By eliminating routine stress testing prior to non-cardiac thoracic surgery for patients without a history of cardiac symptoms, hospitalists can reduce the burden of costs on patients and eliminate the possibility of adverse outcomes due to inappropriate testing.
“Functional status has been shown to be reliable to predict peri-operative and long-term cardiac events,” says Douglas E. Wood, MD, chief of the division of cardiothoracic surgery at the University of Washington in Seattle and president of the STS. “In highly functional asymptomatic patients, management is rarely changed by pre-operative stress testing. Furthermore, abnormalities identified in testing often require additional investigation, with negative consequences related to the risks of more procedures or tests, delays in therapies, and additional costs.”
Pre-operative stress testing should be reserved for patients with low functional capacity or clinical risk factors for cardiac complications. It is important to identify patients pre-operatively who are at risk for these complications by doing a thorough history, physical examination, and resting electrocardiogram.
8 Society of Nuclear Medicine and Molecular Imaging (SNMMI)
Recommendation: Avoid using a CT angiogram to diagnose pulmonary embolism (PE) in young women with a normal chest radiograph; consider a radionuclide lung (V/Q) study instead.
Hospitalists should be knowledgeable of the diagnostic options that will result in the lowest radiation exposure when evaluating young women for PE.
“When a chest radiograph is normal or nearly normal, a computed tomography angiogram or a V/Q lung scan can be used to evaluate these patients. While both exams have low radiation exposure, the V/Q lung scan results in less radiation to the breast tissue,” says society president Gary L. Dillehay, MD, FACNM, FACR, professor of radiology at Northwestern Memorial Hospital in Chicago. “Recent literature cites concerns over radiation exposure from mammography; therefore, reducing radiation exposure to breast tissue, when evaluating patients for suspected PE, is desirable.”
Hospitalists might have difficulty obtaining a V/Q lung scan when nuclear medicine departments are closed.
“The caveat is that CT scans are much more readily available,” Dr. Auron says. In addition, a CT scan provides additional information. But unless the differential diagnosis is much higher for PE than other possibilities, just having a V/Q scan should suffice.
Hospitalists could help implement protocols for chest pain evaluation in premenopausal women by having checklists for risk factors for coronary artery disease, connective tissue disease (essentially aortic dissection), and VTE (e.g. Wells and Geneva scores, use of oral contraceptives, smoking), Dr. Auron says. If the diagnostic branch supports the risk of PE, then nuclear imaging should be available.
“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan,” he says.
LISTEN NOW to Rahul Shah, MD, FACS, FAAP, associate professor of otolaryngology and pediatrics at Children’s National Medical Center in Washington, D.C, and co-chair of the American Academy of Otolaryngology-Head and Neck Surgery Foundation’s Patient Safety Quality Improvement Committee, explain why hospitalists should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.
9 American Academy of Pediatrics (AAP)
Recommendation: Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
Respiratory illnesses are the most common reason for hospitalization in pediatrics. Recent studies and surveys continue to demonstrate antibiotic overuse in the pediatric population, especially when prescribed for apparent viral respiratory illnesses.8,9
“Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses such as bronchiolitis and croup remain a leading cause of admission,” says James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics at the University of Washington School of Medicine in Seattle.