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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5537_Библиотеки_им_академика_М_И_Перельмана.pdf
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- •Contents
- •List of Contributors
- •Hospitalists as Leaders
- •Key Pearls
- •Challenges
- •The Future
- •References
- •Key Clinical Pearls
- •Introduction
- •The Path to Leadership
- •Leading in Care Delivery
- •Leading in Hospital Quality and Patient Safety
- •Leading in Education
- •Introduction
- •Diagnosis
- •Clinical Scenario
- •Diagnosis Study
- •Discussion
- •Prognosis
- •Clinical Scenario
- •Prognosis Study
- •Discussion
- •Therapy
- •Clinical Scenario
- •Therapy Trial
- •Discussion
- •Economics
- •Clinical Scenario
- •Economics Study
- •Economics Criteria
- •Discussion
- •References
- •Key Pearls
- •Introduction
- •A New Paradigm: The Evidence Hierarchy
- •Becoming an Evidence-based Practitioner
- •Answering Questions
- •Resources to Answer Background Questions
- •Resources to Answer Foreground Questions
- •Summary
- •References
- •Key Pearls
- •Introduction
- •The Clinical Exam as Diagnostic Test
- •Assessing Volume Status
- •Acute Blood Loss
- •Non-Blood Loss Causes of Hypovolemia
- •How to Perform Postural Vital Signs
- •Cardiac Murmurs
- •Systolic Murmurs
- •Aortic Stenosis
- •How to Perform the Useful Physical Exam for Aortic Stenosis
- •Mitral Regurgitation
- •How to Examine the Useful Physical Exam for Mitral Regurgitation
- •Diastolic Murmurs
- •Aortic Insufficiency
- •How to Perform the Useful Physical Exam for Aortic Insufficiency
- •Hepatomegaly
- •How to Perform the Useful Physical Exam to Assess Hepatomegaly
- •Ascites
- •How to Perform the Useful Physical Exam to Assess for Ascites
- •Central Venous Pressure
- •Evaluation of JVP
- •Abdominojugular Reflux Test
- •Kussmaul Sign
- •Pleural Effusion
- •How to Perform the Useful Physical Exam
- •Conventional Percussion
- •Chest Expansion
- •Tactile Fremitus
- •References
- •Patient Safety and Hospital Quality
- •Key Pearls
- •Background
- •Communication Standards
- •Systematic Approaches
- •Conclusions
- •References
- •Key Pearls
- •Accountability
- •Causal Factors of Error (Swiss cheese model)
- •Reporting
- •Root Cause Analysis
- •Disclosure
- •References
- •Key Pearls
- •Introduction
- •Key Pearls
- •Background and Essential Elements of Teamwork
- •Quality
- •Choosing Performance Improvement Targets
- •Do Your Homework — Gather Baseline Data
- •Form the Right Team
- •Define Goals
- •Break Down the Problem — Process Maps
- •Collect Data
- •Analyze the Findings
- •Implement Change
- •Measure, Track and Repeat
- •Summary
- •References
- •Challenges to Improving Teamwork
- •Assessment of Teamwork
- •Examples of Successful Interventions
- •Team Training
- •Daily Goals of Care
- •Interdisciplinary Rounds
- •Nurse-Physician Unit Co-Leadership
- •Conclusions
- •References
- •Key Pearls
- •Background
- •Barriers
- •Successful Strategies
- •Remaining Challenges
- •References
- •Key Pearls
- •Required Components of the Discharge Process
- •Optional Components of the Discharge Process
- •Conclusions
- •References
- •Key Pearls
- •Introduction
- •Drivers for Health Information Technology
- •The Electronic Health Record
- •Clinical Decision Support (CDS)
- •The Risks and Benefits of HIT
- •Roles for Hospitalists in Health Informatics
- •Conclusion
- •References
- •Business of Hospital Medicine
- •Key Pearls
- •Introduction
- •Hospitalist Movement a Way Out to Provide Cost Effective Treatment
