Weekly Updates - January 13, 2013

Sunday, January 13, 2013

From the Director

Hi everyone!

First, our condolences to Ryan Schulties on the Packers loss. I am not sure what he and Jason bet on the game, but hopefully a good time was had by all at the playoff party. Planning is beginning in earnest for the Annual Charity Auction....please contact Carling Ursem if you wish to donate any items to the charity auction, or if you know someone we should contact.  

Kudos this week go to Laura Musselwhite and Alex Fanaroff (and attending Susanna Naggie) for receiving the VA equivalent of a gold star - a wonderful letter from a patient's family. Additional kudos to Tara Weiselberg and John Stanifer on their SAR talks, and Hany Elmariah for a great chairs conference. Also congrats to Jen Rymer and Nick Rohrhoff who will represent us on the GME quality and safety council.

Yes, we are STILL in recruitment mode, so thanks also to those who are touring, going to dinner, chatting with the applicants at lunch and speaking at the end of the day. Also thanks to our faculty interviewers!

As you may recall, next year all residency programs must adapt to a milestone-based evaluation system. Many of you chose to participate in our resident portion of the evaluation "q-sort" where you prioritized the behaviors we will use to in your evaluations next year. Drs. Hargett, Arcasoy and I are almost finished analyzing the data and will have the first draft of the inpatient evaluation for everyone to see very soon. Dr. Cho and the team of ambulatory educators are working in parallel on the ambulatory version. We are excited to pilot the evaluation soon.  

SARs - don't forget to register for the ABIM exam.  Deadline to avoid the late fee is FEB 1.  Don't make this cost more than it already does!!! You should all have your ITE results by now - please see me or your advisor with any questions!   http://www.abim.org/exam/certification/internal-medicine.aspx

Ambulatory Care Leadership Track is here! Please see below and contact Alex Cho for more Info! 

Interested in Ambulatory Medicine?

The Ambulatory Care Leadership Track (ACLT), now in its first year, is recruiting for 2013-14.  Intended for those interested in primary care and other subspecialty areas that are primarily clinic-based, the ACLT offers residents additional ambulatory block time and clinical placements in clinical areas outside internal medicine, driven by individual interest and importance to practice in the outpatient setting.  ACLT residents also have additional didactic time, in Academic Half-Day and focusing on areas such as communication, advanced evidence-based medicine practice, and health policy and leadership.  The ACLT is open to rising JARs and SARs who are in good standing and have strong clinical skills, with the endorsement of the residency program director.  Kudos to current ACLT residents Kim Bryan, Jeremy Halbe, Lauren Prats, Leah Rosenberg, and Tara Weiselberg, for pioneering this concept as members of the inaugural cohort!  Interested residents should complete the attached interest form and send it to Alex Cho at alex.cho@duke.edu.”

This week's pubmed from the program goes to...Sam Horr Horr S, Roberson R and Hollingsworth JW, Respir Care. 2012 Jul 10. [Epub ahead of print]:  Pseudohypoxemia in a Patient With Chronic Lymphocytic Leukemia.

Have a great week!


QI Corner:

GME Incentive Program February Updates

Month 5 just in!  We continue to meet HCAHPS Patient Satisfaction for the year, but we remained a little off our mark for the month (Meet = 75%, P5 = 62.5%).  We are still excelling in CMS Evidence-Based Care Score (Meet = 94.4%, P5 = 96.96%).  We also remain a little off for our 30-Day Readmissions numbers (Meet = 12.94%, P5 = 13.85%).  Catheter Associated-Urinary Tract Infection remains a tremendous area for improvement (Meet = < 6 per year, Year to date = 19).  If the counting stopped today, everyone would receive an extra $400!  Stay tuned for a program-specific measure in 2013-2014.


The color-coding scheme is similar to that on the Duke University Hospital balanced scorecard.  The scheme helps us to understand how we are performing relative to peer academic medical centers.  Blue means we are performing at or above the top decile of our peer institutions.  Green means we are performing between the top quartile and top decile of our peer institutions.  Yellow means we are performing between the median and top quartile of our peer institutions.  Red means we are performing below the median of our peer institution.

