From the Director
Two weeks till the new interns show up for orientation….we start medicine orientation on June 26, with "shadow day" on the 30th…it will be here before we know it.
This past week was a pretty rough week for the Zaas house, but a really good reminder of what a fantastic family we are here in the IM residency. To be honest, I wasn't sure if I should bring this up in the Med Res News, but it has been a tremendous help to have support from you all that I thought I should. Many thanks to all, and special thanks to
Erin, Randy, Jen, Lynsey and Lauren; to Jon, Bill, Murat, Lish, Alex, Sharon, Diana, Lynn and Dave B, and to Bobby Aertker, Nancy Lentz, Tyler Black, Carling Ursem, Brice Lefler, and Rajiv Agarwal, to Alyson McGhan, Kevin Trulock, Marc Samsky, Hany Elmariah, Bronwen Garner Alex Fanaroff, Matt Hitchcock, Stephen Bergin, Joel Boggan, and Vaishali Patel, and also Tom Holland and Tony G. Very very grateful for you all!
First kudos of the week goes to
VAISHALI PATEL for her amazing grand rounds! Great work Vaishali. Also congratulations to our award winners and nominees…
Best SAR Talk Awards to
Rebecca Sadun, Lauren Porras and Alex Fanaroff (nominees were: Alex Fanaroff, Lauren Porras, Rebecca Sadun, Kevin Shah, Christopher Hostler, Meredith Clement).
The
Stead Teaching Award went to the much deserving
Lou Diehl (
nominees were: Kevin Harrison, Joe Govert, Lou Diehl, Chris Woods, Saumil Chudgar, Dave Butterly, Rich Riedel, Joe Rogers).
The
VA Teaching Award went to an equally deserving
Micah McClain (nominees were: Ken Lyles, Chris Woods, Micah McClain, Eugene Oddone, Marie Carlson, Ralph Correy).
Kudos this week go to
Murat Arcasoy for putting together a FANTASTIC resident research night. Loved seeing all the posters, and we had plenary level talks from
Laura Musselwhite, Mandar Aras and Alex Fanaroff. The Poster awards were for
Nina Beri (Research) and Tim Mercer (QI).
Dr. Dzau was there too! Thanks to all the faculty who support our residents in their research, and to all who presented and attended. We have a great write up in Medicine News, so check it out!
Best Grand Rounds went to
Dr. Frank Neelon (nominees included Susanna Naggie and Carl Berg) and the
Research Mentor Award to
Brice Weinberg (
nominees Jon Bae, Amy Abernethy). Other kudos to
Amanda Elliott for her chair's case, with
Audrey Metz getting the diagnosis! Kudos as well to
Hany Elmariah who has gone above and beyond to help his fellow SARs get their last remaining procedures logged.
Another Kudos goes to
Jon Bae whose hilarious use of the confidential comment line caused Randy's blood pressure to go up 15 points. I think someone has a picture of Randy trying to strangle Jon when he found out that it was a joke that residents were requesting Hot Pockets in the snack basket, and a DVD player in the call room. Nicely played, Jon. However, we do always welcome suggestions or concerns in the confidential comment line, found at the end of the weekly updates and a link on medhub.
Reminder to all who round on the 8th floor…
WE CANNOT LEAVE ANY PHI in 8200! Really, we shouldn't be leaving it anywhere, but an unsecure location is even more dangerous. Please always remember to recycle any papers with PHI in the designated shred bins. If you don't need to print it, don't print it. If you need to print it, recycle appropriately when you are done.
This week's pubmed from the Program goes to
Nick Rohrhoff and Joel Boggan for their article in JAMA's "Too Much Medicine" series..
JAMA IM - A Double Whammy - 2014
Have a great week, and please be sure to make it to Grand Rounds for Krish Patel!
Aimee
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What Did I Read This Week?
