Hospitalist Medicine

01 Admission & History Framework

Hospital medicine (hospitalist medicine) is the specialty devoted to the care of acutely ill patients from the moment of admission through discharge. The hospitalist performs the initial history and physical examination, writes admission orders, coordinates specialist consultations, manages day-to-day inpatient care, and orchestrates a safe transition back to the outpatient setting. A structured, systematic approach to admission prevents errors, ensures all safety measures are addressed, and satisfies documentation requirements for medical necessity.

The Complete Admission H&P

The admission history and physical examination (H&P) is the cornerstone document of the hospitalization. It establishes the chief complaint, constructs a differential diagnosis, documents the patient’s baseline status, and justifies the level of care. A thorough H&P includes: Chief Complaint (in the patient’s own words), History of Present Illness (onset, location, duration, character, aggravating/alleviating factors, radiation, timing, severity — OLDCARTS), Past Medical/Surgical History, Medications (with doses and frequency — critical for reconciliation), Allergies (with reaction type), Family History, Social History (tobacco, alcohol, drugs, living situation, functional status, advance directives), Review of Systems (10-system minimum for comprehensive), and the Physical Exam (vitals plus organ-system examination).

Admission Orders — ADC VANDALISM Mnemonic

The ADC VANDALISM mnemonic ensures no critical admission order is overlooked. Each letter maps to an essential order category:

Level of Care Determination

Choosing the appropriate level of care is a critical admission decision. General medical floor is appropriate for stable patients requiring IV medications, monitoring, or workup. Telemetry/stepdown is needed for patients requiring continuous cardiac monitoring (new arrhythmia, chest pain with elevated troponin, heart failure, electrolyte abnormalities with ECG changes) or more frequent nursing assessments (q2h). Intensive care unit (ICU) is indicated for hemodynamic instability requiring vasopressors, respiratory failure requiring mechanical ventilation or high-flow oxygen >15 L/min, acute MI with complications, status epilepticus, or any condition requiring continuous 1:1 nursing.

Code Status Discussion

Code status must be addressed at every admission. Patients should be asked whether they have an advance directive, a healthcare power of attorney (HCPOA), or a POLST/MOLST form. Document the discussion and the patient’s stated preferences: Full Code (CPR, intubation, all interventions), DNR/DNI (do not resuscitate / do not intubate — clarify what interventions are desired: pressors, ICU transfer, BiPAP), or Comfort Measures Only (symptom management only, no life-prolonging treatments). Code status does not equal goals of care — a DNR patient may still desire aggressive treatment of reversible conditions.

02 Hospital Systems & Quality Metrics

Modern hospitalists operate within a complex quality and regulatory framework. Understanding these metrics is essential because they directly influence hospital reimbursement, public reporting, accreditation, and patient safety.

CMS Core Measures

The Centers for Medicare & Medicaid Services (CMS) mandates reporting on condition-specific quality measures. Key hospitalist-relevant core measures include: Pneumonia — blood cultures before first antibiotic dose, appropriate initial antibiotic selection, antibiotic administration within 6 hours (previously 4 hours for sepsis); Heart Failure — documentation of LVEF, ACEi/ARB/ARNI at discharge for HFrEF, discharge instructions including weight monitoring, activity, diet, medication list, follow-up; VTE — VTE prophylaxis within 24 hours of admission, anticoagulation overlap for warfarin initiation; Sepsis (SEP-1) — 3-hour bundle (lactate, blood cultures, broad-spectrum antibiotics) and 6-hour bundle (repeat lactate if initial >2.0 mmol/L, 30 mL/kg crystalloid for hypotension/lactate ≥4, vasopressors if refractory).

Value-Based Purchasing (VBP)

CMS withholds a percentage of DRG payments (currently 2%) and redistributes based on hospital performance across four domains: Clinical Outcomes (30-day mortality for AMI, HF, pneumonia, COPD, CABG — 25% weight), Safety (HAI measures, PSI-90 composite — 25%), Efficiency and Cost Reduction (Medicare spending per beneficiary — 25%), and Person and Community Engagement (HCAHPS — 25%). Hospitals scoring above the median earn back more than the 2%, while poor performers lose revenue.