1/16/13 MR PSQC 5p-6p in Med Res Library: Working Dinner Meeting on OSH Transfers

Do you love food?  Do you loathe transfers that arrive without any information?  Then this meeting is for YOUJoin us for dinner and get involved with improving our outside hospital transfer process.  This month, we will also be bringing you Dancing Skunks.  Please RSVP to George Cheely by clicking here by 5pm on 1/15 so we can ensure adequate sustenance.   You could be the next Quality Champion!  

George R. Cheely, Jr. M.D., M.B.A.

Duke Quality Scholar


What Did I Read This Week (by Jason Webb, MD )

[box]Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. NEJM 2013; 368:11-21.[/box]   

Why I Chose This Article: We frequently encounter patients with upper GI bleeding, and it is unclear what the evidence is for choosing a threshold for initiating blood transfusions. I was interested in determining how I could guide my decision making in when to consider initiating RBC transfusions for patients with UGIB, and how this decision will impact a patient’s survival and bleeding outcomes.

Background: Acute GI bleeding is a common medical emergency encountered by internists, and can be associated with high morbidity and mortality. UGIB is a condition frequently associated with the need for blood transfusions, which can be lifesaving. However, frequently the bleeding is not severe and parameters for deciding when to administer a transfusion are controversial. Thus, the study aimed at evaluating whether a restrictive strategy (Hgb 7) for RBC transfusion was safer (less death and re-bleeding) than a liberal transfusion strategy (Hgb 9).

Methods: Randomized trial at a single institution in Spain. Patients were age 18 or older, who had hematemesis, bloody NG lavage, or melena, and could consent to a blood transfusion. They excluded massive exsanguination, ACS, symptomatic peripheral vasculopathy, stroke, TIA, or transfusion within the previous 90 days, recent trauma or surgery, lower GI bleeding, and those deemed low risk for bleeding based on the Rockall score. The patients were randomized depending on the presence or absence of liver cirrhosis. The restrictive-strategy group had a threshold for transfusion of Hgb 7 g/dL, with goal of Hgb 7-9 g/dL, and the liberal-strategy had a transfusion threshold of Hgb 9 g/dL, with a goal of Hgb 9-11 g/dL. Each group was transfused one unit of PRBC and had the Hgb reassessed with an additional unit given if the target range had not been achieved. All patients underwent emergency gastroscopy within the first 6 hours of admission and were treated with epi and cautery. Patients with peptic ulcer bleeding were treated with a PPI infusion for 72 hours and those with suspected portal hypertension were treated with an infusion of somatostatin as well as prophylactic antibiotics for 5 days after admission.

Outcomes: The primary outcome was the rate of death within the first 45 days. Secondary outcomes included the rate of further bleeding and the rate of in-hospital complications.

Study Results: A total of 921 patients underwent randomization with 444 patients in the restrictive-strategy group and 445 in the liberal-strategy group for the intention-to-treat analysis. The baseline characteristics were similar in the two groups. A total of 31% had cirrhosis, and the baseline characteristics of the patients in this subgroup were similar in the two transfusion strategy groups. Bleeding was due to peptic ulcer in 49% and to esophageal varices in 21%.  A total of 225 patients (51%) in the restrictive strategy group, as compared with 61 patients (14%) in the liberal-strategy group, received no transfusion (P<0.001). The mean number of units transfused was significantly lower in the restrictive-strategy group than in the liberal strategy group (1.5°+ 2.3 vs. 3.7°+ 3.8, P<0.001), and a violation of the transfusion protocol occurred more frequently in the restrictive-strategy group (39 patients [9%] vs. 15 patients [3%], P<0.001). 

Outcomes Results: Mortality at 45 days was significantly lower in the restrictive-strategy group than in the liberal strategy group: 5% (23 patients) as compared with 9% (41 patients) (P = 0.02). The risk of death was virtually unchanged after adjustment for baseline risk factors for death. Among patients with bleeding from a peptic ulcer, the risk of death was slightly lower with the restrictive strategy than with the liberal strategy. Death was due to unsuccessfully controlled bleeding in 3 patients (0.7%) in the restrictive strategy group and in 14 patients (3.1%) in the liberal-strategy group (P = 0.01). The rate of further bleeding was significantly lower in the restrictive-strategy group than in the liberal-strategy group: 10% (45 patients), as compared with 16% (71 patients) (P = 0.01). The risk of further bleeding was significantly lower with the restrictive strategy after adjustment for baseline risk factors for further bleeding.

