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April 15, 2014 Issue

Clinical Practice Points


Patient Care
Medical Knowledge

The CAM-S: Development and Validation of a New Scoring System for Delirium Severity in 2 Cohorts

Delirium is a common condition among hospitalized older patients and is associated with poor outcomes. This study validates a novel scale for delirium severity based on the Confusion Assessment Method and demonstrates the relationship between patients’ delirium severity scores and clinical outcomes.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Use the accompanying editorial by Eubank and Covinsky to quickly review why delirium and this study are important.
  • Review the definition of delirium. Ask if all delirious patients seem agitated (the answer is no). Ask your learners to define “hypoactive delirium.”
  • Use the Confusion Assessment Method to assess whether patients are delirious during bedside rounds with your team. With a little practice, assessing whether a patient is delirious takes only a minute or two.
  • Ask what the causes of delirium are in hospitalized patients. Are tests usually needed (e.g., a computed tomography scan of the head)? Ask what simple interventions might be better than medications to manage the delirium. When and what medications should be used?
  • Use a recent In The Clinic on Delirium, which provides the answers to these questions, additional multiple-choice questions, and already prepared slides to use for teaching.


Practice Based Learning and Improvement

Virtual Autopsy With Multiphase Postmortem Computed Tomographic Angiography Versus Traditional Medical Autopsy to Investigate Unexpected Deaths of Hospitalized Patients. A Cohort Study

“Virtual” autopsy by postmortem computed tomography can replace medical autopsy to a certain extent but has limitations for cardiovascular diseases. This study found that the addition of angiography to postmortem computed tomography resulted in the ability to detect cardiovascular diagnoses similar to that of traditional medical autopsy.

Use this study to:

  • Ask about the value of an autopsy. What might we learn about the care we did or did not provide? How might the results of autopsies help quality-improvement efforts at your hospital?
  • Look at the videos that accompany this paper (click on the supplemental video links) to see how the computer-generated reconstruction helped identify pathology. Look at the frontal CXR at the end of Supplemental Video 3 and ask if your learners could have identified the misplaced central venous catheter.
  • Ask why the number of autopsies has decreased. Have doctors lost interest, thinking there is little to be learned? Do they fear litigation based on the findings? Do families think they will need to pay for them? Do autopsies interfere with funeral plans or an open-casket service?
  • Do a role-play activity where learners ask a family whether they would like an autopsy performed. How should the benefits of an autopsy be explained? What questions do families ask?
  • Arrange for your team to review the autopsy results of a patient of yours who died (gross dissection and histology) with a pathologist. Ask your learners to commit to doing this for all of their patients who have an autopsy. Do they think it is worthwhile, or perhaps even their responsibility?

The Business of Medicine


Systems-based Practice
Professionalism
Patient Care

Value-Based Payment for Physicians in Medicare: Small Step or Giant Leap?

The Physician Value-Based Payment Modifier (PVBPM) is the first national value-based purchasing program for physicians in fee-for-service Medicare. The concept of shifting from volume- to value-based payment embodied by the PVBPM is a radical change for the Medicare program. This article discusses the implementation challenges associated with this reform and what they mean for the future of the PVBPM.

Use this article to:

  • Invite an expert in healthcare economics or your hospital’s chief medical officer to discuss how value-based purchasing and payment programs are changing how things are done in your health system.
  • Ask about the advantages and disadvantages to value-based purchasing and payment programs.
  • What are the challenges in measuring and comparing "value"?
  • Who might win and who might lose in these systems? Will they be fair to everyone?

Professionalism
Interpersonal and Communication Skills

On Being a Doctor: Dancing on Thursdays

In this essay, Dr. Burns describes the loving and attentive care provided to a patient by her partner and the conflict that occurs when that care is challenged.

Use this essay to:

  • Play the audio recording of a reading of this On Being a Doctor essay to your group.
  • Ask your learners to recall the things they have seen loved ones do to care for each other.
  • Ask how they think Helen’s departure to a nursing home might affect her health. What about Edward’s health?
  • Ask your learners if they think Helen’s physician should call her family to discuss plans for her care and discuss Edward’s involvement. Is it the physician’s responsibility?

Video Learning


Medical Knowledge

The Consult Guys: Blindness After Surgery

This short medical consult talk show will entertain you while it teaches your team important pearls for consultative internal medicine. Play this month’s video and see if your team can figure out what caused this patient’s loss of vision. Be sure to answer the brief quiz to earn CME credit for yourself!


mksap16

A 66-year-old woman is admitted to the hospital after falling at home and dislocating her artificial hip. The next day she becomes acutely short of breath and is transferred to the intensive care unit. She is diagnosed with acute pulmonary embolism and a heparin infusion is started. Her pain is managed with a patient-controlled intravenous analgesia pump. She undergoes closed reduction of her dislocated hip the following day, with temporary interruption of her anticoagulation. The day after her hip reduction, she is more comfortable and her pain medication requirements are lower. On day five, however, she becomes agitated and fearful, alternating with periods of inattention and somnolence.

On physical examination, vital signs are normal. She is awake but lethargic. It is difficult to obtain a history because of her inattentiveness. The cardiopulmonary examination is normal. There are no focal deficits on the neurologic examination. Results of arterial blood gas analysis are normal.

Which of the following is the most likely diagnosis?

A. Acute hemorrhagic stroke
B. Acute respiratory failure
C. Delirium
D. Opioid withdrawal
E. Recurrent thromboembolism

Correct Answer
C. Delirium

Key Point
Delirium, defined by fluctuating mental status, is common in the intensive care unit and should be controlled to ensure patients' safety and to allow appropriate evaluation.

Educational Objective
Diagnose delirium in the intensive care unit.

The most likely diagnosis is delirium. Delirium is an acute state of confusion that may manifest as a reduced level of consciousness, cognitive abnormalities, perceptual disturbances, or emotional disturbances. It is common in the intensive care unit and should be controlled to ensure patients' safety and to allow appropriate evaluation. Delirium is classified according to psychomotor behavior as hyperactive, hypoactive, and mixed. Pure hyperactive delirium, which accounts for less than 5% of cases of intensive care unit delirium, is characterized by increased psychomotor activity with agitated behavior. Hypoactive or quiet delirium, which accounts for approximately 45% of cases, is characterized by reduced psychomotor behavior and lethargy. Mixed delirium, which accounts for approximately 50% of cases, alternates unpredictably between a hyperactive and a hypoactive manifestation.

An acute stroke is unlikely to cause fluctuating neurologic or cognitive deficits. A hemorrhagic stroke may certainly evolve, producing progressively worsening deficits, but alternating agitation and somnolence would not be typical.

There is no evidence for respiratory failure in this patient. Her arterial blood gas studies and vital signs are normal.

This patient has not been receiving opioids long enough to develop physical dependence and thus be at risk for withdrawal.

Fluctuating mental status would be an unlikely result of a recurrent pulmonary embolism. The interruption of this patient's anticoagulation for a period of a few hours for her hip reduction increases the risk of a recurrent embolism; however, this patient does not have hypoxemia or respiratory distress, which would most likely be evident if she had a recurrent embolism.

Bibliography
Schiemann A, Hadzidiakos D, Spies C. Managing ICU delirium [erratum in Curr Opin Crit Care. 2011;17(3):315]. Curr Opin Crit Care. 2011;17(2):131-140. PMID: 21301333

This question was derived from MKSAP® 16, the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.

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