Hospital Readmission Reduction Program (HRRP)

CMS penalizes hospitals with excess 30-day all-cause readmission rates for six conditions: AMI, heart failure, pneumonia, COPD, THA/TKA, and CABG. Penalties can reach up to 3% of total Medicare reimbursement. The LACE index (Length of stay, Acuity of admission, Comorbidities via Charlson index, Emergency department visits in prior 6 months) predicts 30-day readmission risk and helps target discharge interventions to high-risk patients.

HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)

HCAHPS is the standardized patient experience survey. Key domains include: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medications, discharge information, cleanliness and quietness of hospital environment, care transition (3 questions). Scores are publicly reported on Hospital Compare and directly affect VBP reimbursement.

Leapfrog Group

The Leapfrog Hospital Safety Grade (A through F) evaluates hospitals on 28 patient safety measures including falls, infections, medication errors, and ICU physician staffing. Leapfrog also surveys computerized physician order entry (CPOE) adoption, evidence-based hospital referral, and ICU staffing by board-certified intensivists.

Patient Safety Indicators (PSIs)

AHRQ Patient Safety Indicators are a set of measures using administrative/billing data to screen for potentially preventable complications. PSI-90 is the composite used in VBP. Key individual PSIs include: PSI-03 (pressure ulcer rate), PSI-06 (iatrogenic pneumothorax), PSI-08 (postoperative hip fracture from falls), PSI-09 (perioperative hemorrhage/hematoma), PSI-11 (postoperative respiratory failure), PSI-12 (perioperative PE/DVT), PSI-13 (postoperative sepsis), PSI-14 (postoperative wound dehiscence), PSI-15 (unrecognized abdominopelvic accidental puncture/laceration).

03 Key Terminology & Abbreviations

Hospital medicine uses abbreviations drawn from every medical and surgical subspecialty, plus administrative and regulatory terminology unique to the inpatient setting. Mastery of this vocabulary is essential for efficient chart review, order writing, and communication.

04 Admission Workflow & Order Sets

The admission process is a high-risk transition that demands a systematic approach. Errors in admission orders — missed VTE prophylaxis, incorrect medication doses, inappropriate diet — can cause preventable harm. A standardized workflow reduces variability and improves outcomes.

Admission Criteria

A patient requires inpatient admission when outpatient management is insufficient due to: severity of illness (hemodynamic instability, acute organ failure, active hemorrhage), need for intensive monitoring or nursing (telemetry, q1–2h vitals, 1:1 observation), need for treatments available only in the hospital (IV medications, blood products, emergent procedures), or inability to perform activities of daily living safely (altered mental status, inability to ambulate, no safe discharge plan). The clinical decision must be supported by documentation of medical necessity — why the patient cannot be safely managed at a lower level of care.

Observation vs Inpatient — Initial Determination

At admission, the hospitalist must determine whether the patient meets criteria for inpatient admission or should be placed in observation status. The 2-midnight rule (CMS, effective 2013) states: if the admitting physician expects the patient to require hospital care spanning at least 2 midnights, inpatient admission is generally appropriate. If the expected stay is <2 midnights, the patient should be placed in observation status unless a procedure is on the Inpatient-Only list. InterQual and Milliman criteria provide evidence-based clinical benchmarks for this determination.

Initial Order Set Components

A comprehensive admission order set addresses every element of ADC VANDALISM and includes condition-specific protocols. Common order sets include: General medicine admission, Chest pain / ACS (serial troponins q3h ×3, telemetry, aspirin, heparin), Heart failure (daily weights, 2L fluid restriction, I&Os, BNP, BMP, Mg), Pneumonia (blood cultures ×2, sputum culture, Legionella/pneumococcal urine antigens, appropriate antibiotics), Sepsis (3-hour bundle: lactate, cultures, antibiotics, 30 mL/kg crystalloid), DKA (insulin drip, q1h BG, q2h BMP, AG monitoring, fluid resuscitation protocol).

Medication Reconciliation on Admission

The hospitalist must obtain the best possible medication history (BPMH) from multiple sources: patient/family interview, outpatient pharmacy records, EMR medication list, and pill bottles. Each home medication is continued, held, or modified with documentation of rationale. Common medications held on admission include: oral hypoglycemics (NPO status, insulin preferred inpatient), metformin (contrast studies, AKI risk), ACEi/ARBs (acute kidney injury, hypotension), diuretics (if volume depleted), anticoagulants (procedural planning), and anti-hypertensives (if hypotensive).

