole.
    Costs of Commonly Ordered Diagnostic Tests at Moffitt-Long Hospital:
    Service

    Hospital Charge

    Medicare Reimbursement

    Full Metabolic Panel / Chem-7

    Panel not available at Moffitt. $49$64 per individual test ($409)

    $15.14

    - Na (individual test)

    $53.00

    $6.89

    - K (individual test)

    $51.00

    $6.58

    Liver Function Tests (AST,ALT, Total


    Bilirubin, Alkaline Phosphatase)

    Panel not available at Moffitt. $6366 per individual test.

    $11.70

    CBC

    $98.00

    $9.27

    - Hemoglobin

    $30

    $3.39

    ABG

    $260.00

    $27.04

    ANA

    $71.00

    $15.60

    CRP

    $167.00

    $19.32

    Urinalysis with Micro

    $48.00

    $4.43

    Chest X-Ray (PA/Lateral)

    $251.00

    $57.00

    Abdominal X-Ray (KUB)

    $213.00

    $57.00

    CT Head (+/- contrast)

    $2,551.00

    $420.00

    Common Laboratory Tests

    Common Radiology Exams

    Service

    Hospital Charge

    Medicare Reimbursement

    CT Chest (+/- contrast)

    $3,194.00

    $420.00

    CT Abdomen/ CT Pelvis

    $3,067.00

    $420.00

    MRI Brain

    $5,475.00

    $677.00

    Abdominal Ultrasound

    $767.00

    $125.00

    Blood Culture

    $270.00

    $14.42

    Urine Culture

    $172.00

    $11.28

    Sputum Culture

    $234.00

    $12.34

    EKG

    $176.00

    $22.96

    TTE

    $3,101.00

    $533.71

    Common Micro Tests

    Common Diagnostic Procedures

    Cost of One Night Stay (not including other services)

    ICU

    $19,755.00

    Varies greatly depending on


    medical condition.

    Floor Bed

    $6,556.00

    Varies greatly depending on


    medical condition.

    Data obtained from UCSF billing department, 2010. Based on outpatient charges.
    The UCSF Clinical Laboratories maintain an on-line laboratory manual that is constantly
    updatedhttp://labmed.ucsf.edu/labman/. Contains important information regarding test availability and turnaround
    time and test utilization tips.
    References

    Hamill, Tim (2010). Lab Test Utililization: The right, the wrong, and the overused [PowerPoint slides].

    Health Care Costs


    Context
    Academic hospital physicians strive to balance patient care with clinical teaching and team management. Individual styles
    differ, but the following are some common strategies.
    Plan ahead
    Most effective teaching and management does not happen spontaneously.

    On Day 1: Establish expectations and priorities for medical students and housestaff, especially:
    1.
    Patient care priorities.
    2.
    Specific learning and teaching goals for individuals and the team.
    3.
    Process for feedback and evaluation.
    4.
    Clinics and days off.
    5.
    Call nights.
    6.
    Oral presentations (level of detail, length, references to current literature).
    7.
    Work round and attending round logistics.
    Plan each day
    1.
    Review team priorities each day before rounds. Identify patients who need to be monitored closely,
    discussed in depth, or discharged.
    2.
    Schedule formal teaching (i.e., attending rounds, work rounds, student presentations).
    3.
    Identify learning opportunities by taking time before rounds (or the night before) to review patients
    and possible teaching topics.
    Ward teaching
    Highly rated teachers are enthusiastic, flexible and teach within clinical context.

    Teaching files: It is never too early to develop or collect teaching files (e.g., pneumonia). Effective teaching
    plans identify:
    1.
    Goals for instruction (e.g., ddx and management of shortness of breath).
    2.
    Key teaching points (e.g., initial workup and management of dyspnea).
    3.
    Teaching method (e.g., case-based vs. chalk-talk vs. bedside, etc.).
    4.
    Knowledge of common misconceptions and difficulties among learners (e.g., ABGs).

    Bedside teaching. Can be time consuming, but almost uniformly preferred by students and models physical
    examination and patient interactions.

    Frequent, short, pertinent sessions are highly preferred to episodic long ones.

    Teach clinical reasoning, which can be as valuable as teaching clinical content. Use clinical cases,
    involvement of learners in decision making, and explicit discussion of clinical reasoning.

    Turn to-dos and scut into teachable moments. Take time with learners to reflect on family meetings,
    condolence cards, adverse outcomes, and even sign-out or cross-cover.

    The One Minute Preceptor model focuses the teacher on involving the learner and providing
    immediate feedback.
    The One Minute Preceptor teaching script
    Microskill #1: Get a commitment.

    Ask an open-ended question about the learners thinking process about the data he/she presented.

    Example: What do you think is going on? How do you plan to manage your patients shortness of
    breath?
    Microskill #2: Probe for supporting evidence.

    Test the learners knowledge or thinking process and clinical decision-making regarding their
    commitment.

    Example: What factors did you consider in making that decision? What alternative diagnoses did
    you consider and why?
    Microskill #3: Teach general rules.

    After you have assessed how much the learner knows, summarize a few teaching points that the
    learner can apply to future cases. Target your teaching, such as physical findings, diagnostic workup,
    treatment, or missed connections. This may be in the form of a mini-lecture or assigning reading to a
    learner, with subsequent follow-up.
    Microskill #4: Reinforce what was done right.

    Verbally reinforce specific effective behavior.

