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Internal medicine unites to improve transitions of care

From the October ACP Hospitalist, copyright © 2007 by the American College of Physicians

Experts from all areas of health care met in Philadelphia in July to discuss ways to improve transitions of care. The conference was a joint effort by the American College of Physicians (ACP), the Society of General Internal Medicine (SGIM) and the Society of Hospital Medicine (SHM) and was well attended by enthusiastic representatives from all areas of health care.

Kevin B. Weiss, FACP, chaired the conference steering committee as ACP's representative. Mark V. Williams, FACP, who represented SHM, and Doriane C. Miller, MD, who represented SGIM, served as co-chairs. Agenda items included review of current evidence on transitions between inpatient and outpatient care and the best methods of establishing quality improvement measures.

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Photo by Comstock Complete

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"Most health professionals know this is an issue. The time has come to deal with it," said ACP Regent William E. Golden, MACP, in his opening address to the group.

At the conference, Eric A. Coleman, ACP Member, presented research on four areas of transition in which patients saw strong need for improvement: information transfer among health care providers, preparation for patients and caregivers, provisions for self-management and patient empowerment.

"Patients are remarkably consistent in what they have to teach us," he said.

The experts—who included subspecialty physicians, government representatives, quality experts and various other health care providers—spent two days identifying the major threats to patient safety that occur during handoffs or transitions, as well as potential remedies. The work group included representatives from the nonphysician community, such as nurses and administrators, and emphasized their critical role, especially in home health care, case management and patient- and family-centered care. Beverly Johnson, BSN, president of the Institute for Family-Centered Care, urged the group not to focus single-mindedly on doctor-doctor relations.

"We shouldn't be thinking about doing this for patients. We should be thinking about doing it with patients and families," she said.

Solutions discussed included creating a transition record and improving communication among physicians. The work group's efforts will complement those of the American Board of Internal Medicine Foundation (ABIMF), which earlier this year launched a care coordination improvement alliance that includes nine physician organizations, including ACP and SHM.

The work group plans to compile a proposal and submit it this fall for endorsement by the leadership of ACP, SHM, SGIM and possibly other organizations.

Groups update coronary artery disease guidelines

The American College of Cardiology and the American Heart Association have revised their joint guidelines for managing patients with unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI).

Major changes to the guidelines, which were last published in 2002, include:

• Recommending different initial strategies for high- and low-risk patients, as defined by commonly used risk scores. Unstable and high-risk patients should have more invasive measures—i.e., diagnostic angiography and revascularization—while low-risk and stable patients should start with non-invasive measures like stress tests, echocardiography or radionuclide study;

• Using clopidogrel for at least one year after receiving a drug-eluting stent;

• Halting the use of non-steroidal anti-inflammatory drugs for patients during hospitalization;

• Prescribing ACE inhibitors and aldosterone receptor blockade after a patient is released from the hospital to prevent recurrent heart attack;

• Recommending stricter blood pressure and cholesterol management for UA/NSTEMI patients. LDL should be lower than 100 mg/dL; the ideal is 70 mg/dL. Blood pressure should fall below 140/90; those with diabetes and chronic heart disease should have a reading below 130/80;

• Stopping hormone replacement therapy in postmenopausal women.

The new guidelines reflect evidence from key trials over the past five years, a member of the guidelines writing committee said.

Second-generation smallpox vaccine approved

The FDA licensed a new smallpox vaccine, ACAM2000, to inoculate people at high risk of exposure, as well as for use during a bioterrorist attack.

ACAM2000 supplements the current supply of smallpox vaccine, making the nation more prepared should the virus ever be used as a weapon, an FDA release said. The vaccine will be included in the CDC's Strategic National Stockpile of medical supplies.

ACAM2000 is made using a live form of the smallpox-related vaccinia virus. The vaccine is derived from the only other smallpox vaccine licensed by the FDA, Dryvax, approved in 1931 and now in limited supply because it is no longer manufactured.

Although smallpox vaccination ended in the U.S. in 1972, the U.S. military resumed vaccination of at-risk personnel in 1999, after concluding that the disease posed a potential bioterrorism threat. The last case of naturally occurring smallpox in the U.S. was in 1949 and the last case in the world was reported in Somalia in 1977.

Known stockpiles of the virus are kept only in two approved labs in the U.S. and Russia. The CDC considers it a Category A agent, meaning it presents one of the greatest potential threats for harming public health.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated