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ContextHypoglycemia in people with diabetes is common, especially in those taking medications such as insulin and sulfonylureas (SU) that place them at higher risk. Hypoglycemia is associated with distress in those with diabetes and their families, medication nonadherence, and disruption of life and work, and it leads to costly emergency department visits and hospitalizations, morbidity, and mortality.ObjectiveTo review and update the diabetes-specific parts of the 2009 Evaluation and Management of Adult Hypoglycemic Disorders: Endocrine Society Clinical Practice Guideline and to address developing issues surrounding hypoglycemia in both adults and children living with diabetes. The overriding objectives are to reduce and prevent hypoglycemia.MethodsA multidisciplinary panel of clinician experts, together with a patient representative, and methodologists with expertise in evidence synthesis and guideline development, identified and prioritized 10 clinical questions related to hypoglycemia in people living with diabetes. Systematic reviews were conducted to address all the questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations.ResultsThe panel agreed on 10 questions specific to hypoglycemia risk and prevention in people with diabetes for which 10 recommendations were made. The guideline includes conditional recommendations for use of real-time continuous glucose monitoring (CGM) and algorithm-driven insulin pumps in people with type 1 diabetes (T1D), use of CGM for outpatients with type 2 diabetes at high risk for hypoglycemia, use of long-acting and rapid-acting insulin analogs, and initiation of and continuation of CGM for select inpatient populations at high risk for hypoglycemia. Strong recommendations were made for structured diabetes education programs for those at high risk for hypoglycemia, use of glucagon preparations that do not require reconstitution vs those that do for managing severe outpatient hypoglycemia for adults and children, use of real-time CGM for individuals with T1D receiving multiple daily injections, and the use of inpatient glycemic management programs leveraging electronic health record data to reduce the risk of hypoglycemia.ConclusionThe recommendations are based on the consideration of critical outcomes as well as implementation factors such as feasibility and values and preferences of people with diabetes. These recommendations can be used to inform clinical practice and health care system improvement for this important complication for people living with diabetes.

Background Hospitalized acutely ill medical patients are at risk for fatal and major thromboembolic events. Whether use of extended-duration primary thromboprophylaxis can prevent such events is unknown. Objectives The purpose of this study was to evaluate whether extended-duration rivaroxaban reduces the risk of venous and arterial fatal and major thromboembolic events without significantly increasing major bleeding in acutely ill medical patients after discharge. Methods MARINER (A Study of Rivaroxaban [JNJ-39039039] on the Venous Thromboembolic Risk in Post-Hospital Discharge Patients) studied acutely ill medical patients with additional risk factors for venous thromboembolism (VTE). Medically ill patients with a baseline creatinine clearance ≥50 ml/min were randomized in a double-blind fashion to rivaroxaban 10 mg or placebo daily at hospital discharge for 45 days. Exploratory efficacy analyses were performed with the intent-to-treat population including all data through day 45. Time-to-event curves were calculated using the Kaplan-Meier method. A blinded independent committee adjudicated all clinical events. Results In total, 4,909 patients were assigned to rivaroxaban and 4,913 patients to placebo. The mean age was 67.8 years, 55.5% were men, mean baseline creatinine clearance was 87.8 ml/min, and mean duration of hospitalization was 6.7 days. The pre-specified composite efficacy endpoint (symptomatic VTE, myocardial infarction, nonhemorrhagic stroke, and cardiovascular death) occurred in 1.28% and 1.77% of patients in the rivaroxaban and placebo groups, respectively (hazard ratio: 0.72; 95% confidence interval: 0.52 to 1.00; p = 0.049), whereas major bleeding occurred in 0.27% and 0.18% of patients in the rivaroxaban and placebo groups, respectively (hazard ratio: 1.44; 95% confidence interval: 0.62 to 3.37; p = 0.398). Conclusions Extended-duration rivaroxaban in hospitalized medically ill patients resulted in a 28% reduction in fatal and major thromboembolic events without a significant increase in major bleeding. (A Study of Rivaroxaban [JNJ-39039039] on the Venous Thromboembolic Risk in Post-Hospital Discharge Patients [MARINER]; NCT02111564)

Practice variations in insulin management and glycemic adverse events led nine Dignity Health hospitals to initiate a collaborative effort to improve hypoglycemia, uncontrolled hyperglycemia, and glycemic control.Non-critical care adult inpatients with ≥4 point-of-care blood glucose (BG) readings in a ≥2-day period were included. Balanced glucometric goals for each hospital were individualized to improve performance by 10%-20% from baseline or achieve top performance derived from Society of Hospital Medicine (SHM) benchmarking studies. Baseline measures (2011) were compared to mature results (postintervention, 2014). Protocols for insulin management and hypoglycemia prevention were piloted at one facility and were then spread to the cohort. Interventions included standardized order sets, education, mentoring from physician experts, feedback of metrics, and measure-vention (coupling measurement of patients "off protocol" with concurrent intervention to correct lapses in care).The day-weighted mean BG for the cohort improved by 11.4 mg/dL (95% confidence interval [CI]: 11.0-11.8]; all nine sites improved. Eight of the sites reduced severe hyperglycemic days, and the percentage of patient-days with any BG 299 mg/dL for the total cohort improved from 11.6% to 8.8% (relative risk, 0.76 [95% CI: 0.74-0.78]). The percentage of patient-days with any BG 70 mg/dL remained unchanged at 3.6%. Eight of the sites either reduced hypoglycemia by 20% or achieved SHM best-quartile rates.Multihospital improvements in glycemic control and severe hyperglycemia without significant increases in hypoglycemia are feasible using portable low-cost toolkits and metrics.

Introduction Communication failures during shift-to-shift handoffs of patient care have been identified as a leading cause of adverse events in health care institutions. The I-PASS Handoff Program is a comprehensive handoff program that has been shown to decrease rates of medical errors and adverse events. As part of the spread and adaptation of this program, a comprehensive implementation guide was created to assist individuals in the implementation process. Methods The I-PASS Mentored Implementation Guide grew out of materials created for the original I-PASS Study, Society of Hospital Medicine (SHM) mentored implementation programs, and the experience of members of the I-PASS Study Group. The guide provides a comprehensive framework of all elements required to implement the large-scale I-PASS Handoff Program and contains detailed information on generating institutional support, training activities, a campaign, measuring impact, and sustaining the program. Results Thirty-two sites across North America utilized the guide as part of the SHM program. The guide served as a main reference for 477 hours of mentoring phone calls between site leads and their mentors. Postprogram surveys from wave 2 sites revealed that 85% (N = 34) of respondents felt the quality of the guide was very good/excellent. Site leads noted that they referenced the guide most often during the early part of the program and that they referenced the sections on the curriculum and handoff observations most often. Discussion The I-PASS Mentored Implementation Guide is an essential resource for those looking to implement the large-scale I-PASS Handoff Program at their institution.

BACKGROUND Almost 700 patients suffered from hospital-associated venous thromboembolism (HA-VTE) across 5 University of California hospitals in calendar year 2011. OBJECTIVE Optimize venous thromboembolism (VTE) prophylaxis (VTEP) in adult medical/surgical inpatients and reduce HA-VTE by at least 20% within 3 years. DESIGN Prospective, unblinded, open-intervention study with historical controls. SETTING Five independent but cooperating academic hospitals. PATIENTS All adult medical and surgical inpatients with stays ≥3 days. The baseline year was 2011, 2012 to 2014 were intervention years, and year 2014 was the mature comparison period. VTEP adequacy was assessed with structured chart review of 45 patients per month at each site via random selection beginning partway through the study. HA-VTE was identified by discharge coding, capturing patients readmitted within 30 days of prior VTE-free admit and VTE occurring during index admission. Cases were stratified medical versus surgical and cancer or noncancer. INTERVENTIONS Interventions included structured order sets with “3-bucket” risk-assessment, measure-vention, techniques to improve reliable administration of VTEP, and education. RESULTS Adequate prophylaxis reached 89% by early 2014. The rate of HA-VTE fell from 0.90% in 2011 to 0.69% in 2014 (24% relative risk [RR] reduction; RR: 0.76, 95% confidence interval: 0.68-0.852), equivalent to averting 81 pulmonary emboli and 89 deep venous thrombi. VTE rates were highest in cancer and surgical patients. CONCLUSIONS Hospital systems can reduce HA-VTE by implementing a bundle of active interventions including structured VTEP orders with embedded risk assessment and measure-vention. Journal of Hospital Medicine 2016;11:S22–S28. © 2016 Society of Hospital Medicine

Background Reliable prophylaxis of hospitalassociated venous thromboembolism (HA-VTE) is not achieved in many hospitals. Efforts to improve prophylaxis have had uneven results. Objective To reduce HA-VTE with a scalable quality improvement collaborative. Design A prospective, unblinded, open-intervention study with historical controls. Participants and setting All adult inpatients at 35 community hospitals in California, Arizona, and Nevada. Interventions A centrally supported collaborative implementing standardized VTE risk assessment and prophylaxis. Protocols were developed with 9 "pilot" sites, which received individualized mentoring. Finished protocols were disseminated to 26 "spread" sites, which received improvement webinars without mentoring. Active surveillance for real-time correction of suboptimal prophylaxis was funded in pilot sites and encouraged in spread sites. Planning and minimal improvement work began in 2011; most implementation occurred in 2012 and 2013. Measurements Rates of per-protocol prophylaxis (at pilot sites), and compliance with The Joint Commission VTE measures (all sites), were monitored starting in January 2012. The International Classification of Diseases, 9th Edition-Clinical Modification codes were used to determine the rates of HA-VTE within 30 days of discharge, heparininduced thrombocytopenia, and anticoagulation adverse events; preimplementation (2011) rates were compared with postimplementation (2014) rates. Results Protocol-appropriate prophylaxis rates and The Joint Commission measure compliance both reached 97% in 2014, up from 70% to 89% in 2012 and 2013. Five thousand three hundred and seventy HA-VTEs occurred during 1.16 million admissions. Four hundred twenty-eight fewer HA-VTEs occurred in 2014 than in 2011 (relative risk 0.78; 95% confidence interval, 0.73-0.85). HA-VTEs fell more in pilot sites than spread sites (26% vs 20%). The rates of adverse events were reduced or unchanged. Conclusions Collaborative efforts were associated with improved prophylaxis rates and fewer HA-VTEs.

Quality improvement (QI) efforts hold great promise for improving care delivery. However, hospitals often struggle with QI implementation and fail to sustain improvement in either process changes or patient outcomes. Physician mentored implementation (PMI) is a novel approach that promotes the success and sustainability of QI initiatives at hospitals. It leverages the expertise of external physician mentors who coach QI teams to implement interventions at their local hospitals. The PMI model includes five core components: (1) a hospital self-assessment tool, (2) a face-to-face training session including direct interaction with a physician mentor, (3) a guided continuous quality improvement and systems approach, (4) yearlong individual physician mentoring, and (5) a learning community supported by a resource center, listserv, and webinars. Mentors provide content and process expertise, rather than offering "one-size-fits-all" technical assistance that might not be sustained after the mentoring year ends. Mentors support and motivate QI teams throughout the planning and implementation phases of their interventions, help to engage hospital leadership, garner local physician buy-in, and address institutional barriers. Mentors also guide hospitals to identify opportunities for the adaptation and customization of original evidence-based models of care while ensuring the fidelity of those models. More than 350 hospitals have used the PMI model to implement successful national and statewide QI initiatives. Academic medical centers are charged with improving the health of patients and reengineering care delivery; thus, they serve as the ideal source for physician mentors and can act as leaders in implementing QI projects using the PMI model.