Rate and Rhythm-Control Therapies in Patients with Atrial Fibrillation: A Systematic Review. Ann Intern Med 2014; 160(11):760-773. Al-Khatib SM, Allen LaPointe NM, Chatterjee R, Crowley MJ, Dupre ME, Kong DF, Lopes RD, Povsic TJ, Raju SS, Shah B, Kosinski AS, McBroon AJ, Sanders GD
submitted by: Joel Boggan, MD
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Why did I read this?
This article was just used as part of the real-time Morning Report twitter feed series by the @MedChiefs account from the University of Chicago. When I clicked on the article, I saw it was from Duke, and, combined with the fact that this topic comes up repeatedly on our general medical and cardiology services, I kept reading.
What is the question?
The authors sought to determine the comparative safety and effectiveness of different rate- and rhythm-control strategies for patients with atrial fibrillation.
What did the authors do?
The authors performed a systematic review of RCTs of pharmacologic and nonpharmacologic strategies in adults with AF. They also looked at observational studies of strict vs. lenient rate control strategies and cardiac resynchronization therapy vs. other rhythm-control strategies. Outcomes were restoration of sinus rhythm (conversion), maintenance of sinus rhythm, recurrence of AF at 12 months, development of cardiomyopathy, death (both all-cause and cardiac), MI, CV hospitalizations, HF symptoms, control of AF symptoms, QOL, functional status, stroke and embolic events, bleeding events, and adverse events related to therapy. When more than 3 studies were published for a particular outcome, a meta-analysis was performed, when possible.
Importantly, when looking at the rate- vs. rhythm-control strategies, they grouped all rate and rhythm control strategies together, regardless of class. So, CCBs and BBs were grouped together for rate control. Similarly, they lumped procedures (cardioversion, AV node ablation, pulmonary vein isolation, etc.) together for comparisons against medical therapies, although they did investigate the different procedures individually against one another. They also reported on a set of studies comparing different procedural interventions, but I’m not commenting further on these analyses here.
What did they find?
From a group of 10,495 abstracts and 570 articles, the authors identified 200 articles from 162 studies that involved 28,836 patients. I’m showing you a subset of their analyses, so there are others available in the article.
Rate vs. rhythm strategies
For rate- vs. rhythm-control analyses, 16 RCTs were identified. Thirteen of these articles compared different pharmacologic options, while three compared pulmonary vein isolation with rate-control meds +/- an AV node ablation. The meta-analysis done for 10 of these studies showed moderate strength of evidence that pharmacologic rate- and rhythm-control strategies are of comparable efficacy with regard to their effect on all-cause mortality (odds ratio [OR], 1.34 [95% CI, 0.89 to 2.02];
Q = 21.71;
P = 0.003), cardiac mortality (OR, 0.96 [CI, 0.77 to 1.20];
Q = 3.55;
P = 0.47), and stroke (OR, 0.99 [CI, 0.76 to 1.30];
Q = 7.02;
P = 0.43).
Procedural vs pharmacologic rate control
Six studies compared a procedural vs. a pharmacologic intervention for rate control, and, in the three studies in the former category that reported outcomes at one year, heart rates were lower in those who received an intervention vs. a medication.
Medications for ventricular rate control
Sixteen studies also assessed effectiveness of ventricular rate control by pharmacologic means, where benefit was shown in reducing tachycardia-induced cardiomyopathy, HF, and MI and improving QOL with studied medications. However, the permutations of medications used within the studies made it impossible to conclude whether one medication class (BBs, CCBs, amio, digoxin) was safer or more effective than others at controlling ventricular rates.
Strict vs. lenient rate control
Only one high quality RCT and two observational studies looked at a strict vs. lenient rate control strategy, and the small size of these studies and the imprecision of their findings made it difficult to determine any statistically significant difference in any endpoint between these two strategies.