- •Business Plan for a Hospitalist Program
- •Staffing Structure of the Program
- •Cost Projection
- •Revenue Generation
- •Business Plan Outline and Factors
- •References
- •Key Pearls
- •Metrics
- •Volume
- •Length of Stay
- •Patient Protection and Affordable Care Act (PPACA)
- •Avoidable re-admissions
- •Hospital-acquired conditions
- •Clinical Documentation
- •MS-DRG
- •APR-DRG
- •Satisfaction Surveys
- •Medical Necessity
- •Recovery Audit Contractor (RAC)
- •Concurrent Review
- •Retrospective Denial
- •Dashboards
- •Aligning Interests
- •References
- •Key Pearls
- •Introduction
- •Hospitalist Coding
- •Documenting E&M Codes for Initial and Subsequent Visits
- •Chief Complaint
- •History
- •Physical Exam
- •Medical Decision Making
- •Determining Which Code to Use
- •Documenting E&M Codes for Discharge Day Visits
- •Documenting E&M Codes for Consultation Visits
- •Conclusion
- •References
- •Key Pearls
- •Definition of Non-Physician Practitioners (NPPs)
- •Quality and Cost-Effectiveness of NPs and PAs Care
- •NPPs Roles and Responsibilities
- •Autonomy and Scope of Practice
- •NPPs in Academic Centers
- •NPPs in Small Community Hospital
- •NPPs in Private Physician Hospitalist Service
- •Potential Pitfalls of Collaboration
- •Reimbursement and Billing
- •References
- •Hospitalist as Educator
- •Key Pearls
- •Tips for Teaching that Won’t Slow you Down (Too Much)
- •Teaching Different Levels of Learners
- •The Microskills of Clinical Teaching
- •Example of the Microskills in Action
- •Pearls for Giving Meaningful Feedback with Less Stress
- •Making Time for Teaching
- •References
- •Key Pearls
- •Introduction
- •Framework
- •Set the Stage with Learners — What to Do Before Entering the Room
- •1. Establish your goals ahead of time
- •2. State your established goals clearly to the group
- •3. Define roles and responsibilities
- •4. Establish that there will be debriefing and feedback after the encounter
- •Orient the Patient — What to Do When you Enter the Room
- •1. Introductions
- •2. Explain the goals and structure of the encounter to the patient
- •3. Elicit any additional goals from the patient
- •Key Principles to Follow at the Bedside
- •1. Follow your pre-arranged structure
- •2. Maintain patient respect
- •3. Maintain learner respect
- •Debrief — Outside the Room
- •1. Provide learner-specific feedback
- •2. Elicit feedback about the session
- •Summary
- •References
- •Cardiology
- •Key Pearls
- •Key History Elements and Physical Exam Findings
- •Differential Diagnosis
- •Cardiac Testing
- •Chest Pain Units
- •Conclusion
- •References
- •Key Pearls
- •Definitition and Pathophysiology
- •Diagnosis
- •ECG Evaluation
- •History
- •Physical Exam
- •Cardiac Biomarkers
- •Initial Treatment and Stabilization
- •UA/NSTEMI
- •STEMI
- •Transition to Maintenance Therapy
- •Quality Measures in Acute Coronary Syndromes
- •References
- •Key Pearls
- •Introduction
- •Clinical Profiles
- •Diagnostic Strategies
- •Outcomes of Acute Heart Failure
- •Management of Acute Heart Failure
- •Diuretics
- •Vasodilators
- •Inotropes
- •Transition Home
- •Conclusion
- •References
- •Key Pearls
- •Introduction
- •Aortic Stenosis (AS)
- •Etiology
- •History and Physical
- •Diagnosis and Testing
- •Treatment
- •Mitral Stenosis (MS)
- •Etiology
- •History and Physical
- •Diagnosis and Testing
- •Treatment
- •Aortic Regurgitation (AR)
- •Etiology
- •History and Physical
- •Diagnosis and Testing
- •Treatment
- •Mitral Regurgitation (MR)
- •Etiology
- •History and Physical
