Internal Medicine Residency News, September 2, 2014

By residency1

From the Director

DUKE.RESEARCH.NIGHT.03 (1)Hello! Happy September! I hope everyone had a chance to enjoy some part of the long weekend.  We had a number of fun events this week, starting with the attendings beating the residents at Stead Trivia Night at Bull McCabe's.  Thanks Steve Crowley and the Warren Society for planning, and to the many attendings and residents who showed up! A number of our residents were able to meet with the newly appointed Secretary of Veteran's Affairs, Robert McDonald – thanks to Ashley Bock, Aparna Swaminathan, Nick Rohrhoff, Chris Hostler, Coral Giovacchini, Tim Mercer, Katie Broderick and our Psychiatry colleague Nora Dennis for spending time discussing GME with our special guest.  Attendance at Grand Rounds was outstanding, and I hope you all had a chance to hear his inspirational talk.  Ragnar Palsson followed the outstanding grand rounds with a fantastic chair's conference, proving once again that all that causes active urine sediments and renal failure is not Wegener's.  Brice Lefler, Sneha Vakamudi, and Tim Mercer helped lead us along to (close) to the diagnosis.  Hopefully many of you also saw Dr G as the honorary Duke football coach this weekend as well! Kudos also this week to Rajiv Agarwal from fellow night float resident Alan Erdmann for a great diagnosis and patient care, and to Alan Erdmann from Lish Clark for outstanding notes on night float! Additional big thanks to our outgoing ACRs Aparna Swaminathan, Tim Mercer (with a Med Res News hat-trick this week!) and Alyson McGhan for being PHENOMENAL ACR's! Aparna helped revolutionize DRH AM report, Tim worked to improve our notes at the VA, and Alyson kept busy helping figure out the admission patterns on gen med so that we can optimize daytime admissions for the teams.  We look forward to having Kevin Trulock, Adam Banks and Claire Kappa at the helm!  Also kudos to the MICU Crew — Jonathan Buggey, Jonathan Hansen, Jason Zhu, Adva Eisenberg, Amy Lee and Myles Nickolich from MICU fellow Talal Dahhan for outstanding work. Congratulations to Lauren Ring, Jenny Van Kirk, Jon Musgrove and Azalea Kim who were elected by their peers to the Residency Council.  Looking forward to working with you all.  Also congrats to Adrienne Belasco and Mitch Klement on their wedding this weekend! This week kicks off our In Training Exams! Be on time, be relaxed, and for the first time, you can forget to bring a #2 pencil.  Welcome to the new age…tests are on campus in the computer labs.  Thanks to Jen Averitt, Lauren Dincher, Erin Payne and Lynsey Michnowicz for proctoring.  We also had the opportunity to turn in our "APEI" (that's GME talk for Annual Program Evaluation and Improvement Plan) to Dr. Kuhn and her team this week.  This is an annual document that we prepare for the GME leadership that describes our educational efforts for the past year and what we would like to do next year.  We will post our progress and plans for you to view on Medhub – this year we are working on our EDUCATIONAL ENVIRONMENT (more on our "Back to Basics" curriculum overhaul soon), our AMBULATORY TRAINING (thanks Dani, Alex, et al for your work on the curriculum, noon conferences, and improved scheduling continuity) and our TRANSPARENCY (let us know other ways to reach you with program details in addition to the Med Res News, before conference, and in conversation). This week's first Pubmed from the Program goes to Adva Eisenberg for her upcoming presentation at the Southern Hospital Medicine Conference in Atlanta…“Fool Me Twice: A Case of Recurrent Bacterial Meningitis due to a Spontaneous CSF Leak” Adva Eisenberg, MD1, J Bradford Bertumen, MD2, and Gary Cox, MD2 Second Pubmed: Ryan Nipp, Aaron Mitchell, Allyson Pishko, and Ara Metjian. "Waldenstrom Macroglobulinemia in Hepatitis C: Case Report and Review of the Current Literature," Case Reports in Oncological Medicine, vol. 2014, Article ID 165670, 2014. http://www.hindawi.com/journals/crionm/2014/165670/ Have a great week! Aimee [divider] [box]

What Did I Read This Week?

submitted by: Coral Giovacchini , MD

Reference:Rubin, LG and Schaffner, W. Care of the Asplenic Patient. N Engl J Med 2014; 371: 349-356.

