Journal of hospital medicine : an official publication of the Society of Hospital Medicine
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Severe sepsis and septic shock are common and associated with a 30-50% mortality rate. Evidence-based therapies for severe sepsis supported by international critical care and infectious disease societies exist, but are inconsistently employed. ⋯ Compelling observational data supports the importance of early, effective antibiotics. Well-designed randomized controlled trials and/or meta-analyses demonstrate the impact of activated protein C, early goal-directed therapy, stress-dose steroids, and intensive insulin in well-defined subgroups of patients. These therapies reduce the absolute mortality risk associated with severe sepsis by 9.5-16%; the corresponding numbers needed to treat to save one life are 6.25-10.5. While major trials are ongoing and the evidence for several sepsis therapies are limited to single trials, the available evidence indicates that appropriate use of these treatments can substantially reduce mortality from severe sepsis.
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Rapid response teams and medical emergency teams have been utilized to rapidly manage seriously ill patients at risk of cardiopulmonary arrest and other high-risk conditions but have not been extensively described in the American medical literature. ⋯ An RRT was introduced into an academic medical center, and the results suggested it is capable of preventing clinical deterioration in unstable patients and may have the potential to decrease the frequency of cardiac arrests. The RRT also may fill a gap in patient safety by enabling rapid triage and expedited treatment of off-unit inpatients, outpatients, and visitors. The keys to the early success of our implementation of an RRT were multidisciplinary input and improvements made in real time.
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Deficits in information transfer between inpatient and outpatient physicians are common and potentially dangerous. ⋯ Physicians were not satisfied with the timeliness or quality of discharge summaries. Physicians indicated that suboptimal transfer of information at hospital discharge contributed to preventable adverse events.
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Restrictions in the hours residents can be on duty have resulted in increased sign-outs, that is, transfer of patient care information and responsibility from one physician to a cross-coverage physician, leading to discontinuity in patient care. This sign-out process, which occurs primarily in the inpatient setting, traditionally has been informal, unstructured, and idiosyncratic. Although studies show that discontinuity may be harmful to patients, this is little data to assist residency programs in redesigning systems to improve sign-out and manage the discontinuity. ⋯ We provide recommendations and strategies for best practices to design safe and effective sign-out systems for residents that may also be useful to hospitalists working in academic and community settings.
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Comparative Study
Inpatient management of diabetes and hyperglycemia among general medicine patients at a large teaching hospital.
Because of the relationship between inpatient hyperglycemia and adverse patient outcomes, current guidelines recommend glucose levels less than 180 mg/dL in the non-ICU inpatient setting and the use of effective insulin protocols for appropriate patients. ⋯ Management of diabetes and hyperglycemia on a general medicine service showed several deficiencies in process and outcome. Possible targets for improvement include increased use of basal and nutritional insulin and daily insulin adjustment in response to hyperglycemia.