- •Diagnosis and Testing
- •Treatment
- •References
- •Key Pearls
- •Introduction
- •Epidemiology
- •Etiologies and Associated Conditions
- •Clinical Findings
- •History and Physical Examination
- •Electrocardiogram
- •Echocardiography
- •Additional Laboratory Evaluation
- •Management
- •Rate Control
- •Stroke Risk Assessment
- •Antithrombotic Therapy
- •Rhythm Control
- •Cardioversion
- •Maintenance of sinus rhythm
- •Future Trends
- •References
- •Key Pearls
- •Introduction
- •Role of the Electrophysiology Study
- •Bradyarrhythmias
- •Tachyarrhythmias
- •Supraventricular Arrhythmias
- •Regular Narrow Complex Tachycardia with a Short RP Interval
- •AV-nodal re-entrant tachycardia
- •AV re-entrant tachycardia
- •Atrial tachycardia
- •Ventricular Arrhythmias
- •Ventricular Tachycardia in the Absence of Structural Heart Disease (Idiopathic VT)
- •Left bundle branch block VT
- •Right bundle branch block VT
- •Ventricular Tachycardia in the Presence of Structural Heart Disease
- •Ischemic cardiomyopathy
- •Nonischemic cardiomyopathy
- •References
- •Key Pearls
- •Introduction
- •Incidence and Etiology
- •Pathophysiology
- •Clinical Presentation
- •Ophthalmic Manifestations
- •Neurological Changes (Hypertensive Encephalopathy)
- •Cardiovascular Complications
- •The Kidney
- •Hematological Changes
- •Clinical Evaluation (Table 2)
- •Treatment
- •Hypertensive Urgency (Table 3)
- •Hypertensive Emergency (Table 4)
- •Specific Situations (Table 5)
- •References
- •Key Pearls
- •Introduction
- •Patient History
- •Physical Examination
- •Cardiac Syncope: Arrhythmia and Structural Heart Disease
- •Select Options for Monitoring and Diagnostic Evaluation
- •References
- •Pulmonary
- •Key Pearls
- •Pathophysiology
- •Diagnosis
- •Clinical History
- •Physical Examination
- •General Appearance
- •Vital Signs
- •Chest
- •Cardiac Exam
- •Extremities
- •Neurologic
- •Basic Diagnostic Testing
- •Advanced Diagnostic Testing
- •Differential Diagnosis
- •Early Management of the Acutely Dyspneic Patient
- •Key Management Strategies
- •References
- •Key Pearls
- •Introduction
- •Definition, Precipitating Factors and Mortality Risk
- •Evaluation of Patients Hospitalized with an Asthma Exacerbation
- •History
- •Physical Examination
- •Objective Testing
- •Management of Patients Hospitalized with an Asthma Exacerbation
- •Medications
- •Adjunct Therapy
- •Monitoring Parameters
- •Treatment of Comorbid Conditions
- •When to Consult a Specialist
- •Goals for Discharge
- •Summary
- •References
- •Key Pearls
- •Introduction
- •Acute Exacerbations
- •Treatment of Acute Exacerbations
- •Conclusions
- •References
- •Key Pearls
- •Introduction
- •Clinical Evaluation
- •History
- •Clinical Exam
- •Radiologic Evaluation
- •Pulmonary Function Testing, Echocardiography, Laboratory Data and Ancillary Testing
- •Surgical Lung Biopsy
- •Management of DPLD
- •References
- •Key Pearls
- •Introduction
- •Definition
- •Classification
- •Clinical Presentation
- •Evaluation (see Fig. 1)
- •Medical Treatment
- •Surgical Treatment
- •Prognosis
- •References
- •Critical Care
- •Key Pearls
- •Introduction
- •Definitions, Pathophysiology, and Epidemiology
- •What Is SIRS/Sepsis/Severe Sepsis/ Sepsis with Shock
- •What Causes Sepsis
- •What Causes Shock in Sepsis
- •What Is the Cause of Microcirculatory Disturbance in Sepsis
- •Sepsis Recognition and Intervention: Principles and Action Plan
- •Key Recognition Principles and Guidelines
- •Key Intervention Principles
- •Role of Monitoring: What to Measure — When and How Reliable