    Example: That was a terrific synopsis. It shows that youve gathered the history and performed the
    physical exam in an organized, thoughtful manner, and have incorporated these findings into your
    assessment.
    Microskill #5: Correct mistakes.

    After allowing the learner to identify his/her error, discuss the specific mistake and suggest new
    behaviors for the future.
    Example: I agree that the most likely cause for nausea in this patients case is gastroenteritis.
    However, remember that the general rule is that we should also consider pregnancy in this young
    woman, particularly since she is a day late with her period.

    Feedback and Evaluation

    Learners respond best if feedback is immediate (e.g., after presentations), frequent (e.g., everyday or call
    cycle), and specific (i.e., more than great job).

    Schedule formal feedback and evaluation.

    An approach to giving effective feedback:


    Step 1: Ask for self-reflection (e.g., How do you think youre doing?).
    Step 2: Focus on types of behaviors, not the person.
    Step 3: Reinforce positive behaviors.
    Step 4: Give specific constructive feedback (sandwiched between positives & goal setting).
    Step 5: Develop new goals and a plan for improvement.
    References

    Irby DM. Three exemplary models of case-based teaching. Acad Med 1994;69:947-953.

    Furney SL, Orsini AN, Orsetti KE, et al. Teaching the one-minute preceptor. Arandomized controlled trial. J
    Gen Intern Med 2001;16:620-624.

    Neher JO, Stevens NG. The one-minute preceptor: Shaping the teaching conversation. Fam Med
    2003;35:391-393.

    Wachter RM, Goldman L, Hollander H. Hospital Medicine, Second Edition. 2005: Chapter 11: Effective
    clinical teaching in the inpatient setting.

    NIGHT CALLS
    Common Nighttime Calls
    Intravenous access

    Patients who lose IVs overnight often have poor venous access (i.e., ESRD patients or IV drug
    users). First, determine whether IV access is necessary. If a patient can wait safely until the morning,
    more experienced staff can place peripheral IVs or more definitive venous access like PICC lines or
    other catheters. Consider whether IV medications can be given orally overnight. Some quick tips:
    Lower extremities (not in diabetics) can be a good option, consider hanging the patients legs off the bed to
    allow veins to fill and dilate. Warm compresses may also help.
    If there is no good venous access in the extremities (or if contraindicated by cellulitis, phlebitis, etc.), then you
    should consider external jugular or central venous line placement.
    Ask for help/supervision for an EJ until you are comfortable doing it alone.

    Hyperglycemia

    Insulin sliding scales used in the inpatient setting are usually poor at maintaining tight control of blood
    sugar. It is important to determine whether a patient is symptomatic from hyperglycemia and what
    the patients blood sugar control has been like during the hospitalization.
    Blood sugars > 200 mg/dL initiate an osmotic diuresis.
    Steroids, TPN, or enteric feeding can often exacerbate hyperglycemia in the diabetic patient.
    Usually, the insulin sliding scale will provide sufficient coverage for a single high blood glucose level.
    However, if the patient is a risk for a hyperosmolar hyperglycemic state (admitted for this diagnosis or prior
    history of it), or if the patient is symptomatic (nausea, vomiting, hypovolemia, tachypnea), then the patient
    should be seen and evaluated, pay attention to the last electrolyte panel, or order a new one (i.e. increased
    anion gap). See Endocrine: Diabetic Ketoacidosis and Hyperosmolar Non-Ketotic Coma.

    Hypoglycemia

    Defined as glucose < 50 mg/dL with symptoms.

    Some patients, however, feel symptomatic with blood sugars of 51-80 mg/dL.

    Frequently it is the result of excessive lowering of glucose in patients with dietary changes in the hospital
    (NPO status/diabetic diet).

    However, infection and sepsis should be considered in all hypoglycemic patients.

    If hypoglycemia is mild and the patient is stable, give oral glucose (e.g., orange juice).

    For more serious episodes of hypoglycemia, treat with 50g (1 amp) of intravenous dextrose (D50).

    If no clear cause of hypoglycemia can be found, or if the patient has any other troubling signs of infection, a
    full evaluation for infections is warranted.
    Clarification of orders

    The goal of the on-call physician should be to fix serious problems, but leave the overall patient
    management plan to the primary team.

    If any orders are unclear, and you do not believe they will alter the care of the patient overnight, it may be
    best to wait and let the primary team clarify them.

    On-Call Radiology
    Commonly, on-call physicians are asked to interpret chest radiographs to assess the position of devices (e.g., central venous
    catheters, nasogastric tubes) and to rule out complications of their placement (e.g., pneumothorax). If there is ever any doubt,
    a radiologist should be consulted for assistance with interpretation.
    Pneumothorax (PTX)
    Particularly important to consider in ICU patients who are receiving positive end-expiratory pressure (PEEP). 5-15% of those
    on mechanical ventilation can develop extrapulmonary air (PTX, pneumomediastinum, subpleural air).
    Tips for identifying a PTX:

    A small PTX in an upright patient collects at the apex. The lung apex retracts toward the hilum and the sharp
    white line of the visceral pleura will be visible, separated from the chest wall by the radiolucent pleural space
    which is devoid of lung markings.

    If a pneumothorax is suspected but not initially apparent, an expiratory film will make it easier to see because
    lung volume will be at its lowest.

    A lateral decubitus film with the affected side up may reveal air along the lateral chest wall.

    A deep sulcus sign [deep lateral costophrenic angle on the involved side] or a wavy heart border sign in
    patients that with pneumothorax who are supine may be seen.