Safely improve glycemic control in the critical care units of nine hospitals.Critical care adult inpatients from nine hospitals with ≥4 point-of-care blood glucose (BG) readings over ≥2 days were targeted by collaborative improvement efforts to reduce hyper- and hypoglycemia. Balanced glucometric goals for each hospital were set targeting improvement from baseline or goals deemed desirable from Society of Hospital Medicine (SHM) benchmarking data. Collaborative interventions included standardized insulin infusion protocols, hypoglycemia prevention bundles, audit and feedback, education, and measure-vention (coupling measurement of patients "off protocol" with concurrent interventions to correct suboptimal care).All sites improved glycemic control. Six reached prespecified levels of improvement of the day-weighted mean BG. The day-weighted mean BG for the cohort decreased by 7.7 mg/dL (95% confidence interval [CI], 7.0 mg/dL to 8.4 mg/dL) to 151.3 mg/dL. Six of nine sites showed improvement in the percent intensive care unit (ICU) days with severe hyperglycemia (any BG299 mg/dL). ICU severe hyperglycemic days declined from 8.6 to 7.2% for the cohort (relative risk, 0.84; 95% CI, 0.80 to 0.88). Patient days with any BG70 mg/dL were reduced by 0.4% (95% CI, 0.06% to 0.6%), from 4.5 to 4.1%, for a small but statistically significant reduction in hypoglycemia. Seven of nine sites showed improvement.Multihospital improvements in ICU glycemic control, severe hyperglycemia, and hypoglycemia are feasible. Balanced goals for glycemic control and hypoglycemia in the ICU using SHM benchmarks and metrics enhanced successful improvement efforts with good staff acceptance and sustainability.BG = blood glucose CMI = case-mix index CY = calendar year DKA = diabetic ketoacidosis EMR = electronic medical record GBMF = Gordon and Betty Moore Foundation ICU = intensive care unit IIP = insulin infusion protocol SHM = Society of z Hospital Medicine.

BACKGROUND Hospital-acquired venous thromboembolism (HA-VTE, VTE occurring during a hospitalization) codes in hospital billing data are often used as a surrogate for hospital-associated VTE events occurring during or up to 30 days after a hospitalization, which are more difficult to measure. OBJECTIVE Establish the incidence and composition of HA-VTE/superficial venous thrombosis (SVT) coded in a large cohort of medical patients. DESIGN Retrospective analysis of discharges. SETTING Eighty-three academic medical centers in UHC (formerly University HealthSystem Consortium). PATIENTS Patients with medical diagnoses hospitalized >2 days between October 1, 2009, and March 31, 2011. MEASUREMENTS Incidence and anatomic location of HA-VTE codes, defined as International Classification of Diseases, Ninth Revision, Clinical Modification codes for VTE coupled to a present-on-admission indicator flag set to “No.” RESULTS Among 2,525,068 medical hospitalizations, 12,847 (0.51%) cases had ≥1 thrombotic code; 2449 (19.1%) with pulmonary embolism (PE), and 3848 (30%) with lower-extremity deep venous thrombosis (LE-DVT) without PE. Upper-extremity DVT (2893; 22.5%) and SVT (3248; 25.3%) comprised the bulk of remaining cases. Among cases with HA-PE/LE-DVT, 34.3% had cancer, 47.8% received care in an intensive care unit, 78% had severe or extreme severity of illness, and 16.5% died in the hospital. Overall, 54.9% of the patients who developed a HA-PE/LE-DVT had been started on VTE pharmacoprophylaxis on hospital day 1 or 2. CONCLUSION At academic centers, HA-VTE/SVT is coded in 0.51% of medical inpatients, and HA-PE/LE-DVT is coded in half of those. Most patients with HA-PE/LE-DVT are severely ill and develop VTE despite receiving prophylaxis. Journal of Hospital Medicine 2014;9:221–225. © 2014 Society of Hospital Medicine