Pulmonary vein isolation vs. antiarrhythmic medications
One additional procedural series of results I will comment on was the 9 RCTs highlighting pulmonary vein isolation vs. antiarrhythmic medications for rhythm control. Data from these trials provide high strength of evidence that rhythm control using pulmonary vein isolation is superior to antiarrhythmic medications in reducing recurrent AF over 12 months of follow-up (OR, 5.87 [CI, 3.18 to 10.85];
Q = 33.82;
P < 0.001), particularly in younger patients with little or no structural heart disease and no or mild left atrial enlargement.
What can we conclude?
1) In older patients with mild symptoms from AF, rate-control and rhythm-control strategies using medications are similarly efficacious for mortality endpoints and stroke, at least for the first few years of therapy.
2) Pulmonary vein isolation is superior to antiarrhythmic medications at preventing AF recurrence in younger patients without structural heart disease.
3) Few studies have compared different rate control medications for significant outcomes.
Further work is needed to determine longer-term (beyond 4 years) outcomes of rate vs. rhythm strategies, as there is a signal that rhythm control may lead to decreases in mortality beyond five years. Additionally, work should focus on different rate-control medications and their effectiveness and safety to determine a preferred group in specific groups of patients.
How can this apply to your practice?
When encountering patients with AF in the clinic or on the wards, decisions about treatment can be directed by the patient’s age and comorbidities. If the patient is older or has more medical comorbidities that may limit longevity, one could pursue either a rate or rhythm strategy without a specific heart rate target. If the patient is younger or has fewer medical problems that may limit longevity, a referral to EP may be warranted for consideration of pulmonary vein isolation or other procedures.
QI Corner (Joel Boggan, MD)
Hand Hygiene
After a long several months of work by our fabulous hand hygiene champions, all their (and your) hard work has paid off! Here are the data through May . . . congrats on reaching our goal!
| Month |
Location |
Observations Last 30 days |
Compliant Last 30 Days |
Non-Compliant Last 30 days |
HH Rate last 30 days |
| Jan |
7100 |
8 |
8 |
0 |
100% |
| Jan |
7300 |
6 |
6 |
0 |
100% |
| Jan |
7800 |
18 |
18 |
0 |
100% |
| Jan |
8100 |
6 |
5 |
0 |
84% |
| Jan |
8300 |
4 |
3 |
0 |
75% |
| Jan |
9100 |
4 |
4 |
0 |
100% |
| Jan |
9300 |
5 |
5 |
0 |
100% |
"Clinic Corner" Pickett Road, submitted by Dr. Rubin and DOC by Daniella Zipkin
First up:
Duke Outpatient Clinic: "Hey guys, there is a brand new DOC Newsletter hot of the presses - check it out here!!"
DOC Newsletter 2014 June
Next: A lot of information shared by Dr Rubin regarding
Pickett Road
Thank you to the SARs for the two Candy dispensers. The key is to turn the button on (in the back) then put your hand under the dispenser, and then turn it off! Or else there will be M&Ms everywhere!
Download EPIC Haiku- this will CHANGE your life! Really and you can use this in patient.
- 1. MUST be in Pickett Clinic (or in hospital) LOG into CLUBS
- 2. Go to Maestro.duke.edu
- 3. Go to maestro Care Mobile Apps: Learn more about apps on your mobile device
- 4. Maestro Care Mobile Device Support
- 5. Configure: clic on Haiku Configuration
- 6. Log into Epic Haiku and you can take patients pictures strange rashes, look at your schedule and inbasket
Just a reminder to residents and providers that lab
testing stops at 4:30 each day. The lab will continue to draw until 5:15. The tech uses the last 30 minutes of her shift to finish testing already received, perform shutdown of instruments and run daily reports.
Re: Home Health face to face encounters
Recently we have had some of our home health referrals get rejected for payment. The main reasons for the rejections are-
#1- Homebound reason states-"transportation reasons". The quality improvement examiner is kicking out all transportation statements.
#2- Submitting the face to face encounter out of the time frame. It is taking almost 2 months for the face to face encounter to be completed.