    Depression of the hemidiaphragm is the most reliable sign for a tension PTX

    Any suspicion of PTX warrants a non-contrast CT scan of chest since CXR correlates poorly with actual
    size.

    Endotracheal tube (ETT) placement


    12-15% of patients will have malpositioning of the ETT on initial placement.

    The tip of the ETT should be positioned 4-6 cm above the carina with the patients neck in a neutral position.

    Flexion of the neck = movement of ETT inferiorly (towards carina) on CXR and vice versa.

    Central Venous Catheter (CVC) Position and Placement

    A CVC catheter tip should ideally be located at the cavoatrial junction.

    A PICC line catheter tip should be located the inferior aspect of the SVC.

    CXR landmarks and findings related to CVC placement

    The arch of the azygous vein is a landmark for the SVC.

    The right mainstem bronchus is a landmark for the junction of the SVC and the right atrium. Therefore,
    inferior to the right mainstem bronchus corresponds to a position within the right atrium.

    The development of a new pleural effusion after line placement should be considered pleural hematoma or
    extravasation of fluid from the line until proven otherwise.

    Nasogastric (NG) and feeding tubes (FT)

    NG tubes are usually inserted for decompression of the stomach. Obstruction of the esophagus may occur
    if the NG tube is not inserted far enough into the stomach; at least 10 cm of the tip should be within the
    stomach.

    Ideal placement of feeding tubes depends partly on the clinical situation. In general, a feeding tube placed in
    the stomach poses no greater aspiration risk than a feeding tube placed beyond the pylorus. For patients
    with high reflux risk, placement beyond the pylorus is often recommended, though supportive data is
    lacking. IV metoclopramide may aid in the passage of feeding tubes beyond the pylorus.

    The unintentional placement of a feeding tube into the airway is a potentially life-threatening complication
    that is not always obvious. Placement is sometimes difficult to determine with a portable radiograph of a
    poorly positioned patient. Merely assuring that the tip of the feeding tube is over the gastric bubble is not
    adequate confirmation -- one must follow the entire course of the tube to ensure that it does not follow the
    course of a bronchus. Obtain an Xray to confirm correct placement. If there is any question, do not clear the
    feeding tube for use.

    UCSF Medical Center small-bore feeding tube placement verification procedure for adults
    o

    X-ray confirmation is required before using for medication, fluids or feedings

    Placement must be confirmed by a radiologist

    After verification, the provider must write an order indicating that a radiologist has confirmed
    placement: OK to use FT tube, placement verified by radiologist.

    References

    Henschke CI, Yankelevitz DF, Wand A, et al. Chest radiography in the ICU. Clin Imaging 1997;21:90-103.

    Common Clinical Scenarios


    Bradycardia
    Definition: There is considerable variation in the resting heart rate of healthy, asymptomatic populations. Simply defined a
    HR <60bpm is considered bradycardia. Common symptomatic and hemodynamic findings in bradycardia include:
    syncope/pre-syncope, fatigue, weakness and hypotension.
    Differential Diagnosis
    Intrinsic Causes

    Evaluation

    Idiopathic degeneration
    (aging)
    Infarction or ischemia
    (especially inferior MI)
    Infiltrative diseases (sarcoid,
    amyloid) Collagen vascular
    disease (SLE, RA)
    Surgical trauma (valve
    replacement, heart
    transplant)
    Infectious diseases (Chagas
    disease, endocarditis)

    Extrinsic Causes

    Autonomically-mediated
    syndromes
    Neurocardiogenic syncope
    Carotid sinus hypersensitivity
    vagal tone (micturition, strain, vomiting)
    Cushings reflex (d/t intracranial pressure,
    associated with HTN and bradycardia)
    Medication-induced
    Beta-blockers, calcium-channel blockers,
    clonidine (reflexive), digoxin, antiarrhythmics
    (amiodarone), eye drops (timolol)
    Hypothyroidism (myxedema)
    Hypothermia Electrolyte
    abnormalities ( or K+)
    Severe hypoxia
    Obstructive Sleep Apnea

    Conduction System Abnormalities Causing Bradycardia:


    o
    Sinus-node Dysfunction: sinus bradycardia, sinus arrest (pause >3sec), sinoatrial exit
    block, bradycardia-tachycardia syndrome (alternating atrial tachyarrhythmia and
    bradycardia).
    o
    AV Conduction Disturbances: 1st degree AV block, Type I and Type II 2nd degree A-V
    block, 2nd degree with high grade A-V block (3:1 conduction) and 3rd degree A-V block
    (complete heart block, A-V dissociation).
    Determine if the patient is hemodynamically stable or unstable/symptomatic (if so, see ACLS
    bradycardia).
    Obtain 12-Lead ECG (for all new onset bradycardia or clinical change, have it ready or in process as you
    are on your way to the bedside); be sure to compare to old ECG.
    Take a history and examine the patient, pay attention to symptoms described above and vital sign
    abnormalities and mental status.
    Evaluate medication list and recently given medications (i.e.: -blocker, CCB) and obtain electrolyte panel
    and TSH if not done recently.
    Management
    If symptomatic or unstable bradycardia follow ACLS protocols for temporary pacing and consult cardiology
    for temporary pacing wire placement.
    Medications are a common cause of bradycardia. Though be careful with abrupt discontinuation of certain
    medications such as rate control agents that may result in a rebound tachycardia. Holding one dose or
    decreasing the standing dose may be a good first attempt.
    Assure that atropine and pacer pads are easily available (i.e. at the bedside if available per nursing protocol).
    Transcutaneous pacing is uncomfortable and a transition to temporary pacing wire should be made if long
    term pacing will be needed, these patients should be transferred to the ICU and cardiology should be
    consulted.
    Treat the underlying conditions i.e. cardiac ischemia, medication overdoses, hypothyroidism
    (seeEndocrine: hypothyroidism), electrolyte abnormalities
    Special Situations:

    o
    Beta-blocker overdose (if severe --> glucagon)
    o
    CCB overdose (1 amp of CaCl2, may require calcium drip)
    Class I indications for pacemaker placement in asymptomatic patients:
    o
    3rd degree AV block with documented asystole >3sec in awake patients or escape rates
    <40 bpm
    o
    3rd degree AV block with wide QRS escape rhythm
    o
    Mobitz type II 2nd degree AV block or 3rd degree AV block in patients with chronic bifasicular
    or trifascular block.
    o
    Ventricular dysfunction
    o
    Bradycardia markedly inappropriate for age
    Key points
    Asymptomatic bradycardia in a young, athletic patient can be normal! But dont ignore the call.
    It is important to identify the underlying rhythm in bradycardia as the management differs depending on the
    etiology.
    Medications are often the cause! Check electrolytes - pay close attention to the K!
    Inferior myocardial infarctions often cause bradycardia due to increased vagal tone and require pre-load for
    management of hypotension.
    References
    Mangrum, J.M and DiMarco, J. Management of bradycardia. N Engl J Med 2000; 342:703-709.
    2005 American Heart Association Guidelines for Cardiopulmonary Resucitation and Emergency
    Cardiovascular Care. Part 7.3: Management of Symptomatic bradycardia and tachycardia. Circulation
    2005; IV-67-IV-77.

    Narrow Complex Tachycardia


    Definition: HR >100 with a QRS duration < 0.12 sec (120ms), can be regular or irregular. Given their narrow QRS duration
    they originate above the ventricle and are commonly referred to as a supraventricular tachycardia (SVT). An SVT may also
    have a wide QRS when there is aberrant conduction. Tachycardia is classified according to whether: regular or irregular,
    narrow complex or wide complex.
    Differential diagnosis

    Regular

    Irregular

    Sinus tachycardia

    Atrial Fibrillation

    Atrial flutter with regular block

    Atrial Flutter with variable block


    Multifocal atrial tachycardia (MAT)

    A-V nodal reentry (AVNRT)

    Atrial tachycardia

    Accessory-pathway mediated reentry


    (aka: AVRT, Wolf-Parkinson-White)

    Main Causes of Regular Narrow Complex Tachycardia (NCT):


    o

    Sinus tachycardia (ST): generally a physiologic response to a stress on the body and is
    often the marker of an underlying illness. The maximum HR of a normal individual is 220
    minus age. When cardiac function is compromised the cardiac output may be dependent
    on the HR due to a fixed stroke volume (SV). Common etiologies in the differential
    diagnosis:

    Normal response to infection, sepsis, pain, hypovolemia, fever and


    hypotension

    Pulmonary embolism, hypoxia

    Cardiac tamponade, pericarditis

    Metabolic conditions: hyperthyroidism

    Alcohol withdrawal

    Response to sympathomimetic drugs (i.e.: vasopressors, bronchodilators,


    beta agonists)

    Atrial tachycardia (AT): paroxysmal in nature and is caused by a focus of enhanced


    automaticity within the atria or a focus of an ectopic atrial pacemaker. Can be difficult to
    diagnose.

    A-V nodal reentry tachycardia (AVNRT): 60% of cases of SVT are caused by AVNRT,
    caused by a dual conduction pathway within the A-V node itself, typically one that conducts
    fast and one that conducts slowly. AVNRT is usually set off by a premature atrial contraction
    (PAC).

    ECG Findings: rate usually <250bpm, will have p-waves on rhythm strip
    and may require adenosine (see below) to diagnose.

    ECG Findings: p-waves are often absent. The p-waves are buried within
    the QRS complex that creates S-waves in inferior leads (pseudo-S
    waves) and apparent R waves in V1 (pseudo-R) though can be found.
    Typically have a long RP interval which is longer than the PR interval
    (RP>PR)

    A-V reentry tachycardia (AVRT): an SVT that is generated by an accessory pathway


    and accounts for 30% of cases of SVT.Acommon example is Wolf-Parkinson-White
    (WPW) syndrome.

    Have a short RP interval that is less than the PR interval and the p-wave
    is discrete from the QRS complex and usually retrograde.

    WPW: characterized by the presence of the delta wave, which is a


    broadened up sloping of the R wave.

    Atrial flutter with regular block: characterized by a classic saw-tooth p-wave which
    typically has a rate of ~300 bpm. The ventricular rate is determined by the rate of
    conduction block. Often flutter as a regular 2:1 block resulting in a ventricular rate of 150
    bpm. If regular, 300/ventricular rate should characterize the rate of AV block.

    Main Causes of Irregular Narrow Complex Tachycardia:


    o

    Atrial fibrillation (AF): very common in acutely ill patients, especially older individuals.
    Characterized by a lack of p-waves or flutter waves in all leads and an irregularly irregular
    rhythm. Please see Cardiology: Atrial Fibrillation for more detailed information on
    etiologies, management.