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Over the past few weeks, the care of asplenic patients has come up several times in sign outs, VA case conferences, and even alluded to during our recent SAR Emergency Lecture series and a Chair’s Conference Case this past month. This clinical practice review was recently published in the NEJM and is a nice summary of the clinical conundrum, treatment guidelines and management considerations in such patients. Clinical Problem Current estimates suggest that there are approximately 1 million total asplenic patients treated currently in the United States. In the article, the authors urge readers to consider the fact that the asplenic population is quite heterogeneous, including not only the typically thought of surgically asplenic patient, but also those with functional asplenic/hyposplenia seen in conference with diseases that we often treat at DUMC/DVAMC including sickle cell anemia, congenital heart disease (i.e. Ivemark Syndrome), untreated HIV, severe celiac disease, and even chronic GvHD. One of the main concerns in caring for these patients is the risk of “post-splenectomy sepsis”, which can carry up to a 50% mortality risk for all-comers, though generally is more fatal is surgically asplenic patients, and has been found to be an independent risk factor for hospitalization for pneumonia or meningitis in military veterans. The pathophysiology behind increased risk of sepsis includes impaired clearance of IgG-coated encapsulated bacteria from the blood stream (remember these are not opsonized as well!) and an overall decreased humoral immunity with lower levels of serum IgM antibodies as well as a lower number of memory B cells to produce IgM. The pathogen classically associated with post-splenectomy sepsis is S. pneumoniae; however other organisms to be considered include H. influenzae b, N. meningitidis, Capnocytophagia canimorsis (after a dog bite), Bebasia (after a tick bite), and Bordatella holmesii. Despite the classical teaching, the most common organisms isolated from adults with bacteremia and underlying functional asplenia from sickle cell disease continue to include gram negative bacilli and S. aureus, often associated with indwelling catheter use. Clincal Strategies There are many areas of uncertainty that remain in the clinical treatment of asplenic patients, including the role of vaccination boosters, the role of prophylactic antibiotics, appropriate empiric antimicrobial treatment strategies and the role of screening for functional asplenia in associated diseases. The most important strategies in our clinical armatorium remain prevention, education, and the early and appropriate treatment of the signs of infection. In 2000, the heptavalent pneumoncoccal conjugate vaccine (PCV7) was introduced, and has markedly reduced the incidence of invasive pneumococcal disease not only among children, but also within the entire US population, presumably via a herd immunity theory. Following this, the triskaidecavalent (PCV13, or Prevnar13) was introduced in 2010 with further reductions in pneumococcal disease in this patient population. Current recommendations for this population are to give PCV13, followed by PPSV23 8 weeks later (this is slightly different after surgical splenectomy, with a recommendation to wait at least 2 weeks after the operation prior to administering PPSV23; CDC.gov has a very comprehensive table on timing of these immunizations). All patients in this population are recommended to get a PPSV23 booster at a sequential 5 year interval. Other immunizations that are recommended including the Hib vaccine for those who were not immunized in childhood, the quadrivalent meningococcal conjugate vaccine (MenACWY), as well as an annual influenza vaccine. With regards to antimicrobial prophylaxis, although this is recommended for all asplenic children <5 years old, this is not necessarily true for adults, and various organizations have published differing guidelines with suggestions ranging from no need for prophylaxis to a call for lifelong penicillin prophylaxis in all persons with surgical asplenia. Though there is not a clear consensus, adults in whom prophylaxis is generally recommended include any patient who has previously survived an episode of post-splenectomy sepsis, or any surgically or functionally asplenic adult who suffers a dog bite (given the risk of C. canimorsus). Once a patient with known asplenia presents with a fever or other localizing signs of infection, prompt initiation of appropriate antimicrobial therapy is warranted (recommendations range from outpatient oral penicillin based regimen to IV 3rd generation or higher cephalosporins- most commonly ceftriaxone) with a goal of covering the above-mentioned organisms. Consideration can be given to adding vancomycin for additional MRSA coverage in the appropriate patient populations (i.e. your patients with indwelling lines, frequent healthcare access, etc), or if CNS disease/infectious meningitis is a concern. Interestingly, because of the high risk of progression to fulminant sepsis, many outpatient care providers have taken the strategy of providing a standing empiric antibiotic prescription for these patients to have available at the first sign of fever or infection.   Summary
  • Remember that “asplenia” can take several forms, including congenital, surgical and functional (i.e. our sickle cell patients!)
  • The clinical presentation of asplenic sepsis can be profound and carries up to a 50% mortality risk
  • Asplenic patients should be educated that any illness with fever or other localizing signs of infection needs prompt medical attention, and likely should receive prompt initiation of antimicrobial therapy (possibly even self-initiated in the outpatient setting)
  • Always be sure to cover encapsulated organisms in patients presenting with asplenic sepsis, with special attention to other environmental risk factors (i.e. dog bites)
  • All asplenic patients are recommended to have vaccinations against pneumococci, H. influenzae b, meningococci, as well as an annual influenza vaccine
  • Strongly consider lifelong prophylactic antimicrobial therapy in any adult having already survived an episode of asplenic sepsis with a typical organism
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QI Corner