Background: Venous thromboembolism (VTE) is common after hospitalization in acutely ill medical patients, yet extended thromboprophylaxis has not been widely implemented due to concerns about bleeding. The MARINER study (NCT02111564) compared thromboprophylaxis with rivaroxaban (10mg daily or 7.5mg daily in subjects with creatinine clearance 30- Methods: We evaluated all bleeding events in subjects taking at least one dose of study drug from randomization until 2 days after the last dose (safety population) and their association with ACM through the Day 75 visit in 3 mutually exclusive groups: (1) subjects with no MB or NMCRB; (2) subjects whose first event was NMCRB; and (3) subjects whose first event was MB. Subjects only developing minimal or trivial bleeding were grouped with those who had no bleeding. Using a Cox proportional hazards model that included the bleeding group variable and baseline covariates that were significantly associated with ACM at p Results: The incidence of ACM among subjects who had a NMCRB was not increased over that in subjects without bleeding (2/136, 1.5% vs 218/11800, 1.8%, HR 0.41 95%CI 0.10, 1.67, p=0.213), while those experiencing MB had a higher incidence of death (4/26, 15.4% vs 218/11800, 1.8%, HR 3.43 95%CI 1.23, 9.54, p=0.018). Results of landmark analyses from the first bleeding event or end of treatment + 2 days to ACM for the three groups are displayed (Figure). Limitations: This analysis was post hoc and the MARINER trial excluded subjects at a high risk of bleeding. Conclusion: Although few subjects had MB events, those who did had an increased risk of ACM, while those who had NMCRB events did not. This suggests that the modest increase in NMCRB in trials of extended thromboprophylaxis may be an acceptable tradeoff to prevent VTE. Disclosures Spyropoulos: Janssen R&D, LLC: Consultancy; ATLAS (Colorado Prevention Center): Consultancy; Bayer Healthcare: Consultancy; Portola: Consultancy; Boehringer Ingelheim: Consultancy, Research Funding; Daiichi Sankyo: Consultancy. Ageno:Bayer: Membership on an entity's Board of Directors or advisory committees, Other: research support,travel support ; BMS Pfizer: Other: travel support; Boehringer Ingelheim: Membership on an entity's Board of Directors or advisory committees, Other: conference and travel support; Portola: Membership on an entity's Board of Directors or advisory committees, Other: travel support; Aspen: Membership on an entity's Board of Directors or advisory committees, Other: travel support; Sanofi: Membership on an entity's Board of Directors or advisory committees, Other: travel support; Daiichi Sankyo: Membership on an entity's Board of Directors or advisory committees, Other: travel support. Albers:Janssen R&D, LLC: Consultancy; Bayer Healthcare: Consultancy. Elliott:Bayer Healthcare: Consultancy; University of Cincinnati: Honoraria; Spectrum Health: Honoraria; Janssen R&D, LLC: Consultancy. Halperin:Ortho-McNeil-Janssen: Consultancy; Johnson & Johnson: Consultancy; ATLAS (Colorado Prevention Center): Consultancy; NIH: Consultancy; Pfizer: Consultancy; Daiichi Sankyo: Consultancy; Boehringer Ingelheim: Consultancy. Hiatt:Bayer Healthcare: Consultancy; NIH: Research Funding; Janssen R&D, LLD: Consultancy. Maynard:Janssen R&D, LLC: Consultancy. Steg:Novartis: Consultancy; Regeneron: Consultancy; Lilly: Consultancy; Pfizer: Consultancy; Boehringer Ingelheim: Consultancy; Bristol-Myers Squibb: Consultancy, Speakers Bureau; Amgen: Consultancy, Speakers Bureau; Amarin: Consultancy; Servier: Consultancy, Research Funding; Merck: Research Funding, Speakers Bureau; Sanofi: Consultancy, Speakers Bureau; Bayer Healthcare: Consultancy, Research Funding; Janssen R&D, LLC: Consultancy, Research Funding; AstraZeneca: Consultancy. Weitz:Novartis: Consultancy, Honoraria; Merck: Consultancy, Honoraria; Ionis: Consultancy, Honoraria; Daiichi-Sankyo: Consultancy, Honoraria; Bristol-Myers Squibb: Consultancy, Honoraria; Boehringer Ingelheim: Consultancy, Honoraria; Bayer Healthcare: Consultancy, Honoraria; Janssen R&D, LLC: Consultancy; Pfizer: Consultancy, Honoraria; Portola: Consultancy, Honoraria. Spiro:Bayer U.S. LLC: Employment, Equity Ownership. Lu:Janssen R&D, LLC: Employment, Equity Ownership. Sugarmann:Janssen Research and Development LLC: Employment, Equity Ownership. Lipardi:Janssen Research and Develompent: Employment, Equity Ownership. Raskob:Boehringer Ingelheim: Consultancy; Eli Lilly: Consultancy; Pfizer: Consultancy, Honoraria; Tetherex: Consultancy; Daiichi Sankyo: Consultancy, Honoraria; Anthos: Consultancy; BMS: Consultancy, Honoraria; Janssen R&D, LLC: Consultancy, Honoraria; Portola: Consultancy; Novartis: Consultancy; Bayer Healthcare: Consultancy, Honoraria. Barnathan:Janssen Research and Development LLC: Employment, Equity Ownership. OffLabel Disclosure: Rivaroxaban is a Factor Xa inhibitor. The study evaluated the efficacy and safety of rivaroxaban post-hospitalization in subjects with an acute medical illness as thromboprophylaxis for venous thromboembolism.

Hospitalization of persons with dementia can pose specific challenges for family caregivers, with post-discharge issues in managing acute clinical care needs coupled with dementia-related care that can exacerbate caregiver fatigue and capacity. We established an academic-practice collaboration to develop an evidence-based and innovative multi-component health system-level program to support family caregivers of persons with dementia in transition from hospital to community. Using an implementation science approach aimed to decrease the gap in translation of caregiver research into practice, we co-designed the program/implementation plan as a quality improvement initiative reflecting an integration of evidence from family caregiving literature and the health system’s unique context, workflows, stakeholder perspectives, resources, and values/priorities. This paper highlights insights gained and lessons learned in establishing a successful academic-practice collaboration, including time/investment to establish a shared project vision and identify/leverage existing organizational capacity to successfully deliver a program to improve the health and wellbeing of family caregivers.

Purpose Consensus recommendations to help ensure safe insulin use in hospitalized patients are presented. Summary Insulin products are frequently involved in medication errors in hospitals, and insulin is classified as a high-alert medication when used in inpatient settings. In an initiative to promote safer insulin use, the American Society of Health-System Pharmacists (ASHP) Research and Education Foundation convened a 21-member panel representing the fields of pharmacy, medicine, and nursing and consumer advocacy groups for a three-stage consensus-building initiative. The panel’s consensus recommendations include the following: development of protocol-driven insulin order sets, elimination of the routine use of correction/sliding-scale insulin doses for management of hyperglycemia, restrictions on the types of insulin products stored in patient care areas, and policies to restrict the preparation of insulin bolus doses and i.v. infusions to the pharmacy department. In addition, the panelists recommended that hospitals better coordinate insulin use with meal intake and glucose testing, prospectively monitor the coordination of insulin delivery and rates of hypoglycemia and hyperglycemia, and provide standardized education and competency assessment for all hospital-based health care professionals responsible for insulin use. Conclusion A 21-member expert panel convened by the ASHP Foundation identified 10 recommendations for enhancing insulin-use safety across the medication-use process in hospitals. Professional organizations, accrediting bodies, and consumer groups can play a critical role in the translation of these recommendations into practice. Rigorous research studies and program evaluations are needed to study the impact of implementation of these recommendations.

