Eugene S. Chu

A structured handoff program for interns.

Purpose To develop, teach, and supervise a structured process for handing off patient care and to evaluate its effect on interns’ knowledge, skills, and attitudes toward handoffs. Method The authors developed a formal process for interns on the medicine ward services to hand off patient care at their teaching hospital. In July 2006, attending physicians began to teach and supervise the process. To evaluate the entire structured handoff program (the process, teaching, and supervision), interns were surveyed on the first day and during the last week of each of their month long rotations. Results From June through December 2006, the authors obtained 137 of 144 surveys (95% response) they had administered to 72 consecutive interns rotating through the hospital. During the first three months of the academic year, first-year interns had little confidence in their ability to hand off patients, make contingency plans, or perform read-backs when they began their rotations, but after exposure to the handoff program, their perceptions of these abilities increased (all P < .05). Eighty-five percent of the interns felt that attending supervision of the handoff process was useful or extremely useful, but only 51% viewed the lecture/small-group session about handoffs as useful. Conclusions The structured handoff program improved the participating interns’ perceptions of their knowledge of the handoff process and their ability to transfer the care of their patients effectively. The formal program for teaching handoffs, that included attendings’ supervision of the process, was well received.

ACUTE center for eating disorders

BACKGROUND While patients with anorexia nervosa have a high mortality rate, more are living into adulthood. Patients with severe malnutrition secondary to anorexia nervosa often require hospitalization for medical stabilization prior to treatment in eating disorders programs. METHODS We developed the ACUTE Center at Denver Health Medical Center to medically stabilize adults with the medical complications of severe malnutrition due to an eating disorder. The first 2 years of patient characteristics and outcomes are reported. RESULTS From October 2008 through December 2010, the ACUTE unit had 76 admissions of which 62 were for medical stabilization, comprising 54 patients. Eighty-nine percent of patients were female. The mean age was 27 years old (range 17-65). The mean body mass index on admission was 12.9 kg/m(2) (standard deviation [SD] 2.0). At admission, patients were hyponatremic, anemic, and leukopenic, with low bone density, but had normal albumin levels. The mean body mass index on discharge was 13.1 ± 1.9 kg/m(2). Median length of stay was 16 days (interquartile range [IQR] 9-29 days). Eighteen percent were discharged to home and eighty-two percent were discharged to inpatient psychiatric eating disorder units. Inpatient mortality was zero. DISCUSSION Patients with this degree of severe malnutrition due to eating disorders are medically complex and relatively uncommon. Regionalized subspecialty centers of excellence, in which a multidisciplinary team is led by practitioners of hospital medicine who have developed expertise in a rare condition, may improve clinical outcomes, optimize healthcare resources, and provide unique professional and academic opportunities for the clinicians involved.

Abuse and clinical value of diuretics in eating disorders therapeutic applications

OBJECTIVE Diuretic abuse as a means of purging is common in patients with bulimia nervosa. We sought to illustrate the pathophysiologic effects of diuretics and purging on a patient with bulimia nervosas fluid and electrolyte status and to clarify the role of diuretics in the management of volume status during refeeding. METHOD We reviewed the literature pertaining to diuretic abuse, purging, bulimia nervosa, and diuretic therapy. RESULTS Purging behaviors lead to volume depletion and a state of heightened aldosterone production. Patients with bulimia nervosa commonly undergo rapid rehydration with intravenous fluid administration. In the setting of hyperaldostreronism, aggressive rehydration leads to avid salt retention and the development of marked amounts of edema. DISCUSSION Providers should understand both the background renal pathophysiology of the patient with bulimia nervosa and the mechanisms of action of diuretics to correctly use diuretics as focused therapeutic agents for this patient population.

Clinical Issues Encountered in the Refeeding of the Patient with Anorexia Nervosa

Anorexia nervosa is a challenging disorder to treat, both from a medical and a psychiatric standpoint. Part of the clinical difficulty is based on the patients ardent desire to resist meaningful weight restoration, and the debilitating fear of food which defines this disorder. However, there are also a litany of medical complications which can interfere with the refeeding process and which affect many different body systems. One particularly concerning sequela of this refeeding is known as the refeeding syndrome. This potentially fatal syndrome most commonly occurs with aggressive refeeding programs that do not incorporate close surveillance for the signs and symptoms of the newly acquired anabolic condition. Without early detection and intervention, progressive cardiopulmonary failure can occur. Cautious and restrained provision of calories together with vigilant oversight and checking of electrolytes on a frequent basis will prevent this sobering syndrome. The biochemical, cardiac, and gastrointestinal systems are most prominently affected during early periods of weight restoration. However, weight restoration remains the key to a successful treatment outcome in patients with anorexia nervosa, and thus, familiarity with these issues is imperative for the caregivers of anorectic patients.

Outcomes of care by hospitalists.

n engl j med 358;16 www.nejm.org april 17, 2008 1755 The Authors Reply: Readers question our use of data obtained up to 2 years before patients were placed on the waiting list and our exclusion of transplantation-center experience and the 15% of patients with missing data. The median time from clinical measurements to placement on the waiting list was 183 days and was uncorrelated with the outcome. To avoid selection effects associated with the length of time since listing, our analyses implicitly compared patients who had undergone transplantation with patients who had been on the waiting list for about the same time and who had not received a transplant. We excluded patients with missing data instead of imputing values or attempting a review of original charts. Of the 88 patients who were excluded, 70 had missing clinical data during the 2 years before placement on the waiting list. Excluded patients were slightly younger but otherwise indistinguishable from included patients for modeled covariates. They were more likely to undergo transplantation, but had no difference in mortality after listing or transplantation. A preliminary analysis of pediatric lung transplantation showed reduced harm but no benefit at large centers. In reply to Dawwas et al., we used all patients in our model development to maximize statistical power. We used bootstrapping to rebuild the model with randomly resampled populations and found the reported model to be robust. The high significance and magnitude of the effects establish discriminatory power. This is our second study with the use of a different patient population and markedly different methods to show a lack of survival benefit associated with lung transplantation in children with cystic fibrosis.1 To assist clinicians in listing patients for transplantation, we excluded factors from analysis that were unknowable at the time of decision making; these factors include donor characteristics and the future experience of transplantation centers. Anbar and Sweet et al. suggest that healthier patients waited longer than sick patients for transplantation, perhaps biasing the results against transplantation. However, waiting times relative to health have not been carefully studied. Transplantation may also be deferred in patients who are deemed to be too sick to undergo the surgery, resulting in a different bias. Preliminary examination of center-specific data suggests that healthier patients at large centers had shorter times to wait before transplantation than sicker patients at small centers. Sweet et al. report that the current lung-allocation score predicts that 69% of patients benefit from transplantation. This assertion of realized benefit constitutes a hypothesis that cannot be tested retrospectively. Under the lung-allocation scoring system, patient selection is based on the estimated survival benefit, confounding an analysis of the survival benefit of transplantation. The question of the benefit of transplantation for children with cystic fibrosis cannot be resolved by retrospective study because of unobserved biases. The best solution is to positively answer our call for a prospective, randomized trial of lung transplantation.