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Comfort care for patients dying in the hospital

by jmiller on January 27, 2016

Great review article  (NEJM Dec 24, 2015) that reviews the need for comfort-care skills in hospital practice; setting goals at the end of life: the importance of communication; understanding comfort care; evidence-based management of symptoms in dying patients; pain; dyspnea; cough; xerostomia; nausea and vomiting; constipation; anorexia and cachexia and the role of hydration and nutrition; fever; anxiety and insomnia; delirium; palliative sedation to unconsciousness at the end of life.  The information presented “should provide clinicians in fields other than palliative care with a framework for delivering basic comfort care to hospitalized patients who are near death.”  Click here to read full text.

Understanding variation in 30-day surgical readmission in the era of accountable care: effect of the patient, surgeon, and surgical subspecialties

by jmiller on January 27, 2016

Article concludes:  “Readmission occurred in more than 1 in 10 patients, with considerable variation across surgical subspecialties.  Variation in readmission was overwhelmingly owing to patient-level factors while only a minority of the variation was attributable to factors at the surgical subspecialty and individual surgeon levels”.  (Jama Surgery, Nov 1015)  Click here to view full text.

Evidence for a standardized preadmission showering regimen to achieve maximal antiseptic skin surface concentrations of chlorhexidine gluconate, 4%, in surgical patients

by jmiller on January 27, 2016

Article concludes: a standardized preadmission shower regimen that includes 118 ml. of aqueous chlorhexidine gluconate, 4%, per shower; a minimum of 2 sequential showers; and a 1-minute pause before rinsing results in maximal skin surface concentrations of chlorhexidine gluconate that are sufficient to inhibit or kill gram-positive or gram negative surgical would pathogens.  This showering regimen corrects deficiencies present in current nonstandard preadmission shower protocols for patients undergoing elective surgery.  (Jama Surgery, Nov 2015).  Click here to read full text.

Consensus statement by the American Assn of Clinical Endocrinologists and Amer Coll Endocrinology on the comprehensive type 2 diabetes management algorithm

by jmiller on January 13, 2016

“Since originally drafted in 2013, the algorithm has been updated as new therapies, management approaches, and important clinical data have emerged.  The 2016 edition includes a new section on lifestyle therapy as well as discussion of all classes of obesity, antihyperglycemic, lipid-lowering, and antihypertensive medications approved by the FDA through December 2015.  (Endocrine Pract, Jan 2016)  Click here to read full text.

“Effect of hospitalist workload on the quality and efficiency of care” and editorial “Hospital workload: the search for the magic number”

by jmiller on January 13, 2016

Hospitalists per patient is a frequently visited topic for literature searches.  The article concludes, “Increasing hospitalist workload is associated with clinically meaningful increases in LOS and cost.  Although our findings should be validated in different clinical settings, our results suggest the need for methods to mitigate the potential negative effects of increased hospitalist workload on the efficiency and cost of care.  The average hospitalist workload was a census of approximately 15 patients per day.  Higher workloads were associated with significant inefficiencies; each additional patient per physician was associated with an increase in mean length of stay of 2 full days and in hospital costs of $262.  (Jama, May 2014)  Click here to read full text.

“A conceptual framework for appropriateness in surgical care: reviewing past approaches and looking ahead to patient-centered shared decision-making”

by jmiller on December 14, 2015

Concludes, “It is our belief that encouraging patient engagement and ensuring high-quality shared surgical decision-making will result in fewer inappropriate procedures. There is evidence that patients who engage in high-quality decision-making are not only more likely to play a more active role in behaviors that will ensure a positive surgical outcome but are also less likely to choose surgery that will not benefit them.  These patients may elect to choose alternative treatments or nonsurgical therapies.”  (Anesthesiology, Dec)  Click here to read full-text.

“A randomized trial of intensive versus standard blood-pressure control” and “Redefining blood-pressure targets – SPRINT starts the marathon”

by jmiller on December 14, 2015

“Among patients at high risk for cardiovascular events but without diabetes, targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, resulted in lower rates of fatal and nonfatal major cardiovascular events and death from any cause, although significantly higher rates of some adverse events were observed in the intensive-treatment group.  (NEJM, Nov. 26)  Click here to read full-text.

Evidence for a standardized preadmission showering regimen to achieve maximal antiseptic skin surface concentrations of chlorhexidine gluconate, 4%, in surgical patients” and editorial “Chlorhexidine gluconate, 4%, showers and surgical site infection reduction”

by jmiller on December 14, 2015

Concludes, “A standardized preadmission shower regimen that includes 18 ml of aqueous chlorhexidine gluconate, 4%, per shower; a minimum of 2 sequential showers; and a 1-minute pause before rinsing results in maximal skin surface concentrations of chlorhexidine gluconate that are sufficient to inhibit of kill gram-positive or gram-negative surgical wound pathogens.  This showering regimen corrects deficiencies present in current non-standardized preadmission shower protocols for patients undergoing elective surgery.  (JAMA Surg, Nov.)  Click here for full-text.

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