QI Committee

How many times have you ordered a TSH/T4 on a hospitalized patient? If the test returns abnormal, it may have you wondering what to do – is further testing needed, or should you start the patient on levothyroxine? This Journal of Hospital Medicine article addresses the nuances of inpatient thyroid function testing.

Key Points:

• Nonthyroidal illness syndrome (NTIS), also known as sick euthyroid syndrome, is the biggest confounder of TSH testing in the hospital.
• NTIS can be caused by a host of other common clinical conditions among inpatients: infection, kidney or liver injury, malnutrition, MI, stroke, malignancy, or recent surgery.
• The prevalence of NTIS is 62%, while the prevalence of true unrecognized thyroid disease in inpatients is 1-2.5%. The high prevalence of NTIS means the specificity of TSH testing in inpatients is low.

When should we not order thyroid testing?

• Do NOT routinely order TSH on admission
• Do NOT order for patients on stable doses of thyroid hormone replacement

When should we actually order thyroid testing?

• Only if you have high clinical suspicion (I.e., high pretest probability) for thyroid dysfunction, specifically if there are 5+ symptoms
• May be reasonable in specific clinical scenarios where thyroid dysfunction is a reversible cause, such as: atrial fibrillation, SIADH, unexplained sinus tachycardia (after more common causes have been excluded), and delirium (after more common causes have been excluded)
• If NTIS is suspected, avoid further inpatient testing and consider outpatient testing once acute illness as resolved

How does decreasing inpatient thyroid testing benefit us?

• Saves healthcare dollars
• Prevents patient harm associated with overcasting or over treatment
• Decreases provider time spent ordering and interpreting abnormal results of unclear significance

Wendy Tong, IM PGY-2

Citation: Wootton T, Bates R. Things we do for no reason: routine thyroid-stimulating hormone testing in the hospital. J Hosp Med. 2020; 15(9): 560-562. doi:10.12788/jhm.3347

Why is hypokalemia dangerous?

• Symptoms can manifest below a K of 3.0 mEq/L, with severe symptoms (muscle weakness, rhabdomyolysis, respiratory weakness, ileus, nausea/vomiting, and arrhythmias) not usually developing until K <2.5 mEq/L
• In patients with cirrhosis, hypokalemia is associated with worsening hepatic encephalopathy
• In patients with structural heart disease, heart failure or taking antiarrhythmics, they are also at higher risk for arrhythmias with hypokalemia
• In patients with myocardial infarction, hypokalemia is associated with increased frequency of ventricular arrhythmias and death

Why not just replete everyone?

• Increased nursing and physician workload
• Increased cost
• Patient discomfort and GI upset from PO repletion options
• Burning and pain from IV repletion options
• Hyperkalemia carries significant risk as well if patients are over-repleted or develop AKI

What should we aim for in the inpatient setting?

• K of 3.5-4.0 mEq/L for patients with cirrhosis and heart disease (MI, HF, arrhythmias)
• K of 3.0-3.5 mEq/L is likely safe for all other patients who are asymptomatic
  • Exceptions include patients who are significantly total body potassium depleted (DKA, severe malnutrition, etc.)

References and More Reading:https://twitter.com/tony_breu/status/1092539740287631367

Hypokalemia in acute medical patients: risk factors and prognosis

#195 TWDFNR 3: Potassium, Oxygen, and Antipsychotics

1/
Why do we administer potassium to a goal of ≥4.0 mEq/L?

As an intern, potassium (oral or IV) was likely my most common order. How did this become a key part of inpatient providers' days?

Let's have a look at potassium and find out why we "replete".

— Tony Breu (@tony_breu) February 4, 2019

Should we use sliding-scale insulin as monotherapy for hospitalized diabetic patients?

Slide-scale insulin (SSI) is a method to correct hyperglycemia through frequent dosing of short acting insulin based on a patient’s blood glucose and pre-set rubric. When blood glucose is low little or no insulin is given and when blood glucose is elevated higher doses are administered. A recent publication by the Journal of Hospital Medicine addresses this common practice of managing hospitalized diabetic patients with SSI alone.

 Where did this practice of SSI as monotherapy come from?

• First popularized by Joslin in 1934 it remains a popular strategy. In 2007 a survey of 44 hospitals found 43% of non-critically ill patients with hyperglycemia were treated with SSI alone.
• Inpatient providers not wanting to cause hypoglycemia may sometimes as a more conservative and convenient given ready-made order sets

Key Points                  

• SSI monotherapy does not replicate normal pancreatic physiology of basal insulin secretion indirectly suppressing hepatic gluconeogenesis nor meal-associated insulin stimulated uptake glucose uptake.
• SSI monotherapy is ineffective and potentially harmful. SSI is a reactive strategy and in two large systematic review has never been shown to prevent hyperglycemia in hospitalized patients.
• Patients on SSI monotherapy were at a 3-fold increased risk of developing hyperglycemia vs. SSI with other forms of insulin and may be more likely to have increased hospital length of stay.
• Basal insulin added to SSI when dosed carefully does not increase the risk of hypoglycemia.
• What should you do instead?
  • A weight-based dosing basal plus prandial and correctional insulin regimen. The RABBIT 2 trial, involving T2DM patients, used a total daily dose of 0.4 units / kg for patients with blood sugar ≤200 mg/dL and 0.5 units/kg for those with higher initial glucose levels. Half of the total daily dose given to basal and other half divided among meals. Caution with patients > 70 yo, impaired GFR, or on fluctuating steroid doses.
  • For the insulin naïve or patients whose home diabetic regimen is in question, it could be reasonable start with SSI as monotherapy for 24 hours to inform subsequent insulin dosing. This “dose finding” method has not been validated in the literature.