- •Other Therapeutic Considerations/Controversies
- •Outcome Analysis and Prognosis
- •References
- •Key Pearls
- •Introduction
- •Initiation of Mechanical Ventilation
- •Modes and Settings
- •Monitoring and Supportive Care
- •Monitoring
- •Supportive Care
- •Disease-Specific Conditions and Ventilator Management
- •Obstructive Lung Disease
- •Acute Respiratory Distress Syndrome/ Acute Lung Injury
- •Evaluation of Respiratory Distress in the Mechanically Ventilated Patient
- •Liberation from the Mechanical Ventilator
- •References
- •Key Pearls
- •Glucose Goals
- •Insulin IV Infusion
- •Glucose Monitoring
- •Calculation of SC Insulin Doses
- •References
- •Renal
- •Key Pearls
- •Introduction
- •Common Reasons for ESRD-related Hospitalization
- •Infections
- •Catheter-related Bacteremia
- •Catheter-associated Peritonitis
- •Volume Overload
- •Vascular Access Issues
- •Steal Syndrome
- •Aneurysms
- •Hyperkalemia
- •Tips for Managing Hospitalized ESRD Patients
- •Orders
- •Daily Weights
- •Renal Diet
- •Labs
- •Medications
- •Ancillary Studies
- •Opportunity for Renal Replacement Therapy Preparation and Re-Evaluation During Inpatient Hospitalization
- •References
- •Key Pearls
- •Introduction
- •Initial Workup of AKI
- •Categories of AKI
- •Prerenal AKI
- •Definition
- •Diagnosis
- •Treatment
- •Intrarenal (Intrinsic) AKI
- •Definition
- •Diagnosis
- •Treatment
- •Prevention of Contrast-Induced Nephropathy
- •Prognosis of CIN
- •Prevention of CIN
- •Postrenal AKI
- •Diagnosis
- •Treatment
- •Intravenous Fluids for Postobstructive Diuresis
- •Parameters to Monitor in Postobstructive Diuresis
- •Medications and Procedures in AKI
- •Renal Consult for AKI
- •References
- •Key Pearls
- •Initial Considerations
- •Metabolic Acidosis
- •Causes
- •Clinical Manifestations
- •Compensatory Mechanisms
- •Diagnosis
- •Treatment
- •Metabolic Alkalosis
- •Clinical Manifestations
- •Compensatory Mechanisms
- •Diagnosis
- •Treatment
- •Respiratory Acidosis
- •Clinical Manifestations
- •Compensatory Mechanisms
- •Diagnosis
- •Treatment
- •Respiratory Alkalosis
- •Clinical Manifestations
- •Compensatory Mechanisms
- •Diagnosis
- •Treatment
- •Mixed Acid-Base Disorders
- •Interpretation of Blood Gas Measurements
- •References
- •Key Pearls
- •General Concepts
- •Hyponatremia
- •Workup
- •History
- •Physical exam
- •Labs
- •Treatment
- •Hypernatremia
- •Workup
- •History
- •Physical exam
- •Labs
- •Treatment
- •References
- •Key Pearls
- •Introduction
- •Hyperkalemia
- •Etiology
- •Clinical Manifestations
- •Signs and Symptoms
- •ECG Manifestations
- •Workup
- •Transtubular potassium concentration gradient
- •Plasma Aldosterone Concentration and Plasma Renin Activity
- •Treatment
- •Hypokalemia
- •Etiology
- •Clinical Manifestations
- •Signs and Symptoms
- •ECG Manifestations
- •Workup
- •Random Urine Potassium–Creatinine Ratio
- •24 hr Urinary Potassium Excretion
- •PAC, PRA and PAC/PRA Ratio
- •Treatment
- •References
- •Key Pearls
- •Appendicitis
- •Clinical Presentation
- •Management
- •Acute Cholecystitis
- •Clinical Presentation
- •Management
- •Diverticulitis
- •Clinical Presentation
- •Management
- •Bowel Ischemia
- •Acute Mesenteric Ischemia
- •Clinical Presentation
- •Management
- •Colonic Ischemia
- •Clinical Presentation
- •Management
- •Iatrogenic Abdominal Pain
- •Urological/Renal or Gynecological Causes of Abdominal Pain
- •General Concerns
- •Pain Management

Thomas H. Kalb
Feinstein Institute
Hofstra School of Medicine
New York, NY