05 Discharge Planning & Transitions of Care

Discharge planning begins at admission. Effective transitions of care reduce 30-day readmission rates, prevent medication errors, and improve patient satisfaction. Approximately 20% of Medicare patients are readmitted within 30 days, costing the healthcare system billions annually.

Discharge Readiness Criteria

A patient is ready for discharge when: the acute condition is stabilized or resolving, the patient can tolerate oral medications and nutrition, vital signs are stable and trending toward normal for ≥24 hours, no pending critical test results, the patient (or caregiver) demonstrates understanding of the care plan, a safe discharge destination has been identified, and follow-up appointments are arranged. Specific criteria vary by condition — for heart failure: net negative on diuresis, weight at or near dry weight, stable on oral diuretics for ≥24 hours, oxygen saturation ≥92% on room air or baseline O₂ requirements.

IDEAL Discharge Framework

The AHRQ IDEAL framework guides patient-centered discharge education:

Discharge Summary Elements

The Joint Commission requires the discharge summary to include: reason for hospitalization, significant findings (labs, imaging, procedures), procedures performed, hospital course, condition at discharge, discharge diagnosis (principal and secondary), discharge medications (with changes from admission highlighted), follow-up instructions (appointments, labs), pending results, and patient education. The summary must be completed within 30 days but ideally within 24–48 hours to be available for the outpatient follow-up visit.

LACE Index for Readmission Risk

Total score range: 0–19. Score ≥10 indicates high readmission risk; these patients should receive intensified discharge planning including post-discharge phone calls within 48–72 hours, early outpatient follow-up (within 7 days), and referral to transitional care programs.

Post-Acute Care Disposition

Home: independent with ADLs, safe environment, caregiver available if needed. Home with home health: needs skilled nursing visits (wound care, IV antibiotics, physical therapy) but is otherwise safe at home. Skilled nursing facility (SNF): requires 24-hour nursing supervision, skilled care (IV medications, wound care, PT/OT), and a qualifying 3-midnight inpatient stay for Medicare Part A coverage. Inpatient rehabilitation facility (IRF): requires intensive rehabilitation (minimum 3 hours/day, 5 days/week), must be able to participate actively; common for stroke, hip fracture, major joint replacement. Long-term acute care hospital (LTAC): for patients requiring prolonged hospital-level care (ventilator weaning, complex wound care, IV antibiotics >14 days) with average LOS ≥25 days.

06 Handoff Communication — I-PASS & SBAR

Communication failures during care transitions are the leading root cause of sentinel events. Standardized handoff tools reduce preventable adverse events by 23–30% (I-PASS study, NEJM 2014). Every patient handoff — shift change, service transfer, cross-cover — must be structured, verbal, and accompanied by a written or electronic signout.

I-PASS Framework

SBAR Communication

SBAR is the standard framework for nurse-to-physician (or any inter-professional) communication about acute changes:

Signout Best Practices

Written signout should be updated daily and include: patient name, room, age, one-liner, code status, allergies, key medications (anticoagulants, insulin, pressors), active issues, anticipated problems overnight, and contact information for the primary team. Verbal signout should occur face-to-face in a quiet environment with minimal interruptions. The outgoing team should explicitly identify "watchers" — patients at highest risk for overnight decompensation — and provide specific contingency plans. Cross-cover physicians should round on watchers early in the shift.

07 Observation vs Inpatient Status

The distinction between observation and inpatient status is one of the most consequential administrative decisions in hospital medicine. It affects hospital reimbursement, patient cost-sharing, and eligibility for post-acute care benefits. Hospitalists must understand the regulatory framework and its clinical and financial implications.

Medicare 2-Midnight Rule

Under the 2-midnight rule (CMS-1599-F, effective October 2013), hospital stays are presumed appropriate for inpatient admission if the admitting physician expects the patient to require medically necessary hospital services spanning at least 2 midnights. The physician must document: (1) the reason the patient requires hospital care, (2) the expected length of stay, and (3) the plan of care. Stays expected to be <2 midnights are generally observation unless the patient undergoes a procedure on the Inpatient-Only (IPO) list or an exception applies (e.g., patient dies or is transferred before the second midnight, or the clinical documentation supports a rare, unforeseen circumstance).

