Week in Review — 9/1/2017
Good Afternoon Doctors!

We hope that everyone had a wonderful week and that everyone gets to enjoy at least part of this Labor Day weekend!
We have a lot of important updates and announcements so be sure to read updates section carefully!

University Announcements:

I. As many of you know, our beloved substance abuse counselor Art Cohen has officially retired after 43 years at UMMC. Dr. Joy Chang in the Department of Psychiatry is organizing a retirement party and open house in his honor! Please see attached pdf for further info!
II. There has been in update to CAP Guidelines!! See below:
Changes to UMMC Community-Acquired Pneumonia (CAP) Guideline:
Ceftriaxone has historically been the first-line agent for CAP in UMMC guidelines. Due to recent initiatives to reduce the use of antibiotics known to increase the risk of C. difficile, some changes have been made to this guideline. For patients without a penicillin allergy, ampicillin-sulbactam is now the first-line agent, with ceftriaxone being reserved for patients with a mild penicillin allergy and fluoroquinolones only for severe penicillin allergy. Additionally, the preferred dosing for azithromycin in CAP has been changed to 500 mg daily for 3 days. The guideline has been updated in the Antimicrobial Guidelines App and order set updates are in progress.

Clinical Data
• Third-generation cephalosporins have been shown to increase the risk of C. difficile infection in several studies1-4
• Ampicillin-sulbactam is an IDSA guideline-recommended treatment for CAP5, and beta-lactam/beta-lactamase inhibitors carry a lower risk of causing C. difficile than 3rd generation cephalosporins 3
• Azithromycin’s pharmacological properties allow for short-course administration since it achieves high and sustained tissue concentrations, and has a long elimination half-life6
• Efficacy of the 500 mg x 3 day dosing for azithromycin has been shown in mild to moderately severe CAP7,8, acute bacterial sinusitis9 and severe COPD exacerbations8,10

Other Pearls
• Reported susceptibilities for S. pneumoniae to penicillin at UMMC are based on the meningitis breakpoint (0.06 mcg/mL), which does not apply to respiratory isolates (non-CNS breakpoint 2 mcg/mL). For respiratory isolates, the breakpoint of 2 mcg/ml should be used clinically to determine susceptibility to penicillin (and therefore inferred to ampicillin) even if the organism is reported intermediate or resistant by the CNS breakpoint.
• Ampicillin-sulbactam does not add any additional activity over ampicillin for S. pneumoniae. It is used empirically for CAP to cover organisms that may produce beta-lactamases, such as Haemophilus influenzae and Moraxella catarrhalis.
• Azithromycin achieves high and sustained tissue concentrations (in spite of poor serum concentrations) and should be given PO whenever possible for CAP and COPD.
III. Reminder again for Flu Prevention! It is mandatory for all residents to get vaccinated! Free flu vaccines will be available outside of Borges during noon conference from 12-1:30pm during the follow dates:
o Tuesday 9/12/17
o Friday 9/22/17
o Monday 9/25/17
IV. Critical Lab results reporting: For UHC – critical lab results are paged to the IMED pager and the senior resident MUST respond, attempt to contact pt (if needed) and also DOCUMENT this encounter in Epic. The epic note should be routed (CC’d) to the PCP and the attending in clinic (or Dr. Baek if you don’t know who the attending should be).
V. For all of those interested in global health or doing an international rotation, take a few minutes to watch this incredible video featuring our outstanding resident Clare Coda on her trip to to Uganda through Mission Doctors Association. It is a short 5 minute video made while she was there.
3.) PSQI Announcements from Dan:
Hello and Happy Labor Day Weekend to everyone. We have a few announcements from your Quality Chief:

-All residents completing their Longitudinal QI projects this year received their first follow up email today. Please make sure to provide your group information and your project ideas. If you want to come up with group names, be my guest!
-UMMC is working on renovating/updating their incident reporting system, so that practice (much like we do at the VA) will soon be available to all of you!
-The next QIPS meeting is on October 12th! If you have an interest in QI and want to meet QI advocates from other departments, join us! There is free food 😊
-UMMC is constantly looking for more resident involvement in QI related activities or meetings. If you have an interest, please let me know, and I will connect you with Dr. Gulati.

-The VA is working on improving patient movement from the ED to the wards. A proposal is in place in which patients deemed to be clinically stable for the floors, may arrive on the floors prior to you seeing them in the ED. This should only happen if you have received a “warm” hand off from the ED provider. Additionally, the nurses are supposed to receive “warm” hand offs as well. Please be aware that patients may be coming upstairs earlier than expected. If you are not being notified of new admissions coming to floor, please notify me. We are working closely with the medical and nursing directors of the flow center to keep track of this change in our practice.
-Per Dr. Hochberg: Please note that there will be no Med/Surg Weekend Social Worker available on Saturday, 9/2/17. Med/Surg Social Work staff will return on Tuesday, 9/5/17, following the Labor Day holiday.
-As a reminder to all teams, please be sure to use the standardized H&P and Progress note templates every day. Remember that the standardized H&P is found as follows:

-A reminder to use the new Urine Culture Panel, when you are evaluating a patient for UTI, as this will reflex to culture.
-All senior residents: When new admissions arrive on the floor, make sure to edit the White Card, and add your attending to the white card. Alvin Kennedy and I are working on making the team lists accurate. The ED is not always placing accurate information in the admission order. You can go in and edit the information to the correct team and attending. This may help the ward clerks assign the correct teams. When your attendings change on service, you can also change the name of the attending on the white card to help expedite the assignment change in CPRS.

Have a great weekend!

Daniel J. Escobar, MD
Chief Resident of Patient Safety and Quality Improvement
Department of Internal Medicine
Baltimore Veteran’s Affairs Medical Center/UMMC

4.) Shout Outs:
Shout out to Sam Black for doing an outstanding job with running and documenting a rapid response at the VA, Jock Moore for staying late to help do an admission while on dayfloat and Adam Zviman for handling a tough family meeting in the MICU! Swing by the office to pick up your gift cards!

5.) Podcast of the week:
Instead of an article of the week, check out this incredible podcast by our very own Dr. Neda Frayha freaturing Art Cohen who retired yesterday after working for 45 years at UMMC.

RISE program: Available 24/7 for stressful clinically – related events. Pager #12602.
Employee Assistance Program: 410-328-5860 (anonymous)

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