Organizations have raised concerns regarding stress in the medical work environment and effects on health care worker performance. This study's objective was to assess workplace stress among interns, residents, and attending physicians using Ecological Momentary Assessment technology, the gold-standard method for real-time measurement of psychological characteristics.The authors deployed handheld computers with customized software to 185 physicians on the medicine and pediatric wards of four major teaching hospitals. The physicians contemporaneously recorded multiple dimensions of physician work (e.g., type of call day), emotional stress (e.g., worry, stress, fatigue), and perceived workload (e.g., patient volume). The authors performed descriptive statistics and t test and linear regression analyses.Participants completed 5,673 prompts during an 18-month period from 2004 to 2005. Parameters associated with higher emotional stress in linear regression models included male gender (t = -2.5, P = .01), total patient load (t = 4.2, P.001), and sleep quality (t = -2.8, P = .006). Stress levels reported by attendings (t = -3.3, P = .001) were lower than levels reported by residents (t = -2.6, P = .009), and emotional stress levels of attendings and residents were both lower compared with interns.On inpatient wards, after recent resident duty hours changes, physician trainees continue to show wide-ranging evidence of workplace stress and poor sleep quality. This is among the first studies of medical workplace stress in real time. These results can help residency programs target education in stress and sleep and readdress workload distribution by training level. Further research is needed to clarify behavioral factors underlying variability in housestaff stress responses.

In BriefWe performed a 130-patient case-control study to examine the patient and hospital care risk factors for experiencing a hypoglycemic patient-day,comparing these factors to similar control patients who were not experiencing a hypoglycemic patient-day. We also examined adherence to our hypoglycemia management protocols, documentation of the event, and adjustments to medications and nutritional regimens that occurred in response to the hypoglycemic event. The most powerful risk factors for hypoglycemia were unexpected nutritional interruption, prior hypoglycemia during the hospital stay, and asynchrony of nutrition delivery and insulin administration. Adherence to hypoglycemia management and documentation standards was poor. Here, we outline strategies to focus improvement efforts on adherence to hypoglycemia treatment protocols and proactive management of patients with these key hypoglycemia risk factors.

Inpatient glycemic control is a constant challenge. Institutional insulin management protocols and structured order sets are commonly advocated but poorly studied. Effective and validated methods to integrate algorithmic protocol guidance into the insulin ordering process are needed.We introduced a basic structured set of computerized insulin orders (Version 1), and later introduced a paper insulin management protocol, to assist users with the order set. Metrics were devised to assess the impact of the protocol on insulin use, glycemic control, and hypoglycemia using pharmacy data and point of care glucose tests. When incremental improvement was seen (as described in the results), Version 2 of the insulin orders was created to further streamline the process.The percentage of regimens containing basal insulin improved with Version 1. The percentage of patient days with hypoglycemia improved from 3.68% at baseline to 2.59% with Version 1 plus the paper insulin management protocol, representing a relative risk for hypoglycemic day of 0.70 [confidence interval (CI) 0.62, 0.80]. The relative risk of an uncontrolled (mean glucose over 180 mg/dl) patient stay was reduced to 0.84 (CI 0.77, 0.91) with Version 1 and was reduced further to 0.73 (CI 0.66, 0.81) with the paper protocol. Version 2 used clinician-entered patient parameters to guide protocol-based insulin ordering and simultaneously improved the flexibility and ease of ordering over Version 1.Patient parameter and protocol-based clinical decision support, added to computerized provider order entry, has a track record of improving glycemic control indices. This justifies the incorporation of these algorithms into online order management.

Patients with cancer are at increased risk for venous thromboembolism (VTE). An online survey to measure PE/DVT terminology awareness and understanding of VTE risks revealed 24% and 15% of the 500 cancer patients surveyed had heard of term DVT/PE; 19% and 17% could name signs/ symptoms of DVT/PE; 3% recognized cancer treatments as risk factors for DVT/PE. Only 25% of the patients received prevention education from providers

Diabetes is one of the most common diagnoses in hospitalized patients. A third of all persons admitted to urban general hospitals have glucose levels qualifying them for the diagnosis of diabetes, and a third of these hyperglycemic patients have not previously been diagnosed with diabetes. The impact of hyperglycemia on the mortality rate of hospitalized patients has been increasingly appreciated. Extensive evidence from observational studies indicates that hyperglycemia in patients with or without a history of diabetes is a marker of a poor clinical outcome. In addition, the results of prospective randomized trials in patients with critical illness or those undergoing coronary bypass surgery suggest that aggressive glycemic control improves clinical outcomes including reductions in: a) shortand long-term mortality, b) multiorgan failure and systemic infection, and c) length of hospitalization. The importance of glycemic control is not limited to patients in critical care areas but may also apply to patients admitted to general surgical and medical wards. The development of hyperglycemia in such patients with or without a history of diabetes has been associated with prolonged hospital stay, infection, disability after hospital discharge, and death. In general-surgical patients, serum glucose 220 mg/dL on postoperative day 1 has been shown to be a sensitive, albeit nonspecific, predictor of the development of serious postoperative hospital-acquired infection. A retrospective review of 1886 admissions to a community hospital in Atlanta, Georgia, found an 18-fold increase in mortality in hyperglycemic patients without a history of diabetes and a 2.5-fold increase in mortality in patients with known diabetes compared with controls. A meta-analysis of 26 studies identified an association of admission glucose 110 mg/dL with the increased mortality of patients hospitalized for acute stroke. More recently, hyperglycemia on admission was also shown to be independently associated with adverse outcomes in patients with community acquired pneumonia. In view of the increasing evidence supporting better glycemic control in the hospital, the American Association of Clinical Endocrinologists (AACE) in late 2003 convened a consensus conference on the inpatient with diabetes, cosponsored or supported by other prominent professional organizations, including the Society of Hospital Medicine (SHM). An expert panel agreed on and pubE D I T O R I A L

Article-at-a-Glance Background Nearly 2million osteoporosis-related fractures occur yearly in the United States, with more than 400,000 requiring hospital admissions. Fewer than 30% receive proper evaluation and care for osteoporosis, representing a large opportunity to enhance secondary prevention of fractures. Methods to improve identification and triage of hospitalized fragility-fracture patients are desirable. Methods A multidisciplinary team was created, and definitions were established for an evidence-based best-practice protocol to assess, treat, and document an osteoporosis diagnosis and triage patients with hip-fragility fractures on the basis of the best-practice recommendations from The Joint Commission and the National Osteoporosis Foundation. The team initiated a preauthorized osteoporosis consultation from the endocrinology service for hip-fracture patients, "triggered" via a brief query in admission orders or by the orthopedic service nurse practitioner. Osteoporosis consultations used a consultation template reflecting the protocol. Results Data were analyzed for 71 baseline patients and 61 intervention patients. The groups possessed similar age, gender, race, and body mass index characteristics. The baseline (on-demand consultation) group suffered from poor performance, with only 3%–21% of patients receiving the desired evaluation, documentation, treatment, or outpatient follow-up. Intervention (triggered-consultation) patients improved markedly postintervention, With performance increasing by 52%–76% on all parameters except outpatient follow-up, which changed insignificantly (6%–15%). Conclusion Although triggered consultation was effective, multimodal layered interventions may achieve even better results and address several identified barriers.