USA
Surinder Kaul
Baylor College of Medicine
Houston, TX
USA
Leslie Dubin Kerr
Mount Sinai School of Medicine
New York, NY
USA
Sarah Kharkhanechi
McMaster University
Hamilton, ON
Canada
June Kim
Mount Sinai School of Medicine
New York, NY
USA
Michael C. Kim
Mount Sinai Medical Center
New York, NY
USA
Tonia K. Kim
Mount Sinai School of Medicine
New York, NY
USA
Deborah R. Korenstein
Mount Sinai School of Medicine
New York, NY
USA
Maria E. Lamothe
Mount Sinai School of Medicine
New York, NY
USA
Kyle Lapidus
Mount Sinai Medical Center
New York, NY
USA
Mikyung Lee
Mount Sinai School of Medicine
New York, NY
USA
Alice C. Levine
Mount Sinai School of Medicine
New York, NY
USA
Teresa Lim
Mount Sinai School of Medicine
New York, NY
USA
Evgenia Litrivis
Mount Sinai School of Medicine
New York, NY
USA
xx
List of Contributors

Richard MacKay
Mount Sinai School of Medicine
New York, NY
USA
Charles E. Mahan
New Mexico Heart Institute
Albuquerque, New Mexcio
USA;
University of New Mexico College
of Pharmacy
Albuquerque, New Mexcio
USA
Lara V. Marcuse
Mount Sinai School of Medicine
New York, NY
USA
Deborah B. Marin
Mount Sinai School of Medicine
New York, NY
USA
Brian A. Markoff
Mount Sinai School of Medicine
New York, NY
USA
Joseph R. Masci
Elmhurst Hospital Center
Elmhurst, New York
USA
Jeffrey I. Mechanick
Mount Sinai School of Medicine
New York, NY
USA
Raj K. Medapalli
Mount Sinai School of Medicine
New York, NY
USA
Marc Miller
Mount Sinai School of Medicine
New York, NY
USA
Noga C. Minsky
Mount Sinai School of Medicine
New York, NY
USA
Somnath Mookherjee
University of California
San Francisco, CA
USA
Adam S. Morgenthau
Mount Sinai School of Medicine
New York, NY 10029
USA
Thanu Nadarajah
McMaster University
Hamilton, ON
Canada
xxi
List of Contributors

xxii
Niru S. Nahar
Haslem Hospital Center
New York, NY
USA
Ajith P. Nair
Mount Sinai School of Medicine
New York, NY
USA
Rajeev L. Narayan
Mount Sinai School of Medicine
New York, NY
USA
Ira S. Nash
Mount Sinai Medical Center
New York, NY
USA
Kathy Navid
Mount Sinai Queens Hospital
Long Island City, NY
USA
Sofia Novak
North Shore-Long Island Jewish
Health System
Lake Success, NY
USA
Vladan Novakovic
Mount Sinai School of Medicine
New York, NY
USA;
James J. Peters Veterans Affairs
Hospital
Bronx, NY
USA
Kevin J. O’Leary
Northwestern University Feinberg
School of Medicine
Chicago, IL
USA
William K. Oh
Mount Sinai School of Medicine
New York, NY
USA
Okey Justin Oparanaku
Mount Sinai School of Medicine
New York, NY
USA
Keren Osman
Mount Sinai School of Medicine
New York, NY
USA
Maria L. Padilla
Mount Sinai Medical Center
New York, NY
USA
David G. Paje
Henry Ford Hospital
Wayne State University School of
Medicine
Detroit, MI
USA
List of Contributors

Tuhin Pankaj
Office of the President
Baylor College of Medicine
Houston, TX
USA
Gopi Patel
Mount Sinai School of Medicine
New York, NY
USA
Kalpesh K. Patel
Baylor College of Medicine
Division of Gastroenterology and
Hepatology
Houston, TX
USA
Sanjay H. Patel
Mount Sinai School of Medicine
New York, NY
USA
Tony Philip
Hofstra North Shore-Long Island
Jewish Hospital System
Lake Success, NY
USA
Sean P. Pinney
Mount Sinai School of Medicine
New York, NY
USA
Maurice Policar
Elmhurst Hospital Center
Elmhurst, NY
USA
Jonathan Potack
Mount Sinai School of Medicine
New York, NY
USA
Brian D. Radbill
Mount Sinai School of Medicine
New York, NY
USA
Meenakshi M. Rana
Mount Sinai School of Medicine
New York, NY
USA
Anand C. Reddy
Mount Sinai School of Medicine
New York, NY
USA