    Atrial flutter with variable AV block: will look similar to AF except with the presence of flutter

    waves. Often the flutter waves will be visible in the inferior leads with a rate of ~300 bpm.
    o

    Multifocal atrial tachycardia (MAT):a result of multiple ectopic atrial pacemakers, which in
    turn generates at least 3 morphologically distinct p-waves with differing PR intervals on
    ECG.

    Associated with: pulmonary disease (COPD), underlying ischemic cardiac


    disease, valvular disease, hypokalemia and hypomagnesemia,

    Evaluation

    Obtain 12-lead ECG and full set of vital signs to determine hemodynamic stability.

    For hemodynamically unstable patients or those showing signs of rate related cardiovascular compromise
    (ongoing chest pain, altered mental status, hypotension or other signs of shock), follow ACLS unstable SVT
    protocols.

    Compare current ECG to prior 12 lead ECG, evaluate for evidence of delta waves when at a slower rate as
    this will effect management.

    Management

    If unstable, follow ACLS protocol and do not delay synchronized cardioversion.

    Confirm the absence of delta waves on prior ECG; if there is any question do not proceed with adenosine
    until after this is confirmed.

    Evaluate for characteristic findings on 12-lead ECG for each type of SVT during the event, which may
    isolate the diagnosis or illustrate its termination.

    Vagal maneuvers: Can often break SVT

    Types: cough or bear down as if to have a bowel movement.

    Carotid Massage: stimulates baroreceptors that trigger a reflexive increase in vagal activity
    and slowing conduction through the AV node. Place firm pressure to the neck at the level of
    the cricoid cartilage for 5 sec with circular motion. Prior to doing so, auscultate for carotid
    bruits, if present do not perform this procedure.

    The role of adenosine:


    o

    Adenosine functions by slowing conduction through the AV node, and can be used to treat
    and diagnose the underlying rhythm if unclear.

    60-80% of patients treated with a 6mg dose of adenosine will break their SVT and 90-95%
    will break with a dose of 12mg.

    If the rhythm doesnt break, it often will slow it enough to reveal the underlying rhythm such
    as atrial flutter or sinus tachycardia.

    Dosing and Administration

    Peripheral IV: 6mg X1, may repeat X1 6mg dose several minutes later if
    not broken, then increase to 12mg dose X1

    Central Line: lower doses of 3mg with a repeat dose and then increased
    dose of 6mg.

    Continuous ECG monitoring during administration.

    Rapid IV flush is required due to very short half-life.

    Adverse Reactions: bronchospasm, ventricular fibrillation (VF, very rare),


    chest pain and dyspnea (more common).

    AVOID IN: severe COPD

    DO NOT USE IN: Heart transplant recipients (causes prolonged asystole), wide complex
    tachycardia (unless SVT with aberrancy is certain, causes VF), and WPW (causes rapid
    ventricular rate and can degrade to VF, treat with procainamide if occurs), previous allergy.

    Rate control agents: if the SVT doesnt break with adenosine or rapidly reoccurs, consider an IV -blocker or
    IV CCB.
    o

    For treatment and management of atrial fibrillation, please see Cardiology: Atrial
    Fibrillation.

    Key points

    Sinus tachycardia is usually not treated and is a signal for an underlying problem.

    Synchronized cardioversion and ACLS protocol for unstable SVT should not be delayed.

    Always look for delta waves or a widened QRS duration before giving adenosine.

    Adenosine makes patients feel terrible, be aware.

    Adenosine is both diagnostic and therapeutic; always use continuous ECG monitoring during
    administration.

    Atrial flutter can often be very difficult to rate control.

    References

    Delacretaz, E. Suprventricular Tachycardia. N Engl J Med 2006; 1039-1051

    2005 American Heart Association Guidelines for Cardiopulmonary Resucitation and Emergency
    Cardiovascular Care. Part 7.3: Management of Symptomatic bradycardia and tachycardia. Circulation
    2005; IV-67-IV-77.

    Ganz LI, Friedman PL. Supraventricular tachycardia. N Engl J Med 1995;332:162-173.


    Appendix A: Formulas
    Wide Complex Tachycardia

    Definition: HR >100 with a QRS duration >0.12s (120ms). Can be classified as regular or irregular. Increased QRS
    duration correlates with either aberrant intraventricular conduction of an impulse that is supraventricular in origin or that the

    origin of the impulse is from the ventricular portions of the conduction system.
    Differential Diagnosis
    Regular

    Monomorphic Ventricular Tachycardia


    SVT with aberrancy
    Pre-excitation tachycardia (antidromic
    AVRT)

    Irregular

    Ventricular Fibrillation
    Irregular SVT with aberrancy
    Polymorphic Ventricular
    tachycardia

    Regular Wide Complex Tachycardia:


    o
    Monomorphic ventricular tachycardia (VT): a rhythm that originates from the ventricular
    conducting system with only one QRS morphology. Most wide complex tachycardias
    (WCT) can be assumed to be VT until proven otherwise. Predisposing factors include
    cardiomyopathy, prior myocardial infarction and electrolyte abnormalities, particularly of
    potassium and magnesium. Identification is made by diagnostic criteria illustrated
    in Cardiology: Diagnosis of Wide Complex Tachycardia and ACLS: Stale/Unstable
    VT Protocol.

    Non-sustained VT: self terminates in <30 sec.