[caption id="attachment_16361" align="aligncenter" width="148"]Aaron Mitchell, MD Aaron Mitchell, MD[/caption] Just a reminder to everyone: our next Morbidity and Mortality noon conference will be coming up on Wednesday, September 17. We are going to change the format this time, and present cases of procedure-related mishaps. But - we need the cases to come from you! Have you ever hurt yourself or had a preventable blood exposure during a procedure? Caused a patient unnecessary discomfort by making an easy mistake? Had a bad complication you would like to share? Let us know! You do not have to present if you would feel uncomfortable, and the case can remain annonymous if you would like. - Aaron and Lish [divider]

From the Chief Residents

Grand Rounds

Fri., Sept.5, 2014: Dr. Richard Reidel, Oncology

Noon Conference

Date Topic Lecturer Time Vendor
9/2/14 SAR Emergency Series: Pneumonia/Debriefing Titerence/Galanos 12:15 Dominos
9/3/14 SAR Emergency Series: Common HIV Management Questions Brice Lefler 12:15 Cosmic Cantina
9/4/14 SAR Emergency Series: Endocrine Emergencies Claire Kappa 12:15 Subway
9/5/14 ITEs - No Conference Chick-Fil-A
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From the Residency Office

 

ITEs Start This Week!

Friday, September 5th marks the first testing date for the ITEs!  House staff - please check your Amion to know what date you are scheduled to take the exam.  As a reminder, the exams are being administered electronically this year!  Please be sure to review the information below and contact Jen Averitt in the MedRes office if you have any questions.  Good luck!! The following is important information – PLEASE REVIEW CAREFULLY BEFORE your test date!
  • Please take a few minutes to take a practice test at http://acp.startpractice.com  Please try and practice BEFORE 9/2/14 as the test may become unavailable after the national testing window opens
  • The testing center is located at 406 Oregon St, Lab 101, Durham  There is free parking in front of the building
  • Please be at the testing center NO LATER THAN 8:00 am on test day!!
  • There is no food allowed inside the testing room, but a boxed lunch will be provided for you in the building.  You will be allowed a 30 minute lunch break.
If you are unable, for any reason, to make your test date, YOU MUST CONTACT EITHER JEN AVERITT OR A CHIEF RESIDENT AS YOU WILL NEED TO HAVE YOUR TESTING DATE RE SCHEDULED!

ETHOS for Noon Conference Attendance Tracking!