Recovery Audit Contractor (RAC) Audits

RACs review Medicare claims to identify overpayments. Short inpatient stays (<2 midnights) are prime targets. If a RAC determines a stay did not meet inpatient criteria, the hospital must repay the full DRG payment and may re-bill under observation (at a significantly lower rate). Hospitalists can protect their institution by documenting medical necessity thoroughly, using clinical criteria (InterQual/Milliman) to support decisions, and converting to observation proactively when criteria are not met.

Financial Implications for Patients

The distinction carries major financial consequences: Inpatient: covered under Medicare Part A (hospital deductible of $1,632 in 2024, then $0 copay for days 1–60). Observation: covered under Medicare Part B (20% coinsurance for all services, self-administered drugs not covered — patients may be billed full price for home medications like atorvastatin, metformin, or lisinopril given during observation). Most critically, observation days do not count toward the 3-midnight qualifying inpatient stay required for Medicare Part A coverage of skilled nursing facility (SNF) care.

Self-Administered Drug List

Under observation status, Medicare Part B does not cover self-administered drugs — medications the patient could normally take themselves. This includes most oral medications (antihypertensives, statins, oral hypoglycemics, anticoagulants). The hospital may charge the patient directly. IV medications, nebulized treatments, and injections administered by nursing staff are generally covered under Part B. Some hospitals have policies absorbing these costs; others pass them to the patient.

Condition Code 44

Condition Code 44 allows a hospital to change a patient’s status from inpatient to outpatient/observation during the stay (before discharge) when utilization review determines that inpatient criteria are not met. Requirements: the physician must concur with the status change, UR must approve, and the patient must be notified (Medicare Outpatient Observation Notice — MOON). Condition Code 44 cannot be applied retroactively after discharge. When applied correctly, it allows re-billing under Part B observation, preserving at least partial reimbursement rather than risking a RAC denial and full repayment.

08 Community-Acquired Pneumonia

Community-acquired pneumonia (CAP) is the most common infectious cause of hospitalization and the leading infectious cause of death in the United States, with approximately 1.5 million hospitalizations and 50,000 deaths annually. The hospitalist must rapidly assess severity, initiate appropriate empiric therapy, and de-escalate based on culture data.

CURB-65 Severity Score

Interpretation: 0–1 = low risk, consider outpatient treatment (30-day mortality ~1.5%); 2 = moderate risk, consider short hospitalization or closely supervised outpatient (mortality ~9%); 3–5 = high risk, hospitalize; score 4–5 consider ICU (mortality ~22%).

PSI/PORT Score

The Pneumonia Severity Index (PSI) uses 20 variables to stratify patients into Risk Classes I–V. Class I = age <50, no comorbidities, normal vitals (outpatient). Class II = ≤70 points (mortality 0.6%). Class III = 71–90 points (mortality 0.9%, brief observation). Class IV = 91–130 points (mortality 9.3%, inpatient). Class V = >130 points (mortality 27%, inpatient/ICU). Points are assigned for: age (years for men, years minus 10 for women), nursing home residence (+10), neoplastic disease (+30), liver disease (+20), CHF (+10), cerebrovascular disease (+10), renal disease (+10), altered mental status (+20), RR ≥30 (+20), SBP <90 (+20), temp <35 or ≥40 (+15), HR ≥125 (+10), pH <7.35 (+30), BUN ≥30 (+20), Na <130 (+20), glucose ≥250 (+10), hematocrit <30 (+10), PaO₂ <60 (+10), pleural effusion (+10).

Empiric Antibiotic Therapy

De-escalation & Duration

Switch from IV to PO antibiotics when the patient is: clinically improving (defervescing, decreasing WBC), hemodynamically stable, tolerating oral intake, and has a functioning GI tract. Minimum 5 days of therapy is standard per ATS/IDSA 2019 guidelines. Extend to 7 days for complicated infections (empyema, lung abscess, Pseudomonas, S. aureus bacteremia). Procalcitonin levels <0.25 ng/mL or decreasing by ≥80% from peak support antibiotic discontinuation.

09 Acute Heart Failure

Acute decompensated heart failure (ADHF) accounts for over 1 million hospitalizations annually in the US and is the leading cause of 30-day readmission. The hospitalist manages the acute episode, optimizes guideline-directed medical therapy (GDMT), and coordinates a transition designed to prevent readmission.