Article-at-a-Glance Background The Society of Hospital Medicine's (SHM's) Glycemic Control Mentored Implementation (GCMI) program, which, like all MI programs, is conducted as an improvement collaborative, is intended to help hospitals improve inpatient glycemic control in diabetic and nondiabetic patients by educating and mentoring quality teams. Methods Hospital quality improvement (QI) teams applied for participation in GCMI from 2009 through 2012. Accepted sites were assigned either a hospitalist or endocrinologist mentor to work through the life cycle of a QI project. SHM's Implementation Guide, online resources, measurement strategies, Web-based Glycemic Control Data Center for Performance Tracking, webinars, interactive listserve, and other tools help mentors guide these teams through the program. Mentors in GCMI bring expertise in both inpatient glycemic control and QI. Results One hundred fourteen hospital QI teams were enrolled into the GCMI program in the course of 2.5 years. Of these 114 sites, 90 completed the program, with 63 of them uploading data to the Data Center. Feedback from the sites was consistently positive, with the listserve, Data Center, and mentorship reported as the top three most effective components of the program. Ninety-five percent of respondents stated that they would recommend participation in an SHM–mentored implementation program to a colleague. Participants reported improved leadership skills and increased institutional support for glycemic control. Conclusions Hospital quality teams participating in the GCMI program gained support to overcome barriers, focus on improving glycemic control, network with peers and expert mentor physicians, collect and analyze data, and build quality leaders. The features and structure of this program can be used in other multisite QI goals and projects.

© 2013 Wolters Kluwer Health, Inc. All rights reserved. Background: Symptomatic venous thromboembolism is a common postoperative complication. The Agency for Healthcare Research and Quality (AHRQ) has developed a Patient Safety Indicator 12 to assist hospitals, payers, and other stakeholders to identify patients who experienced this complication. Objectives: To determine whether newly created and recently redefined ICD-9-CM codes improved the criterion validity of Patient Safety Indicator 12, based on new samples of records dated after October 2009. Research Design, Subjects, Measures: Two sources of data were used: (1) UHC retrospective case-control study of risk factors for acute symptomatic venous thromboembolism occurring within 90 days after total knee arthroplasty in teaching hospitals; (2) chart abstraction data by volunteer hospitals participating in the Validation Pilot Project of the AHRQ. Results: In the UHC sample, the positive predictive value (PPV) was 99% (125/126) and the negative predictive value was 99.4% (460/463). In the AHRQ sample, the overall PPV was 81% (126/156). Conclusions: The PPV based on both samples shows substantial improvement compared with the previously reported PPVs of 43%-48%, suggesting that changes in ICD-9-CM code architecture and better coding guidance can improve the usefulness of coded data.

BACKGROUND Hospital-acquired venous thromboembolic (HA-VTE) events are an important, preventable cause of morbidity and death, but accurately identifying HA-VTE events requires labor-intensive chart review. Administrative diagnosis codes and their associated "present-on-admission" (POA) indicator might allow automated identification of HA-VTE events, but only if VTE codes are accurately flagged "not present-on-admission" (POA=N). New codes were introduced in 2009 to improve accuracy. METHODS We identified all medical patients with at least 1 VTE "other" discharge diagnosis code from 5 academic medical centers over a 24-month period. We then sampled, within each center, patients with VTE codes flagged POA=N or POA=U (insufficient documentation) and POA=Y or POA=W (timing clinically uncertain) and abstracted each chart to clarify VTE timing. All events that were not clearly POA were classified as HA-VTE. We then calculated predictive values of the POA=N/U flags for HA-VTE and the POA=Y/W flags for non-HA-VTE. RESULTS Among 2070 cases with at least 1 "other" VTE code, we found 339 codes flagged POA=N/U and 1941 flagged POA=Y/W. Among 275 POA=N/U abstracted codes, 75.6% (95% CI, 70.1%-80.6%) were HA-VTE; among 291 POA=Y/W abstracted events, 73.5% (95% CI, 68.0%-78.5%) were non-HA-VTE. Extrapolating from this sample, we estimated that 59% of actual HA-VTE codes were incorrectly flagged POA=Y/W. POA indicator predictive values did not improve after new codes were introduced in 2009. CONCLUSIONS The predictive value of VTE events flagged POA=N/U for HA-VTE was 75%. However, sole reliance on this flag may substantially underestimate the incidence of HA-VTE.

The Society of Hospital Medicine (SHM) created "Mentored Implementation" (MI) programs with the dual aims of educating and mentoring hospitalists and their quality improvement (QI) teams and accelerating improvement in the inpatient setting in three signature programs: Venous Thromboembolism (VTE) Prevention, Glycemic Control, and Project BOOST (Better Outcomes for Older adults through Safe Transitions).More than 300 hospital improvement teams were enrolled in SHM MI programs in a series of cohorts. Hospitalist mentors worked with individual hospitals/health systems to guide local teams through the life cycle of a QI project. Implementation Guides and comprehensive Web-based "Resource Rooms," as well as the mentor's own experience, provided best-practice definitions, practical implementation tips, measurement strategies, and other tools. E-mail interactions and mentoring were augmented by regularly scheduled teleconferences; group webinars; and, in some instances, a site visit. Performance was tracked in a centralized data tracking center.Preliminary data on all three MI programs show significant improvement in patient outcomes, as well as enhancements of communication and leadership skills of the hospitalists and their QI teams.Although objective data on outcomes and process measures for the MI program's efficacy remain preliminary at this time, the maturing data tracking system, multiple awards, and early results indicate that the MI programs are successful in providing QI training and accelerating improvement efforts.