After much work with the wonderful folks in the ETHOS offices, as of September 2, 2014 we will be able to track Internal Medicine Noon Conference attendance using the ETHOS system.  From September 2-5, we will continue to use the old badge swipe system in addition to ETHOS so everybody can get used to the process, but as of 9/8/14 we will ONLY use ETHOS for tracking attendance.  Most of you should already have an ETHOS account which you use for tracking your attendance at Grand Rounds, but EVERYONE should read the following instructions carefully, as it applies to new and current account holders.  you MUST have your Duke Unique ID entered in to you ETHOS account in order for the system to work properly! How do I Set up an ETHOS account for the first time? How to register with Ethos
  • Go to the Duke Continuing Medical Education home page.
  • In the upper right corner, click Join. The Account Information page opens.
  • Complete the fields on the screen. A field with an asterisk is required.
  • NOTE:  Please make sure you include your Duke Unique ID– even though it does not show as a required field.
  • Be sure to include your mobile phone number; you will use this number to send a text message with a code supplied at each event and get credit for CME events you attend.
  • At the bottom of the account information form, click Create New Account. A green feedback message near the top of the screen informs you that a confirmation has been sent to the email address you provided.
  • Open the email (from dcri.cme@dm.duke.edu) and click the top link in the body of the message.
  • In your browser window, enter a password of your choice in both fields and note your user name. Click Save at the bottom of the page.
  • In the same window, click the Mobile settings tab in the gray menu bar at the top of the page. If you entered your mobile number when you registered, it should appear on this page. Click confirm number. You will receive a text message to that mobile number with a confirmation code from DCRI CME.
  • Enter the confirmation code in the box in your browser window and click Confirm Number. A message will appear below your number saying “Your number has been confirmed.”
  • Now when you attend an event for CME credit you can use your registered mobile phone to text the provided event codes and earn CME credit.
To record your CME attendance via text message, follow these steps
  • The 6-character SMS code will be provided on a slide during your CME event.
  • Begin a new text message on your registered mobile phone. Note: The provided code is only good for eight hours. You must text the code the day you attend Medicine Grand Rounds.
  • In the To field, enter the Duke CME phone number: 919-213-8033. Tip: Add this number to your mobile phone contacts.
  • In the message area, type the 6-character SMS code that was provided during the session (note: this code is not case sensitive).
  • Press send.
  • If you have set up your Ethos account, you will receive the successful confirmation text message, “Your attendance has been recorded for “[Name of Session].”
To add your Duke Unique ID to your account
  • Log into Ethos by visiting the Duke Continuing Education home page and click Log In at the top right of the page.
  • Enter your username and password. Click My Account in the upper right corner.
  • Under My Profile, click Edit
  • Scroll down until you see Duke Unique ID filed.  make sure it is correct
  • Save the changes to you My Profile page

Recycle Your Old Batteries

In an effort to further our “Go Green” initiative, we are now recycling batteries! We have a dead batteries collection box in the Med Res office (Duke North, Room 8254) so please feel free to bring in your dead batteries and we are happy to recycle them for you.  For more information click here.

Flu Vaccination Season 2014

As you know, Duke University Health System (DUHS) requires all healthcare workers who perform their duties in a DUHS facility or a community home-based setting to be vaccinated annually against the flu. This is in alignment with our core value of “caring for our patients, their loved ones and each other.” Annual vaccination against influenza, or policy compliance through a granted medical or religious exemption, is a condition of employment for all DUHS employees. Annual vaccination or policy compliance is also a condition of access to Duke Medicine facilities for those holding clinical privileges in a Duke Medicine facility and learners who wish to train in our facilities. With this in mind, please note these key dates for this flu vaccination season:
  • Start of Flu Vaccination Season: Thursday, September 18, 2014
  • Applications for Medical or Religious Exemption should be submitted before Friday, October 17, 2014.  This will allow sufficient time for review and for communication of the review decision. Please note: Due to the availability of an egg-free formulation of the flu vaccine, egg allergy will no longer be a valid reason for a medical exemption.
  • Policy compliance through vaccination or granted exemption by Monday, November 17, 2014
We will kick off our annual flu vaccination campaign with a 24-hour Duke Medicine Mass Flu Vaccination drill. The drill will begin on Thursday, September 18, 2014. Mass vaccination clinics will be available at each of the hospitals with peer vaccination available throughout DUHS. Following the drill, we will begin our annual flu vaccination program, during which time we will provide many additional opportunities for you to get vaccinated. A schedule of vaccination clinics is posted on the employee intranet at https://intranet.dm.duke.edu/influenza/Lists/Calendar/calendar.aspx.  This list will be updated throughout the flu season. Vaccination is also available at Employee Occupational Health and Wellness (EOHW) during business hours. If you have questions about the flu vaccine or its availability, please visit the DUHS Influenza Resource Guide or duke.edu/flu, ask your manager or contact EOHW. Together, we can stop the flu. Thank you for your commitment to keeping our patients, and our community, safe and healthy.  