Stevenson Hemodynamic Profiles

The Stevenson classification uses bedside assessment of congestion (wet vs dry) and perfusion (warm vs cold) to guide therapy:

Diuretic Strategies

IV furosemide is first-line. Initial dose: give the patient’s total daily oral furosemide dose as IV (2.5:1 oral-to-IV conversion is approximately equivalent, but practice is to give the same number — e.g., 40 mg PO at home = start 40 mg IV). If diuretic-naive, start furosemide 20–40 mg IV. Administer as bolus q12h or continuous infusion (no mortality difference per DOSE trial, but infusion may cause less ototoxicity). Goal: net negative 1–2 L/day (urine output >100–150 mL/h in first 2 hours after dose). If inadequate response after first dose, double the dose (max single bolus 200 mg IV). If still refractory: add metolazone 2.5–5 mg PO 30 minutes before furosemide (sequential nephron blockade — metolazone blocks distal tubule sodium reabsorption). Alternatively, add chlorothiazide 500 mg IV or acetazolamide 500 mg IV (ADVOR trial showed benefit of acetazolamide added to loop diuretic for faster decongestion).

BNP/NT-proBNP Trending

BNP (>100 pg/mL suggests HF; >400 strongly supports) and NT-proBNP (>300 pg/mL for age <50; >900 for age 50–75; >1800 for age >75) are useful for diagnosis and monitoring. A ≥30% decrease in BNP from admission to discharge is associated with lower readmission risk. Persistently elevated or rising BNP despite treatment indicates inadequate decongestion or worsening HF.

GDMT Optimization Before Discharge

Hospitalization is an opportunity to initiate or uptitrate GDMT for HFrEF (EF ≤40%). The four pillars: ARNI (sacubitril-valsartan, target 97/103 mg BID) or ACEi/ARB, beta-blocker (carvedilol, metoprolol succinate, or bisoprolol — initiate only when euvolemic and stable, do not start or uptitrate in acute decompensation), MRA (spironolactone 25–50 mg daily or eplerenone 25–50 mg daily — check K <5.0, eGFR >30), and SGLT2 inhibitor (dapagliflozin 10 mg or empagliflozin 10 mg daily — can initiate in-hospital per EMPULSE trial). Additional therapies: hydralazine-isosorbide dinitrate (for Black patients or those intolerant of ACEi/ARB), ivabradine (HR ≥70 on max beta-blocker), and loop diuretic for persistent congestion.

10 COPD Exacerbation

Acute exacerbations of COPD (AECOPD) are defined by worsening dyspnea, increased sputum volume, and/or increased sputum purulence beyond normal day-to-day variation. AECOPD accounts for ~700,000 hospitalizations per year in the US and carries in-hospital mortality of 2–4%, with 1-year post-hospitalization mortality reaching 23%.

GOLD Classification of COPD Severity

ABG Interpretation in AECOPD

Baseline COPD patients are chronic CO₂ retainers with compensated respiratory acidosis (elevated PaCO₂ 50–60 mmHg with normal pH due to renal HCO₃ retention). During acute exacerbation, PaCO₂ rises further and pH drops (acute-on-chronic respiratory acidosis). A pH <7.35 with PaCO₂ >45 mmHg indicates acute ventilatory failure and is the threshold for initiating non-invasive ventilation. For every 10 mmHg acute rise in PaCO₂, pH drops by ~0.08. For every 10 mmHg chronic rise, HCO₃ increases by ~3.5 mEq/L. Comparing expected vs actual HCO₃ helps determine the chronicity of the respiratory acidosis.

Inpatient Management

Bronchodilators: Albuterol 2.5 mg nebulized q2–4h (or MDI 4–8 puffs q1–4h with spacer) plus ipratropium 0.5 mg nebulized q6h (or combination DuoNeb). Systemic corticosteroids: Prednisone 40 mg PO daily × 5 days (REDUCE trial showed 5-day course equivalent to 14-day; IV methylprednisolone 125 mg q6–12h if unable to take PO, then transition to oral). Antibiotics: indicated when 2 of 3 Anthonisen criteria are met (increased dyspnea, increased sputum volume, increased sputum purulence) or when mechanical ventilation is required. First-line: azithromycin 500 mg day 1, then 250 mg × 4 days; alternatives: doxycycline 100 mg BID × 5 days, amoxicillin-clavulanate 875/125 BID × 5–7 days, or levofloxacin 750 mg daily × 5 days (reserved for complicated cases due to resistance concerns).