The aim was to formulate practice guidelines on the management of hyperglycemia in hospitalized patients in the non-critical care setting.The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee of The Endocrine Society, six additional experts, and a methodologist.This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence.One group meeting, several conference calls, and e-mail communications enabled consensus. Endocrine Society members, American Diabetes Association, American Heart Association, American Association of Diabetes Educators, European Society of Endocrinology, and the Society of Hospital Medicine reviewed and commented on preliminary drafts of this guideline.Hyperglycemia is a common, serious, and costly health care problem in hospitalized patients. Observational and randomized controlled studies indicate that improvement in glycemic control results in lower rates of hospital complications in general medicine and surgery patients. Implementing a standardized sc insulin order set promoting the use of scheduled basal and nutritional insulin therapy is a key intervention in the inpatient management of diabetes. We provide recommendations for practical, achievable, and safe glycemic targets and describe protocols, procedures, and system improvements required to facilitate the achievement of glycemic goals in patients with hyperglycemia and diabetes admitted in non-critical care settings.

BACKGROUND: Hospital-acquired (HA) venous thromboembolism (VTE) is a common source of morbidity/mortality. Prophylactic measures are underutilized. Available risk assessment models/protocols are not prospectively validated. OBJECTIVES: Improve VTE prophylaxis, reduce HA VTE, and prospectively validate a VTE risk-assessment model. DESIGN: Observational design. SETTING: Academic medical center. PATIENTS: Adult inpatients on medical/surgical services. INTERVENTIONS: A simple VTE risk assessment linked to a menu of preferred VTE prophylaxis methods, embedded in order sets. Education, audit/feedback, and concurrent identification of nonadherence. MEASUREMENTS: Randomly sampled inpatient audits determined the percent of patients with “adequate” VTE prevention. HA VTE cases were identified concurrently via digital imaging system. Interobserver agreement for VTE risk level and judgment of adequate prophylaxis were calculated from 150 random audits. RESULTS: Interobserver agreement with 5 observers was high (kappa score for VTE risk level = 0.81, and for judgment of “adequate” prophylaxis = 0.90). The percent of patients on adequate prophylaxis improved each of the 3 years (58%, 78%, and 93%; P < 0.001) and reached 98% in the last 6 months of 2007; 361 cases of HA VTE occurred over 3 years. Significant reductions for the risk of HA VTE (risk ratio [RR] = 0.69; 95% confidence interval [CI] = 0.47-0.79) and preventable HA VTE (RR = 0.14; 95% CI = 0.06-0.31) occurred. We detected no increase in heparin-induced thrombocytopenia (HIT) or prophylaxis-related bleeding using administrative data/chart review. CONCLUSIONS: We prospectively validated a VTE risk-assessment/prevention protocol by demonstrating ease of use, good interobserver agreement, and effectiveness. Improved VTE prophylaxis resulted in a substantial reduction in HA VTE. Journal of Hospital Medicine 2010;5:10–18. © 2010 Society of Hospital Medicine.

In this edition of AJHP , Milligan et al. (see page 1631) outline an approach to reducing severe hypoglycemic adverse drug events (ADEs) across BJC HealthCare (BJC), a diverse hospital system. The collaborative effort resulted in an at least 70% reduction in severe hypoglycemic ADEs in each of the

Article-at-a-Glance Background The Society of Hospital Medicine (SHM) created "Mentored Implementation" (MI) programs with the dual aims of educating and mentoring hospitalists and their quality improvement (QI) teams and accelerating improvement in the inpatient setting in three signature programs: Venous Thromboembolism (VTE) Prevention, Glycemic Control, and Project BOOST (Better Outcomes for Older adults through Safe Transitions). Methods More than 300 hospital improvement teams were enrolled in SHM MI programs in a series of cohorts. Hospitalist mentors worked with individual hospitals/health systems to guide local teams through the life cycle of a QI project. Implementation Guides and comprehensive Web-based "Resource Rooms," as well as the mentor's own experience, provided best-practice definitions, practical implementation tips, measurement strategies, and other tools. E-mail interactions and mentoring were augmented by regularly scheduled teleconferences; group webinars; and, in some instances, a site visit. Performance was tracked in a centralized data tracking center. Results Preliminary data on all three MI programs show significant improvement in patient outcomes, as well as enhancements of communication and leadership skills of the hospitalists and their QI teams. Conclusions Although objective data on outcomes and process measures for the MI program's efficacy remain preliminary at this time, the maturing data tracking system, multiple awards, and early results indicate that the MI programs are successful in providing QI training and accelerating improvement efforts.