    Sustained VT: self terminates in >30 sec or continues indefinitely.


    o
    SVT with aberrancy: caused by a supraventricular impulse that has aberrant
    intraventricular conduction in the setting of a bundle branch block. This can be difficult to
    differentiate from VT at times and has a very different management acutely and chronically.
    o
    Pre-excitation tachycardia: caused by an accessory pathway that conducts at a different
    rate and causes a widening of the QRS complex. Considered to be antidromic AVRT and
    is impossible to distinguish between this and VT.
    Irregular Wide Complex Tachycardia:
    o
    Ventricular fibrillation: a form of pulseless arrest, unorganized ventricular rhythm and
    requires immediate ACLS initiation and defibrillation. This is an ischemic rhythm.
    o
    Irregular SVT with aberrancy: likely related to atrial fibrillation or flutter with variable block.
    o
    Polymorphic ventricular tachycardia: an organized ventricular rhythm with beat-to-beat
    variability in morphology that deteriorates to pulseless arrest and VF quickly and should be
    treated per ACLS protocols immediately. This can represent an episode of ischemia, or
    be related to a prolonged QT interval. Torsades des pointes is an example of polymorphic
    VT that occurs in the setting of QT interval prolongation.

    Management
    1.
    Quickly determine if the patient is hemodynamically stable or unstable, if unstable call for back up via
    code blue and initiate ACLS unstable WCT protocol for unstable VT/VF.
    2.
    If stable, obtain 12 Lead ECG and electrolyte panel including magnesium and consider cardiac biomarkers.
    3.
    Look for precipitating cause and treat accordingly (i.e. ischemia, prolonged QT)
    4.
    Evaluate medication list for QT prolonging agents
    5.
    Stable VT: See ACLS: Stable VT section for anti-arrhythmic recommendations
    Key points

    A wide complex tachycardia should be treated as ventricular tachycardia until proven otherwise.
    Evaluate for hemodynamic stability immediately.
    Check potassium and magnesium levels treat for K >4.0 and Mg >2.0
    Irregular WCT is likely a sign of ischemia or a result of prolonged QT interval.
    Do not hesitate to call a Code Blue for appropriate back up and initiating ACLS protocol.
    Consider electrophysiology or cardiology consult early for aid in management.
    References
    2005 American Heart Association Guidelines for Cardiopulmonary Resucitation and Emergency
    Cardiovascular Care. Part 7.3: Management of Symptomatic bradycardia and tachycardia. Circulation
    2005; IV-67-IV-77.
    Brugada, P; Brugada, J; et al. A New Approach to the Differential Diagnosis of a regular tachycardia with a
    wide QRS. Circulation 1999; 83:1649-1659.

    Hypotension
    Definition: Mean arterial pressure (MAP) <65. Keep in mind that a patient who is usually hypertensive can experience
    hypoperfusion at higher MAPs.
    Differential Diagnosis and Evaluation
    Remember hypotension = death. Presence of normal mentation simply indicates that the patient still has a pulse and should
    not be reassuring in itself.
    Treat all episodes of hypotension very seriously; all hypotensive patients should be seen and evaluated promptly.

    Use this equation to think through the differential diagnosis of hypotension:


    MAP = SVR x CO = SVR x HR x SV (where Stroke volume = Preload x Contractility)
    MAP - mean arterial pressure; SVR - systemic vascular resistance - HR, heart rate; SV - stroke volume.

    Decreased SVR: Exam = warm extremities, sometimes flushing.


    o

    Sepsis: Common cause. Obtain blood cultures x 2. CXR, UA/micro/culture. Rapid


    administration of IVF and antibiotics will be crucial. See Critical Care: early goal-directed
    therapy for sepsis.

    Medications: Look for antihypertensives, pain meds, sedatives, and possible dosage
    errors; if concern for opiate overdose, give narcan.

    Adrenal insufficiency: Is the patient on chronic steroids and unable to mount a stress
    response? Consider stress dose steroids (See Endocrine: Adrenal Insufficiency).

    Anaphylaxis: Look at medication list/diet for offending agent. Give epinephrine 0.2-0.5 ml
    (0.2-0.5 mg) of 1:1000 SC/IM q20 minutes (diluted dosedifferent from code blue dose),
    diphenhydramine 50 mg IV, hydrocortisone 100 mg IV.

    Neurogenic: Spinal shock rare cause in an already hospitalized patient. Spinal


    compression.

    Abnormal heart rate: Look at the ECG for pathologic tachycardia, bradycardia. Unlikely to be primary
    cause unless HR is very high or low.

    Decreased preload: Exam-assess JVP, volume status.


    o

    Hypovolemia: GI bleed, diarrhea, third spacing, insensible losses. Get STAT CBC,
    consider Central Venous Pressure (CVP) monitoring, review Ins and Outs. Unless the
    patient has known ventricular dysfunction, almost never wrong to give an IVF bolus.

    Pulmonary embolism: See Pulmonary: Pulmonary Embolism.

    Tamponade: Get pulses, call cardiology to perform an echo and


    pericardiocentesis. SeeCardiology: Tamponade.

    Right ventricular infarct: Obtain right sided ECG. See Cardiology: RV Myocardial
    Infarction.

    Tension pneumothorax (PTX): Do not wait for a CXR. Insert a 14 or 16 gauge needle
    into the second intercostal space at the midclavicular line ASAP.

    Pulmonary hypertension: See Cardiology: Pulmonary Hypertension.

    Decreased contractility: Exam-listen for gallop, murmurs (especially new), and rales/crackles.

    Myocardial dysfunction: New infarct vs. prior ventricular dysfunction and precipitating event. Review
    history of CAD/CHF and cardiac risk factors. Get STAT ECG, cycle troponins, telemetry; seeCardiology:
    Rule out Myocardial Infarction, ACS, Congestive Heart Failure.