Non-Invasive Ventilation (NIV)

BiPAP is the cornerstone of management for acute respiratory acidosis in AECOPD. Indications: pH <7.35 and PaCO₂ >45 mmHg, severe dyspnea with accessory muscle use, or persistent hypoxemia despite supplemental O₂. Initial settings: IPAP 10–12 cmH₂O, EPAP 4–5 cmH₂O, titrate IPAP up by 2 cmH₂O every 15–30 minutes targeting tidal volume 6–8 mL/kg and improved pH/PaCO₂. Maximum IPAP typically 20–25 cmH₂O. FiO₂ titrated to SpO₂ 88–92% (avoid hyperoxia in CO₂ retainers — suppresses hypoxic respiratory drive). BiPAP reduces intubation rates by ~65% and mortality by ~50% compared to standard therapy alone (Cochrane 2017).

Oxygen Therapy

Target SpO₂ 88–92% in COPD patients (GOLD guidelines). The Haldane effect means that excessive supplemental O₂ in chronic CO₂ retainers can worsen hypercapnia by three mechanisms: (1) loss of hypoxic pulmonary vasoconstriction increasing V/Q mismatch, (2) reduced hypoxic ventilatory drive, and (3) the Haldane effect itself (increased O₂ displaces CO₂ from hemoglobin). Use Venturi masks for precise FiO₂ delivery (24–50%) rather than nasal cannula in the acute setting.

11 Acute Kidney Injury

Acute kidney injury (AKI) occurs in 10–15% of all hospitalized patients and up to 50% of ICU patients. AKI is independently associated with increased mortality, prolonged LOS, progression to CKD, and higher healthcare costs. The hospitalist must rapidly classify the injury, identify the cause, and initiate targeted management.

KDIGO Staging

Prerenal vs Intrinsic vs Postrenal

Prerenal (60–70% of hospital AKI): decreased renal perfusion from hypovolemia (hemorrhage, dehydration, GI losses), hypotension (sepsis, cardiogenic shock), or altered renal hemodynamics (NSAIDs constrict afferent arteriole; ACEi/ARBs dilate efferent arteriole). Labs: BUN:Cr ratio >20:1, FENa <1%, FEUrea <35%, urine osmolality >500, bland sediment. Treatment: volume repletion with isotonic crystalloid (LR preferred), hold offending agents.

Intrinsic (25–35%): damage to the tubules, interstitium, glomeruli, or vasculature. Acute tubular necrosis (ATN) is the most common intrinsic cause — from prolonged ischemia or nephrotoxins (aminoglycosides, contrast, myoglobin). Labs: FENa >2%, FEUrea >50%, muddy brown granular casts on UA. Acute interstitial nephritis (AIN): drug-induced (NSAIDs, PPIs, antibiotics — especially beta-lactams), presents with fever, rash, eosinophilia, WBC casts, eosinophiluria. Glomerulonephritis: RBC casts, proteinuria, dysmorphic RBCs; send complement levels, ANA, ANCA, anti-GBM, hepatitis panel.

Postrenal (5–10%): obstruction. Bilateral ureteral obstruction, bladder outlet obstruction (BPH most common in older men), or obstruction of a solitary kidney. Diagnosis: renal ultrasound showing hydronephrosis. Treatment: relieve obstruction (Foley catheter for bladder outlet, ureteral stent or nephrostomy tube for ureteral obstruction). Post-obstructive diuresis can be massive (UOP >200 mL/h) — replace half of urine output with 0.45% NS to prevent dehydration.

FENa and FEUrea Calculations

FENa = (UNa × PCr) / (PNa × UCr) × 100. Prerenal: <1%; ATN: >2%. FEUrea = (UUrea × PCr) / (PUrea × UCr) × 100. Prerenal: <35%; ATN: >50%. FEUrea is more reliable in patients on diuretics (diuretics increase sodium excretion, making FENa falsely elevated in prerenal AKI).

Renal Replacement Therapy Indications — AEIOU

12 Cellulitis & Skin/Soft Tissue Infections

Skin and soft tissue infections (SSTIs) are among the most common reasons for hospitalization. The hospitalist must distinguish purulent from non-purulent infections, classify severity, identify necrotizing infections early, and select appropriate antibiotic therapy.

