Wertheimer et al. Discharge Before Noon: An Achievable Hospital Goal. Journal of Hospital Medicine. April 2014.

Background: Late afternoon discharges from the inpatient setting are common, time consuming and thought to result in ED bottlenecks, overcrowding and increased LOS.

Methods: A kick-off event including definitions and checklist was held at the beginning of the intervention. Interdisciplinary rounds were held daily with the checklist responsibilities required to be completed on the same day that DBNs were identified. DBN website generated automated emails after CMs logged anticipated DBNs after rounds. Weekday leadership meetings were held, allowing for ongoing PI and feedback. Rewards were given to encourage participation.

Results: DBN increased in the first month from 16% to 42%. The average DBN was 38% over the 13-month intervention.

1. Discuss favorable discharge planning’s impact on discharge time.2. Is DBN achievable at our institutions?

Stephens et al. Who Needs Inpatient Detox? Development and Implementation of a Hospitalist Protocol for the Evaluation of Patients for Alcohol Detoxification. J Gen Intern Med 29(4):587–93.

Background: There is a lack of evidence-based guidelines for treatment of alcohol detoxification and in 2006, the direct health care costs of alcohol consumption related to alcohol-related hospitalizations was $5.1 billion.

Methods: A protocol was developed after literature search and data synthesis by an identified task force of physicians, nurse practioner and case manager. The primary

outcome measures were number of admissions for alcohol detox, 30-day readmissions and LOS.

Results: Patients considered highest risk were those with decompensated acute or chronic medical disease, patients with CIWA 8-15 with h/o seizures or DTs and patients with CIWA >15. After the protocol was implemented, the number of admissions decreased from 18.9 admissions/month to 15.9 admissions/month. Average LOS increased but not significant (2.7 vs 3.4 days, p = 0.09).

1. Examine the protocol for medicine outpatient detoxification and discuss its potential for application at our institutions.

Pitt et al. Spironolactone for Heart Failure with Preserved Ejection Fraction. New England Journal of Medicine 2014;370:1383-92.

Background: Mineralocorticoid-receptor antagonists improve prognosis for reduced LVEF heart failure. Spironolactone was evaluated in patients with preserved LVEF heart failure.

Methods: Randomized, double-blind trial of 3445 patients with symptomatic heart failure with preserved LVEF to spironolactone or placebo. Primary outcome of death secondary to CV causes, cardiac arrest or hospitalization for the management of heart failure.

Results: Primary outcome in 320 of the 1722 patients in the spironolactone group (18.6%) and 351 of 1723 patients in the placebo group (20.4%) (HR 0.89; 95% CI 0.77 to 1.04; p = 0.14). Only hospitalization for heart failure had a significantly lower incidence in the spironolactone group than in the placebo group (206 patients vs 245 patients; HR 0.83; 95% CI 0.69 to 0.99, p = 0.04).

1. Analyze the effects of spironolactone in patients with preserved left ventricular ejection fraction with heart failure.