Who Needs Inpatient Detox? Development and Implementation of a Hospitalist Protocol for the Evaluation of Patients for Alcohol Detoxification

BACKGROUND: Clinicians caring for patients seeking alcohol detoxification face many challenges, including lack of evidence-based guidelines for treatment and high recidivism rates. OBJECTIVES: To develop a standardized protocol for determining which alcohol dependent patients seeking detoxification need inpatient versus outpatient treatment, and to study the protocol's implementation. DESIGN: Review of best evidence by ad hoc task force and subsequent creation of standardized protocol. Prospective observational evaluation of initial protocol implementation. PARTICIPANTS: Patients presenting for alcohol detoxification. INTERVENTION: Development and implementation of a protocol for evaluation and treatment of patients requesting alcohol detoxification. MAIN MEASURES: Number of admissions per month with primary alcohol related diagnosis (DRG), 30-day readmission rate, and length of stay, all measured before and after protocol implementation. RESULTS: We identified one randomized clinical trial and three cohort studies to inform the choice of inpatient versus outpatient detoxification, along with one prior protocol in this population, and combined that data with clinical experience to create an institutional protocol. After implementation, the average number of alcohol related admissions was 15.9 per month, compared with 18.9 per month before implementation (p = 0.037). There was no difference in readmission rate or length of stay. CONCLUSIONS: Creation and utilization of a protocol led to standardization of care for patients requesting detoxification from alcohol. Initial evaluation of protocol implementation showed a decrease in number of admissions

Ultrasound in the diagnosis and management of pleural effusions

We review the literature on the use of point-of-care ultrasound to evaluate and manage pleural effusions. Point-of-care ultrasound is more sensitive than physical exam and chest radiography to detect pleural effusions, and avoids many negative aspects of computerized tomography. Additionally, point-of-care ultrasound can assess pleural fluid volume and character, revealing possible underlying pathologies and guiding management. Thoracentesis performed with ultrasound guidance has lower risk of pneumothorax and bleeding complications. Future research should focus on the clinical effectiveness of point-of-care ultrasound in the routine management of pleural effusions and how new technologies may expand its clinical utility

Recommendations on the Use of Ultrasound Guidance for Adult Thoracentesis: A Position Statement of the Society of Hospital Medicine

Executive Summary: 1) We recommend that ultrasound should be used to guide thoracentesis to reduce the risk of complications, the most common being pneumothorax. 2) We recommend that ultrasound guidance should be used to increase the success rate of thoracentesis. 3) We recommend that ultrasound-guided thoracentesis should be performed or closely supervised by experienced operators. 4) We suggest that ultrasound guidance be used to reduce the risk of complications from thoracentesis in mechanically ventilated patients. 5) We recommend that ultrasound should be used to identify the chest wall, pleura, diaphragm, lung, and subdiaphragmatic organs throughout the respiratory cycle before selecting a needle insertion site. 6) We recommend that ultrasound should be used to detect the presence or absence of an effusion and approximate the volume of pleural fluid to guide clinical decision-making. 7) We recommend that ultrasound should be used to detect complex sonographic features, such as septations, to guide clinical decision-making regarding the timing and method of pleural drainage. 8) We suggest that ultrasound be used to measure the depth from the skin surface to the parietal pleura to help select an appropriate length needle and determine the maximum needle insertion depth. 9) We suggest that ultrasound be used to evaluate normal lung sliding pre- and postprocedure to rule out pneumothorax. 10) We suggest avoiding delay or interval change in patient position from the time of marking the needle insertion site to performing the thoracentesis. 11) We recommend against performing routine postprocedure chest radiographs in patients who have undergone thoracentesis successfully with ultrasound guidance and are asymptomatic with normal lung sliding postprocedure. 12) We recommend that novices who use ultrasound guidance for thoracentesis should receive focused training in lung and pleural ultrasonography and hands-on practice in procedural technique. 13) We suggest that novices undergo simulation-based training prior to performing ultrasound-guided thoracentesis on patients. 14) Learning curves for novices to become competent in lung ultrasound and ultrasound-guided thoracentesis are not completely understood, and we recommend that training should be tailored to the skill acquisition of the learner and the resources of the institution

Credentialing of Hospitalists in Ultrasound-Guided Bedside Procedures: A Position Statement of the Society of Hospital Medicine

Ultrasound guidance is used increasingly to perform the following 6 bedside procedures that are core competencies of hospitalists: abdominal paracentesis, arterial catheter placement, arthrocentesis, central venous catheter placement, lumbar puncture, and thoracentesis. Yet most hospitalists have not been certified to perform these procedures, whether using ultrasound guidance or not, by specialty boards or other institutions extramural to their own hospitals. Instead, hospital privileging committees often ask hospitalist group leaders to make ad hoc intramural certification assessments as part of credentialing. Given variation in training and experience, such assessments are not straightforward "sign offs." We thus convened a panel of experts to conduct a systematic review to provide recommendations for credentialing hospitalist physicians in ultrasound guidance of these 6 bedside procedures. Pathways for initial and ongoing credentialing are proposed. A guiding principle of both is that certification assessments for basic competence are best made through direct observation of performance on actual patients

Who Needs Inpatient Detox? Development and Implementation of a Hospitalist Protocol for the Evaluation of Patients for Alcohol Detoxification

BACKGROUND: Clinicians caring for patients seeking alcohol detoxification face many challenges, including lack of evidence-based guidelines for treatment and high recidivism rates. OBJECTIVES: To develop a standardized protocol for determining which alcohol dependent patients seeking detoxification need inpatient versus outpatient treatment, and to study the protocol’s implementation. DESIGN: Review of best evidence by ad hoc task force and subsequent creation of standardized protocol. Prospective observational evaluation of initial protocol implementation. PARTICIPANTS: Patients presenting for alcohol detoxification. INTERVENTION: Development and implementation of a protocol for evaluation and treatment of patients requesting alcohol detoxification. MAIN MEASURES: Number of admissions per month with primary alcohol related diagnosis (DRG), 30-day readmission rate, and length of stay, all measured before and after protocol implementation. RESULTS: We identified one randomized clinical trial and three cohort studies to inform the choice of inpatient versus outpatient detoxification, along with one prior protocol in this population, and combined that data with clinical experience to create an institutional protocol. After implementation, the average number of alcohol related admissions was 15.9 per month, compared with 18.9 per month before implementation (p = 0.037). There was no difference in readmission rate or length of stay. CONCLUSIONS: Creation and utilization of a protocol led to standardization of care for patients requesting detoxification from alcohol. Initial evaluation of protocol implementation showed a decrease in number of admissions

Ultrasound in the diagnosis and management of pleural effusions

We review the literature on the use of point-of-care ultra-sound to evaluate and manage pleural effusions. Point-of-care ultrasound is more sensitive than physical exam and chest radiography to detect pleural effusions, and avoids many negative aspects of computerized tomogra-phy. Additionally, point-of-care ultrasound can assess pleural fluid volume and character, revealing possible underlying pathologies and guiding management. Thoracentesis performed with ultrasound guidance has lower risk of pneumothorax and bleeding complications. Future research should focus on the clinical effectiveness of point-of-care ultrasound in the routine management of pleural effusions and how new technologies may expand its clinical utility. Journal of Hospital Medicine 2015;000:000–000.VC 2015 Society of Hospital Medicin