Purulent vs Non-Purulent SSTIs

Purulent SSTIs (abscess, furuncle, carbuncle) are most commonly caused by Staphylococcus aureus (including MRSA in 50–60% of community-acquired cases). Management centers on incision and drainage (I&D) — antibiotics alone without I&D are often inadequate. Non-purulent SSTIs (cellulitis, erysipelas) are predominantly caused by beta-hemolytic streptococci (Group A Strep). Treatment is antibiotic therapy without I&D. Erysipelas involves the superficial dermis and lymphatics (raised, well-demarcated borders, "orange peel" texture); cellulitis extends deeper into the subcutaneous tissue (ill-defined borders, warm, tender, erythematous).

Severity Classification & Empiric Antibiotics

Necrotizing Fasciitis

Necrotizing fasciitis is a surgical emergency with mortality of 20–40% even with treatment. Clinical clues: pain out of proportion to exam findings, rapidly spreading erythema, crepitus (gas in tissues), bullae, skin necrosis, hemodynamic instability, and failure to improve on antibiotics. Type I (polymicrobial — diabetics, postoperative) and Type II (monomicrobial — Group A Strep, most common in healthy patients). Treatment: emergent surgical debridement (definitive therapy — every hour of delay increases mortality), broad-spectrum antibiotics (vancomycin + piperacillin-tazobactam + clindamycin 900 mg IV q8h for toxin inhibition), ICU admission, and serial debridements until clean margins.

LRINEC Score for Necrotizing Fasciitis

Score ≥6: suspicious for necrotizing fasciitis (PPV 92%); score ≥8: strongly predictive. However, a low score does not exclude necrotizing fasciitis — if clinical suspicion is high, proceed with surgical exploration regardless. The LRINEC score should never delay surgical consultation.

13 Venous Thromboembolism

Venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), is a leading cause of preventable hospital death. The hospitalist must be proficient in risk stratification, diagnosis, and anticoagulation management.

Wells Score for DVT

Score ≤0: low probability (5% prevalence) — check D-dimer, if negative DVT excluded; ≥1–2: moderate (17%) — D-dimer or ultrasound; ≥3: high probability (53%) — proceed directly to compression ultrasound.

Wells Score for PE

Score ≤4 (unlikely PE): check D-dimer; if negative (<500 ng/mL, or age-adjusted cutoff: age × 10 for patients >50), PE excluded. Score >4 (likely PE): proceed to CT pulmonary angiography (CTPA). If CTPA contraindicated (contrast allergy, CKD), V/Q scan is an alternative.

Anticoagulation for VTE

Massive PE — Systemic Thrombolysis

Massive PE is defined by sustained hypotension (SBP <90 mmHg for ≥15 minutes), need for vasopressors, or cardiac arrest. Treatment: alteplase (tPA) 100 mg IV over 2 hours (or 50 mg IV bolus in cardiac arrest), plus heparin anticoagulation. Absolute contraindications: active internal bleeding, recent (<3 months) hemorrhagic stroke, intracranial neoplasm. Relative contraindications: recent surgery <3 weeks, active peptic ulcer, current anticoagulation. Catheter-directed therapy (half-dose tPA via pulmonary artery catheter or mechanical thrombectomy) is an alternative for patients with relative contraindications to systemic lysis.

Submassive PE — PESI Score

Submassive PE = hemodynamically stable but with evidence of RV strain (RV dilation on CT or echo, elevated troponin, elevated BNP). The Pulmonary Embolism Severity Index (PESI) stratifies risk:

Class I (≤65): very low risk (30-day mortality ~1.6%). Class II (66–85): low risk (3.5%). Class III (86–105): intermediate (7.1%). Class IV (106–125): high (11.4%). Class V (>125): very high (23.9%). sPESI (simplified): 1 point each for age >80, cancer, heart failure/chronic lung disease, HR ≥110, SBP <100, SpO₂ <90%; score 0 = low risk (1.0% mortality), ≥1 = high risk (10.9%).