Maria A. A. Reyna
Mount Sinai School of Medicine
New York, NY
USA
Kendall Rogers
University of New Mexico School of
Medicine
Albuquerque, NM
USA
xxiii
List of Contributors

Michael J. Ross
Mount Sinai School of Medicine
New York, NY
USA
Erin Rule
Mount Sinai School of Medicine
New York, NY
USA
Gabriel Sayer
Massachusetts General Hospital
Boston, MA
USA
Neil Schachter
Mount Sinai Medicial Center
New York, NY
USA
Laura Schimming
Mount Sinai School of Medicine
New York, NY
USA
Niraj L. Sehgal
University of California
San Francisco, CA
USA
Sonia M. Seng
Southcoast Centers for Cancer Care
Fall River, MA
USA
Chirayu J. Shah
Baylor College of Medicine
Houston, TX
USA
Abhinav Sharma
McMaster University
Hamilton, ON
Canada
Brad A. Sharpe
University of California at
San Francisco Medical Center
San Francisco, CA
USA
Patricia Shi
Mount Sinai School of Medicine
New York, NY
USA
Keith Sigel
Mount Sinai School of Medicine
New York, NY
USA
Steve K. Sigworth
Mount Sinai School of Medicine
New York, NY
USA
xxiv
List of Contributors

Maria Skamagas
Mount Sinai School of Medicine
New York, NY
USA
Gwen S. Skloot
Mount Sinai School of Medicine
New York, NY
USA
Ekaterina Sokolova
Mount Sinai Hospital of Queens
Long Island City, NY
USA
Laili Soleimani
Mount Sinai Medical Center
New York, NY
USA
Alex C. Spyropoulos
University of Rochester Medical
Center
Rochester, New York
USA
Carmen M. Stanca
Brooklyn Hospital Center
Brooklyn, NY
USA
Sarah Steinberg
Mount Sinai School of Medicine
New York, NY
USA
James K. Stulman
Mount Sinai School of Medicine
New York, NY
USA
Che-Kai Tsao
Mount Sinai School of Medicine
New York, NY
USA
Stanley Tuhrim
Mount Sinai Hospital
New York, NY
USA
Thomas A. Ullman
Mount Sinai Medical Center
New York, NY
USA
Jaime Uribarri
Mount Sinai School of Medicine
New York, NY
USA
Prashant Vaishnava
Mount Sinai School of Medicine
New York, NY
USA
Tomas Villanueva
Baptist Hospital of Miami
Baptist Health South Florida
Miami, Fl
USA
xxv
List of Contributors

Qingliang T. Wang
Mount Sinai Hospital
New York, NY
USA
Robert Yanagisawa
Mount Sinai School of Medicine
New York, NY
USA
xxvi
List of Contributors

Hospitalists as Leaders

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Hospitalists as Hospital Leaders
Andrew S. Dunn*
Key Pearls
• Hospitalist leadership in quality improvement and patient safety
was spurred on by the Institute of Medicine report, “To Err is Human:
Building A Safer Health System,” which estimated that 44,000–98,000
patients die each year in US hospitals due to medical errors.
• The co-management model shows promise as a means of enhancing
the quality of care for patients with conditions normally cared for by
subspecialists.
• The recognition that hospitals are prone to error and harm has made it
increasingly important for physicians-in-training to become knowledgable in quality improvement methods. Hospitalists will need to be
involved in leading innovative efforts to incorporate new material in
residency training.
• Hospitalist leaders need to understand the risk of burnout and
address this issue directly by paying close attention to work hours
and schedules, allowing flexibility and hospitalist input in their
schedule wherever possible, promoting engagement and ownership
of group policies and performance, and fostering participation in the
quality improvement and other activies that many hospitalists find
stimulating.
3
1
Chapter
* Mount Sinai School of Medicine, New York, NY, USA.
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