Abstract 4731 Deep vein thrombosis (DVT) and pulmonary embolism (PE) impose a major public health burden in the United States, affecting an estimated 350,000 to 600,000 individuals and accounting for ~100,000 deaths in the United States each year, according to The Surgeon General's Call to Action (CTA) To Prevent Deep Vein Thrombosis and Pulmonary Embolism (2008). In response to this CTA, the National Blood Clot Alliance (NBCA), a national, community-based, non-profit organization dedicated to the prevention, diagnosis, and treatment of thrombosis and thrombophilia, conducted a survey to benchmark DVT/PE awareness among the general public. Little information about the public's knowledge of venous thromboembolism (VTE) is found in the literature, making this one of the most comprehensive, relatively large surveys of its kind. This DVT/PE awareness survey was conducted in November 2009, among a representative cross-section of 500 adults, >20 years, participating in online research panels. Among all respondents surveyed, just 21% said that they had heard of a medical condition called DVT (unaided), and, among this group (n=104), 86% correctly identified it as “deep vein thrombosis” on an aided checklist. Among those respondents who had not heard of a DVT or who had made an incorrect checklist selection (n=411), when DVT was identified for them as “deep vein thrombosis,” 29% then said they knew what it was. Among all respondents, just 16% said that they had heard of a medical condition called PE, and, among this group (n=80), 83% identified it correctly as “pulmonary embolism” on an aided checklist. Awareness of specific DVT risk factors and DVT/PE signs/symptoms was low. Results of this survey show that the medical lexicon poses substantial barriers: only 23% of all respondents reported to know what thrombophilia means and just 9% had heard of VTE. Conversely, 8 in 10 of all respondents said that they do know what a blood clot is, and virtually all respondents (98%) said that they believe blood clots can be life-threatening. The leading factors respondents said they believe are risks for causing blood clots included: family history of blood clots (73%), major trauma (71%), major surgery (69%), and being bedridden (68%), while Disclosures: Ansell: Bayer, Inc: Consultancy; Bristol Myers Squibb: Consultancy, Data Safety Monitoring Boards; Daiichi Sankyo: Consultancy; Boehringer Ingleheim: Consultancy; Ortho McNeil: Consultancy; Sanofi Aventis: Speakers Bureau. Brownstein:Ortho-McNeil, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc.: Data reported from project supported by Ortho-McNeil, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc.

Abstract 4740 Deep vein thrombosis (DVT) and pulmonary embolism (PE) affect up to 600,000 individuals and account for ~100,000 deaths in the United States each year, according to The Surgeon General's Call to Action (CTA) To Prevent Deep Vein Thrombosis and Pulmonary Embolism (2008). Oncology patients, particularly those who are hospitalized or undergo chemotherapy, are at increased risk for DVT/PE. Mortality is greater among patients with cancer and venous thromboembolism (VTE) than among those with cancer alone. In response to the Surgeon General's CTA, the National Blood Clot Alliance (NBCA), a national, community-based, non-profit organization dedicated to the prevention, diagnosis, and treatment of thrombosis and thrombophilia, conducted a survey to benchmark DVT/PE awareness among the general public and several at-risk patient groups, including oncology patients. The literature contains little information about at-risk patient knowledge, and almost no information about general public knowledge of VTE, making this the first, large survey of both public and at-risk patient awareness of DVT/PE. The survey was conducted in November 2009, among a representative cross-section of 500 adults, >20 years, participating in online research panels. For comparison, the identical survey was conducted among a sample of 500 adults, >20 years, screened from an online research panel, who had received a cancer diagnosis or experienced recurrence of cancer within the past 6 months, or who were on active cancer treatment. Evaluations comparing survey responses provided by oncology patients who, in connection with their treatment, did require a hospital stay versus those who did not require a hospital stay showed no statistically significant differences in DVT/PE awareness between the two subgroups. Among all oncology patients surveyed, 24% said that they had heard of a medical condition called DVT, compared to 21% of the general public. Among all respondents who said that they knew what a DVT was (unaided) or who were able to correctly identify DVT on an aided checklist, 61% of oncology and 53% of national respondents said they could name DVT risk factors. The most frequently mentioned DVT risk factor was “sitting for a long time” among both the oncology (45%) and national (28%) samples. Among oncology patients who could name DVT risk factors (n=155), 8% named surgery, 1% named cancer treatment. Among national respondents who could name DVT risk factors (n=109), significantly more (79%) said they could name DVT signs/symptoms compared to oncology respondents (63%) who said the same. While not statistically significant, the national sample did show greater recognition of certain DVT signs/symptoms: skin redness/discoloration, 41% national, 21% oncology; leg swelling, 50% national, 31% oncology; and, leg pain, 37% national, 27% oncology. PE awareness was low among both groups, with 15% of all oncology and 16% of all national respondents saying that they had heard of PE. Of those who what said they knew what a PE was (unaided) or identified it correctly from an aided checklist, about one-third of both groups said they could name PE signs/symptoms, with “breathing difficulties” cited most frequently by oncology (69%) and national (73%) respondents. Significantly fewer oncology patients (28%) mentioned chest pain/tightness as a PE sign/symptom, compared to the national sample (57%). About 8 in 10 oncology and national respondents said that they did know what a blood clot is, and virtually all respondents (98%) recognized blood clots as life threatening. DVT/PE awareness/knowledge was low. Despite increased risk, oncology patients demonstrated no greater awareness of DVT/PE than the general public. DVT/PE education, utilizing interventions identified in the Surgeon General's DVT/PE CTA, should target the general public, with special emphasis on at-risk oncology patients to fill gaps relative to increased DVT/PE risks and signs/symptoms. Terms should be further simplified for future public awareness and patient education initiatives. Disclosures: Brownstein: Ortho-McNeil, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc.: Data reported from project supported by Ortho-McNeil, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc. Ansell:Bayer, Inc: Consultancy; Bristol Myers Squibb: Consultancy, Data Safety Monitoring Boards; Daiichi Sankyo: Consultancy; Boehringer Ingleheim: Consultancy; Ortho McNeil: Consultancy; Sanofi Aventis: Speakers Bureau.

• Phenytoin, administered by suspension into a feeding tube through which continuous enteral feedings are being given, is very poorly absorbed. There appears to be very little information regarding this potentially serious problem in the general medical literature. Commonly used doses of phenytoin (300 to 500 mg/d) may result in almost undetectable serum levels. Therapeutic phenytoin levels may be obtained if a very large dose of the drug is given. Our patient required 1800 mg daily In two divided doses to get a serum phenytoin level of 9 μg/mL. Commonly used enteral feedings were being delivered by way of a continuous infusion pump. We found one enteral feeding product that did not severely impair the absorption of phenytoin. The mechanism by which enteral feedings Impair phenytoin absorption is unknown. (Arch Intern Med1987;147:1821)