Please see the below note from the quality improvement examiner:
Also, we
cannot use transportation as a reason for the patient to be homebound. Medicare will deny the claim.
Homebound reason must include
clinical documentation that supports the reason the patient is homebound.
EXAMPLE: It is a taxing effort for patient to leave her home without the assistance of another person due to her cognitive impairment from schizoaffective disorder. She also requires the use of a rollator walker for safe ambulation.
Thank you to
Edva, Bassem, Alan, Audrey and Howard for coming to the town hall. I know that many of you could not make it to the meeting. These are notes from the meeting.
I asked: how to make intern orientation better
- - FOR THE SARS- request for the handoff list to be typed (I am happy if it is just complete) and give to Sharee- ideal to give at orientation not at first day of clinic
- - focus more on EPIC, writing a note, sharing dot phrases
- - still unsure if I should share my favorite orders as this mixes with inpatient orders
- - having the DPC handbook as a reference (This year the book with be printed with all the other guides)
- - encourage them to use templates (steal templates) and use notewriter
- - good to have staff pictures in the resident room
- - try to make quest more check off, not need signatures
- - explain about Acute visit (do no have to address HCM), control of session: limit pt to 1-2 complaints
- - explain about attending pt acutes, post hospitalization visit
- - STAT referral- walk to Danielle or Natasha
- - try to train intern and their patients for 20-30 minute visit, not 1 hour. The template is set so they see 2,2,3,4 patients (first of 4/7 slots then 5/7 slots 2nd half of year)
- - need to train interns how to use inbasket earlier
Questions/answers
- 3 orders: give pt phone number to call (can steal from me)
- 1. Mammogram .srmammogramorbonedensity
- 919-684-7999 to call for Mammogram or bone density appointment at Duke
- 2. DEXA .srmammogramorbonedensity
- 919-684-7999 to call for Mammogram or bone density appointment at Duke
- 3. Colonoscopy .srcolonoscopynumber
Your referral to GI for your colonoscopy/EGD has been ordered and is available the hospital computer system. Please call GI directly to schedule your colonoscopy. The scheduling number is 919-684-6437. They will help you set up your colonoscopy at your convenience and discuss with you the locations that are available.
- I looked up the Rocky Mount Spotted fever: its under LAB6815
- Sorry DPC does not have a social worker. I agree switch to DOC, Jan Dillard is there.
- Pickett Home health: .pickettHH is the dot phrase to put into your note ESP if you put order in for home health
- Consider earlier in the year party- Christmas party at Dr. Peyser house great way to meet the staff
- Laura and Wendy have been able to complete their transition list (95 and 70 patients) in one admin session. This can be done!
Thank you! Sharon Rubin
From the Chief Residents
Grand Rounds
Presenter: Dr. Krish Patel
Duke Chief Resident Grand Rounds
Noon Conference
| 6/9 |
Global Health Gallops |
Aras / Dhawan / Papademetriou / Tolan |
12:00 |
Subway |
| 6/10 |
SAR TALKS |
Bedoya / Elliott |
12:00 |
Saladelia |
| 6/11 |
MSK Exam Part 4 |
Irene Whitt & Lisa Criscione |
12:00 |
Cosmic Cantina |
| 6/12 |
HVCC Conference |
George Cheely |
12:00 |
Chick-Fil-A |
| 6/13 |
Chair's Conference |
Chiefs |
12:00 |
Domino's |
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From the Residency Office
Visiting Professor Lecture sponsored by Duke AHEAD
Who: Charles Prober, MD
When: June 10, 2014; 5 - 6
Where: Trent Semans Center 2nd floor
Make sure and let Kristen know if you are attending by emailing her at
DUKEAHEAD@dm.duke.edu
Thank you.
Charles Prober Announcement
Information/Opportunities
Upcoming Dates and Events
-
June 13: ACLT year end celebration
- Intern Welcome Celebration: June 27 @ the PIT
Useful links