    Medications: Look for -blockers and CCB.

    Valvular dysfunction (AS, AI, MR): Acute worsening of known valve disease? Infarction causing papillary
    muscle rupture? Endocarditis? Get STAT echo.

    Aortic dissection: Any history of peripheral vascular disease? Get STAT chest CT.

    Additional Points on Differential Diagnosis and initial evaluation: After using MAP = SVR x CO, consider the following:

    Overlap syndromes: Get more data with a PAline or echocardiogram + CVP.


    o

    Sepsis + cardiogenic, sepsis + hypovolemia, cardiogenic + hypovolemia.

    Consider other causes of hypotension as listed above and as follows:


    o

    Increased cardiac output without sepsis: ESLD or fulminant hepatic failure, severe
    pancreatitis, trauma with SIRS, thyroid storm, AV fistula.

    Increased CVP without LV failure: pulmonary hypertension, PE, RV infarct, tamponade.

    Non-responsive hypovolemia: adrenal insufficiency, anaphylaxis, cold sepsis.

    Autonomic dysfunction: review patients problem list/past medical history

    Management
    Always start with: Is the patient stable? and go evaluate the patient promptly:

    Above all, stay calm. Crashing patients are scary. Do not try to manage shock by yourself.

    Have a low threshold to transfer a hypotensive patient to the ICU for better nursing support and/or for
    facilitated intubation. Call a code blue for immediate help.

    If the BP is undetectable, palpate for pulses. A palpable femoral pulse indicates systolic blood pressure
    (SBP) > 80 mmHg and a palpable carotid pulse indicates SBP > 60 mmHg.

    Treatment is aimed at the underlying cause (see DDx and evaluation section above), but almost all cases
    call for fluid resuscitation. If suspicion of CHF is low, then give rapid isotonic fluid resuscitation.

    Start O2, additional large bore peripheral IVs, put patient in Trendelenberg, draw basic STAT labs (CBC,
    lytes, BUN, creatinine, glucose, LFTs, blood/urine cultures), and get STAT ECG, CXR, ABG. See Critical

    Care sections (e.g., Initial Choice of vasopressor in hypotension, Stepwise Approach to the ICU patient
    with septic shock) for more information.

    If the patient is stable, then move on to these questions:


    o

    Is this BP real? Measure the BP manually with the correct sized cuff. Get a repeat full set of
    vitals.

    Is the BP any different from prior values? If the patient usually has a BP of 80/40 mmHg,
    then the acuity may be decreased somewhat.

    Is there associated hypoxemia, altered mental status, or increased respiratory rate (reasons
    for intubation)?

    Access? Think about placing additional large bore peripheral IVs, a central line, or a PAline.

    Monitoring? Arterial line placement gives real time accurate blood pressure measurements.
    Foley catheter to measure urine output (renal perfusion).

    Is the mean arterial pressure (MAP) <60 mmHg? MAP = (SBP + 2(DBP))/3. MAP less
    than 60 mmHg = significant risk of hypoperfusion to vital organs.

    Key points

    The patient is mentating fine should only be as reassuring as the patient still has a pulse.

    Treat all episodes of hypotension seriously. Always go to evaluate the patient.

    Use the equation MAP = SVR x CO to help think through the DDx and initial management of hypotension.
    See Hypotension Algorithm below for a quick review.

    Hypotension Algorithm

    References

    Wood Lawrence D, Chapter 20. The Pathophysiology of the Circulation in Critical Illness (Chapter). Hall
    JB, Schmidt GA, Wood LDH: Principles of Critical Care, 3rd edition. 200

    Hypertension
    Definition: BP >140/90. However, not every pt with a BP >140/90 warrants acute intervention.

    Hypertensive emergency: Elevated BP is associated with end-organ damage (brain, eye, heart, and
    kidney)
    Hypertensive urgency: Elevated BP of >200/109 mmHg but no evidence of end-organ damage.
    Differential Diagnosis
    Consider underlying conditions that could be causing hypertension:
    o
    Alcohol withdrawal (tachycardia, tremor, confusion).
    o
    Drug overdose (cocaine, amphetamine).
    o
    Medication interactions (MAO inhibitors, tricyclics).
    o
    Medication withdrawals (-blockers, ACE inhibitors, clonidine).
    o
    Increased intracranial pressure (Cushings reflex).
    o
    ESRD, renal failure, renal artery stenosis.
    o
    Eclampsia, pre-eclampsia (is the patient pregnant?).
    o
    Coarctation of the aorta, aortic dissection (unequal BP in arms?).
    o
    Pheochromocytoma (episodic nature; associated with flushing, diaphoresis, tachycardia).
    o
    Endocrine (Cushings syndrome, thyrotoxicosis, Conns syndrome-primary
    hyperaldosteronism).
    o
    Pain, anxiety (a diagnosis of exclusion).
    o
    Autonomic dysfunction
    For hypertensive emergency, consider these important causes:
    o
    Hypertensive encephalopathy
    o
    Dissecting aortic aneurysm
    o
    Acute left ventricular failure with pulmonary edema
    o
    Acute myocardial infarction
    o
    Eclampsia
    o
    Acute renal failure
    o
    Symptomatic microangiopathic hemolytic anemia
    Evaluation
    High BP seldom warrants acute intervention. Your major concerns should be:
    o
    Whether this represents a hypertensive emergency.
    o
    Whether the hypertension reflects a more serious underlying process.
    o
    Avoid reflexively treating elevated BP since rapid lowering can be associated with significant
    morbidity and death. Treatment should be initiated sooner for patients with a rapid rise in BP
    and pregnant patients.
    Accurate reading? Using correct sized cuff, take the BP again in BOTH arms.
    Perform a chart biopsy: Note the time course of hypertension. Has it been constant since admission, or
    has it developed suddenly? Does the patient have a history of renal or cardiac disease?
    Physical exam: Ask about and examine:
    o
    Brain: headache, confusion, lethargy, stroke (Perform focused neurologic exam).
    o
    Eye: blurred vision (fundoscopic exam: papilledema, flame hemorrhages).
    o
    Heart: chest pain, dyspnea, S3, S4.
    o
    Kidney: low urine output, edema.
    Studies
    CBC with peripheral smear (look for schistocytes), ECG, urinalysis (look for proteinuria), electrolytes, BUN,
    and creatinine (look for renal dysfunction) in all patients.
    CXR in all patients with chest pain or dyspnea
    Head CT for those with neurologic symptoms
    Chest CT with contrast in patients with unequal BP in arms or widening of mediastinum on CXR.
    Management
    For hypertensive urgencies: The majority of patients with diastolic blood pressure >109 have no acute
    end-organ damage and their blood pressure should be lowered over the next 24-48 with oral medications.
    Rapid lower could cause MI or stroke in these patients. The following medications could be used:
    o
    Captopril 6.25-25 mg PO TID (check potassium, creatinine, allergies before); you can titrate