Now Accepting Applications for Global Health Elective Rotations

The Hubert-Yeargan Center for Global Health (HYC) is now accepting applications for Global Health Elective Rotations for July 2015 and March 2016. Application is open to residents from the Departments of Medicine and Pediatrics: Internal Medicine (PGY 2); Med-Peds (PGY 3); Med-Psych (PGY 4); Pediatrics (PGY 2). The application is attached and available at http://dukeglobalhealth.org or submit online http://bit.do/HYC-submit. (Application addendum is available by request – tara.pemble@duke.edu). Interviews will be held in October. For more information about this opportunity, contact Tara Pemble, Program Coordinator at tara.pemble@duke.edu or 668-8352. Application Deadline: September 30, 2014

What is the GME Incentive Program?

The GME Incentive program was started July 2012 as a collaboration between hospital, GME, and Internal Medicine program leadership in order to:
  • Engage trainees in hospital-based quality improvement
  • Provide exposure to models of pay for performance
  • Educate trainees in quality improvement
  • Provide a focus for ACGME program requirements and CLER visits
Each year, residents and hospital leadership select 3-4 measures at the hospital level. These typically mirror the priorities of the overall health system, with the targets for each specific measure based on prior performance data and also aligned with hospital targets (top quartile performance meets and top decile performance exceeds target). For each target met, trainees are paid $200, for a maximum payout of $600. Who is eligible? All GME ACGME or ICGME trainees who have worked for at least 3 months leading up to June 2015. What are the measures for this year (2014-2015)? This year, with resident and leadership input, the following 4 measures have been selected:
  1. HCAHPS Patient Experience Measurement
  2. 30-day same hospital readmissions
  3. Emergency Department Median Consult Time (NEW)
  4. RL-6 Safety Event Reporting (NEW)
What is the reasoning behind these measures? What are the targets?
  1. HCAHPS: As all hospital systems continue to improve, the standards for patient satisfaction will continue to rise as well. Target: Meet the National Median of 87.5% (7 out of 8 dimensions).
  2. 30-day hospital readmissions: Trainees will have an additional opportunity to demonstrate improvement. Target: 13.05% (median of comparable health care systems on the UHC US News Honor Roll).
  3. Emergency Department Median Consult Time: Extended consult times in the ED contribute to increased Left Without Being Seen rate and decreased patient satisfaction and care. Target: Overall decrease in consult time by 10%.
  4. Safety Event Reporting in RL Solutions: Increasing trainee input and awareness for adverse outcomes or near-misses. Trainees only submitted 0.5 (74) of overall reports last year. Target: Increase trainee submitted reports for an average of 2 submissions per trainee.
What were our measures last year (2013-2014)? Last year, we had 3 program measures encompassing the domains of patient satisfaction and quality and patient safety:
  1. HCAHPS (Hospital Consumer Assessment of Healthcare Providers & Systems) surveys: publicly reported data from patient surveys on hospital performance
  2. Duke Hospital 30-day hospital readmission rate
  3. Influenza vaccinations
Additionally, several programs chose program-specific measures:
  • Hand Hygiene: Internal Medicine, Pediatrics, General Surgery, Anesthesia, Neurology, Orthopedics
  • Left Without Being Seen Rate: Emergency Medicine
  • OB Trauma: Vaginal with Instrument: OB/GYN
How was our performance last year?
  1. HCAHPS: Target of 87.5% met
  2. 30-day hospital readmissions: data unavailable through much of the year
  3. Influenza vaccinations: data unavailable through much of the year
  4. Program specific measures: Pediatrics met their target with hand washing.
Trainees received the full pay-out of $600. How will we be updated on our progress? Performance Services will create monthly reports with up-to-date performance metrics that will be distributed to trainees and program directors. Program representatives are also willing to present the program structure to your trainees; contact information is below. What can we do with this information? You can work with your program or peers to create a QI project or initiative to specifically address improving upon these measures. How can I get involved? To get involved or for more information, please contact one of the program co-chairs: Anjni Patel (anjni.patel@dm.duke.edu) or Sarah Dotson (sarah.dotson@dm.duke.edu). Attachments:  

Information/Opportunities

Carolinas HealthCare System Internal Medicine Opportunities 8-2014 Announcement Geriatrician Opportunity Elkin Hospitalist Montana Hospitalist Summit Placement Service Washington State Opportunities Madison WI opportunities www.mercydesmoines.org  

Upcoming Dates and Events

September 2 - 18: Internal Medicine In-Service Training Exams Testing Window  

Useful links

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