Limitations: The study was limited by excluding patients with low risk bleeding and those with severe bleeding who would benefit from early transfusion interventions, however, this study expands greatly on smaller studies which have shown promise with a more restrictive transfusions strategy. Important to remember in this study is that all patients underwent emergent endoscopy and were treated endoscopically for acute bleeding, as well as with somatostatin analogues for variceal bleeding. Thus the restrictive strategy used in this study would only hold such benefit for patients treated in the same manner.

Conclusions: The study found that a restrictive transfusion strategy (Hgb of 7 g/dL), as compared with a liberal transfusion strategy (Hgb of 9 g/dL), decreased mortality among patients with acute upper gastrointestinal bleeding. The risk of further bleeding, the need for rescue therapy, and the rate of complications were all significantly reduced with the restrictive transfusion strategy.

Overall, this study will likely continue to lend greater support to the practice of using a threshold of 7g/dL for initiating RBC transfusions for confirmed upper GI bleeding treated with endoscopic management. 


From the Chief Residents

Grand Rounds

Date Speaker
18-Jan-13 Dr. Whitfield: Genes Impact Health Disparities? I Don’t Buy It.

Noon Conference

Day Date Topic Lecturer Time Vendor
Monday 1/14 INTERVIEW   12:00 Nosh
Tuesday 1/15 SAR talks Kathleen Kiernan, Ivan Harnden 12:00 Bullock's BBQ
Wednesday 1/16 Schwartz Rounds Lynn O'Neill, Lynn Bowlby 12:00 Saladelia
Thursday 1/17 SAR talks Nilesh Patel, Sahar Koubar 12:00 Chic-fil-A
Friday 1/18 INTERVIEW   12:00 Panera


Annual Charity Auction !!!

If you have not attended this event in the past you are missing a GREAT opportunity to bid on an awesome selection of items.  You also get to help TWO great programs -Senior PharmAssist and patients seen at the Duke Outpatient Clinic

When:  Friday, February 15 staring at 7:00

Where:  The Durham Arts Council

Drink tickets and heavy hors d'oeuvre all night!  This is always one of the most fun events of the year. Don't miss Dr. Galanos as emcee for the live auction!

Tickets to go on sale soon.  $20 prior/$25 at the door


From the Residency Office

Procedures / Mini-CEX

Reminder to closely monitor and update your procedure logs.  ABIM requires documented completion of the procedures listed on the following attachment prior to completion of training:

Procedure and Mini CEX Requirements

This year all residents are also required to request faculty observe and complete 3 mini-CEX's in BOTH the inpatient and outpatient setting.

Management and Leadership Pathway for Residents (MLPR)

The Management and Leadership Pathway for Residents (MLPR) will hold an information session for interested residents on Thursday, January 24, from 5:30 – 6:30 in the Faculty Center (in the Library, just off the walkway between the Hospital and Clinics).  Dr. William Fulkerson, Chief Executive Officer, Duke University Hospital and MLPR Program Director, and current residents and faculty will be available to answer questions about the program.  

MLPR is designed for residents who hold advanced management degrees (MBA, MPH, MPP) or a minimum of two years management experience who are interested in future careers as physician executives


Recruiting Dinners and Tour Guide

If you haven't done so already, PLEASE sign up for a Recruitment Dinner and/or to be a Tour Guide on a Recruitment day!  



Contact Information/Opportunities

 Virginia Commonwealth Hospitalist fin

Upcoming Dates and Events

February 1:  CELEBRATE THE END OF RECRUITMENT!! ( IM Residents and staff)

February 13:  Duke/ UNC Game at Motorco

February 15:  Annual Charity Auction, 7 PM at the Durham Arts Center

March 15:  MATCH DAY CELEBRATION at Dr.  Klotman’s!

 April 28:  2nd Annual Stead Tread

Useful links