    up after each dose if not having an adequate effect.


    Metoprolol 12.5 25 mg PO BID, can start IV metoprolol 5mg x3 to assess tolerability.
    Clonidine 0.1 mg PO BID.
    Nitropaste is easy and can be easily removed. However, it can cause headache and is not
    appropriate for long-term use; because of these issues, would generally consider other
    choices for blood pressure management before using nitropaste. Also, always avoid in
    patients with severe/critical AS. See Sliding Scales: Nitropaste for dosing.
    o
    Hydralazine 10 mg PO and titrate up q6h use with caution due to unpredictable effect.
    o
    Avoid short-acting nifedipine (increased mortality).
    For hypertensive emergencies: Requires admission to the ICU and possible arterial line insertion if BP is
    labile. Rapid titration of IV medications should be used.
    o
    Important to note that most patients are also volume depleted and may require isotonic IV
    fluids to prevent hypotension following medication administration. (Assess CVP and be
    careful in those with heart, kidney, or liver disease).
    o
    It is recommended that diastolic BP be reduced by only 10-15% over the first hour (within 510min. for dissecting aortic aneurysm patients). Then, reduce by 25% over next 6-12
    hours. Goal BP should not be lowered to normal levels since autoregulation of blood flow to
    brain, heart, kidneys has likely compensated for chronic hypertension.
    o
    Rapid declines in BP can lead to stroke, MI, or renal failure.
    Use the following medications to get patients out of hypertensive emergencies then transition to PO
    medications.
    o
    Esmolol: 0.5mg /kg loading dose, followed by starting infusion of 50g/kg/min up to
    200g/kg/min. Good for post-operative hypertension and myocardial infarction patients.
    Depending on dose, esmolol ends up being large volume infusion; if volume overload/CHF,
    consider another medication.
    o
    Labetalol: 20 mg IV initial, followed by 20-80mg IV q10 minutes until BP falls; alternatively,
    infusion dosed at 0.5-3.0 mg/min. Good for pregnant patient since little placental transfer.
    o
    Nicardipine: Initial infusion of 5mg/hour, increasing by 2.5mg/hour every 5 minutes to a
    maximum dose of 30mg/hour.
    o
    Nitroprusside: 0.3 mcg/kg/min-4g/kg/min (levels between 4-10 associated with cyanide
    toxicity). Difficult medication to use. Shown to cause increase mortality in post-MI patients.
    Infusions >24 hours not recommended.
    o
    Nitroglycerin: 5g/min-60g/min IV Use for heart disease patients. Usually used with
    another med.
    o
    AVOID hydralazine or nitropaste (unpredictable effects) and nifedipine (associated with
    increased mortality).
    Special situations:
    o
    Ischemic stroke: hypertension in these patients is compensatory and helps preserve
    cerebral perfusion. Treatment should be reserved for when diastolic BP exceeds 120-130
    and systolic BP >210. Avoid nitroprusside, fenoldopam, and nitroglycerin, since these
    medications can increase intracranial BP (see Neurology chapter).
    o
    Pheochromocytoma: use an -blocker such as phenoxybenzamine or phentolamine.
    Avoid -blockers for fear of precipitating a hypertensive crisis (unopposed alpha).
    o
    Pregnancy: use labetalol.
    o
    Cocaine: consider labetalol.
    o
    Scleroderma renal crisis: use an ACE inhibitor.
    Key Points
    Hypertension seldom requires aggressive acute intervention, unless concern for hypertensive
    urgency/emergency.
    For hypertensive emergency, always admit patients to ICU for close monitoring, and avoid lowering blood
    pressure too rapidly (see above for more details).
    Go see any patients who you are worried may have hypertensive urgency/emergency and all patients who
    are symptomatic.
    References
    o
    o
    o

    Varon J, Marik PE. Clinical review: The management of hypertensive crises. Crit Care Med 2003;7:374-384.

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