Ambrus DB, O’Connor MJ. Things We Do For No Reason: Sliding-Scale Insulin as Monotherapy for Glycemic Control in Hospitalized Patients. J Hosp Med. 2019 Feb 1;14(2):114-116. doi: 10.12788/jhm.3109. Epub 2018 Nov 28. PMID: 30534639.

Kristen Lee MD, PGY3

What happens when you file a NETS report?

1. Risk department will review the case
   1. 1. 1. Will advise on any legal exposure and claims.
         2. Help with family disclosure.
         3. Advice with documentation regarding the incident.
2. Clinical Care Evaluation Committee and Chief Medical Officer will review the case.
   1. 1. 1. Perform root cause analysis.
         2. Suggest systemic fixes and provide staff education.
3. You may be asked to present to a committee to better understand the error or near miss and brainstorm solutions.

Why should you file a NETS report?

1. To prevent it from happening again.
2. To involve all institutional resources.
3. To provide education to all involved parties.
4. To help make Northwestern a better hospital.

How to file a NETS report:

NETS Report

Does metformin need to be routinely held in the hospitalized patient?

Metformin is a widely prescribed oral medication used in the management of type 2 diabetes mellitus. It is routine practice to hold metformin in the hospitalized patient due to risk of metformin-associated lactic acidosis (MALA). A recent publication by the Journal of Hospital Medicine addresses this common practice.

Key points:

• Metformin shunts metabolism towards anaerobic respiration, increasing production of lactic acid. Metformin is renally cleared and the risk of developing MALA increases with renal impairment.
• Given that acute kidney injury (AKI) is a common inpatient condition (20% of all inpatient and 50% of intensive care patients) as well as the disease states that increase risk of AKI, metformin is reflexively held by clinicians for all hospitalized patients.
• MALA is exceedingly rare. Since an initial report of 47 cases of MALA to the FDA, repeated studies and systematic reviews have disputed the link between metformin and lactic acidosis, particularly in the absence of significant risk factors or in patients with an eGFR > 30 mL/min/1.73 m2.
• Holding metformin poses risk of harm. Continuing metformin maintains steady blood glucose control and the practice of replacing metformin with correctional insulin monotherapy increases risk of hyperglycemia and is associated with increased length of stay.
• Clinicians should thus consider continuing metformin in all hospitalized patients in the absence of the disease states that increase risk of MALA and contrast-related indications. These include:

1. High risk for or currently suffering from decompensated heart failure, severe sepsis, or other disease states resulting in hypoxia or tissue hypoperfusion
2. An eGFR <30 mL/min/1.73 m2 or AKI; resume metformin when the AKI resolves
3. COVID‐19 infection, until the risk of hypoxia has resolved
4. IV contrast study in the presence of acute renal failure or an eGFR <30 mL/min/1.73 m2; resume metformin 48 hours after contrast administration.
5. Intra‐arterial catheter study that might result in renal artery emboli; resume metformin when renal function normalizes.

Cohen DA, Ricotta DN, Parikh PD. Things We Do for No Reason^TM: Routinely holding metformin in the hospital. J Hosp Med. 2022;17:207‐210. doi:10.12788/jhm.3644

• Andrew Tout, PGY3

In the process of every admission , Epic requires the admitting provider to select the method of venous thromboembolism (VTE) prophylaxis or a contraindication before the orders can be signed. Further, VTE prophylaxis is on many of our admission checklists as topics that must be addressed prior to completing the admission. However, in these low-risk patients, is universal VTE prophylaxis necessary?

A recent publication in the Journal of Hospital Medicine addresses this.

Summary:

• While inpatient VTE including deep vein thrombosis (DVT) and pulmonary embolism (PE) cause significant in-hospital mortality (estimated at 5-10% of in-hospital death, these data come from analysis of patients at high risk of VTE.
• Further, studies may overstate the benefit of universal VTE prophylaxis given that many used asymptomatic VTE discovered on ultrasound or venography as a significant portion of the composite outcome.
• The use of VTE poses risks to the patient as well including bleeding/hemorrhage, heparin-induced thrombocytopenia, and, most commonly, injection site discomfort/pain.
• Consider the use of Risk Assessment Models (Table) to aid in the stratification of VTE risk. In patients who are at low risk of VTE, consider listing their contraindication to VTE prophylaxis as “low risk for VTE” when flagged by Epic.
• Encourage early mobilization further reduce VTE risk.

Barlow, B. , Barlow, A. & Breu, A. C. (2021). Things We Do for No Reason™. Journal of Hospital Medicine, 16 (5), 301-303. doi: 10.12788/jhm.3502.

A Choosing Wisely: Things we do for no reason article addresses the use for antipsychotics and when they are appropriate. Highlights below:

• Approximately 25% of hospitalized patients experience delirium during their stay.
• 10-30% of hospitalized patients are prescribed antipsychotics.
• A systemic review from the Journal of the American Geriatric Society (2016) by Neufeld et al. included 19 studies and found that antipsychotics did not change the severity of delirium, length of delirium, or length of hospital stay.
• The American Geriatrics Society recommends against antipsychotics in older adults with postoperative delirium unless they are agitated or a threat to themselves or others.
• Recommendations from Choosing Wisely to limit the use of antipsychotics:
  • Assess for modifiable factors: meds, pain electrolytes, infection, alcohol withdrawal. Assess if invasive lines can be discontinued.
  • Try behavioral interventions and delirium precautions.
  • If a patient poses a risk of harm to themselves or others, use the lowest effective dose for the shortest possible duration of time.

Citation: Pahwa AK, Qureshi I, Cumbler E. Things We Do For No Reason: Use of Antipsychotic Medications in Patients with Delirium. J Hosp Med. 2019 Mar 20;14:E1-E3. doi: 10.12788/jhm.3166. Epub ahead of print. PMID: 30897059.