Duration of Anticoagulation

Provoked VTE (surgery, immobilization, estrogen, pregnancy): 3 months. Unprovoked VTE: at least 3 months, then reassess — extended anticoagulation if bleeding risk is low (apixaban 2.5 mg BID or rivaroxaban 10 mg daily for extended prophylaxis reduce recurrence by ~80%). Cancer-associated VTE: indefinite anticoagulation (LMWH or DOAC preferred over warfarin; edoxaban and rivaroxaban non-inferior to LMWH in trials, but avoid DOACs in GI/GU malignancies due to higher mucosal bleeding). Recurrent unprovoked VTE: indefinite.

14 Inpatient Diabetes Management

Hyperglycemia (BG >140 mg/dL) occurs in up to 40% of hospitalized patients and is associated with increased infection rates, impaired wound healing, longer LOS, and higher mortality. Insulin is the preferred agent for inpatient glycemic management; oral hypoglycemics are generally held during hospitalization due to unpredictable oral intake, variable renal function, and need for tighter control.

Basal-Bolus-Correction Insulin Protocol

The physiologic basal-bolus-correction regimen mimics normal insulin secretion. Total daily dose (TDD) calculation: 0.4–0.5 units/kg/day for most patients; start lower (0.2–0.3 units/kg) for elderly, renal impairment (CrCl <30), or type 1 DM. Divide TDD: 50% as basal insulin (glargine or detemir once daily, or NPH BID) and 50% as prandial insulin (lispro, aspart, or glulisine divided equally before meals). Correction insulin (same rapid-acting) is added to the prandial dose based on a sliding scale (low-dose: 1 unit per 50 mg/dL over target; medium: 1 per 40; high: 1 per 30). Target glucose: 140–180 mg/dL for most patients; 110–140 mg/dL for ICU patients per ADA guidelines.

DKA Management

Diabetic ketoacidosis (DKA): glucose usually >250 mg/dL (can be euglycemic with SGLT2 inhibitors), pH <7.3, HCO₃ <18, positive serum ketones, anion gap >12.

Fluids: NS 1–1.5 L/h for the first 1–2 hours (15–20 mL/kg/h), then 250–500 mL/h of NS or 0.45% NS (based on corrected Na). When BG reaches 200–250 mg/dL, switch to D5 0.45% NS to prevent hypoglycemia while continuing insulin to close the anion gap.

Insulin: Regular insulin bolus 0.1 units/kg IV, then continuous infusion at 0.1 units/kg/h. Target BG decline of 50–75 mg/dL per hour. If BG does not drop by ≥10% in the first hour, give another 0.1 units/kg bolus. Transition to subcutaneous insulin when: AG closed (<12), BG <200, pH >7.3, HCO₃ ≥15, patient eating. Overlap IV and SC insulin by 2 hours before discontinuing the drip.

Potassium: Check K before starting insulin. If K <3.3 mEq/L: hold insulin, replace K aggressively (20–40 mEq/h IV). If K 3.3–5.3: add 20–40 mEq KCl to each liter of IV fluids. If K >5.3: hold potassium replacement, recheck in 2 hours. Insulin drives K intracellularly — starting insulin with a K <3.3 can cause fatal hypokalemia and cardiac arrest.

Hyperosmolar Hyperglycemic State (HHS)

HHS: glucose usually >600 mg/dL, serum osmolality >320 mOsm/kg, minimal ketosis, pH >7.3, profound dehydration (average fluid deficit 8–10 L). Treatment: aggressive fluid resuscitation (1–1.5 L NS/h initially, then titrate to urine output 0.5–1 mL/kg/h); low-dose insulin infusion (0.05–0.1 units/kg/h — glucose drops rapidly with fluids alone; avoid rapid osmolality shifts that can cause cerebral edema). Mortality is higher than DKA (10–20% vs 1–5%) due to older patient population and comorbidities.

Hypoglycemia Protocol

Hypoglycemia: BG <70 mg/dL. Mild (BG 54–70, patient alert and able to swallow): 15–20 g oral glucose (4 oz juice, glucose tablets), recheck in 15 minutes, repeat if still <70. Severe (BG <54 or altered mental status/unable to swallow): dextrose 50% (D50) 25 mL (12.5 g) IV push, or glucagon 1 mg IM if no IV access; recheck BG in 15 minutes. For all hypoglycemia events: identify the cause (excess insulin, missed meal, renal failure reducing insulin clearance), adjust regimen (reduce TDD by 20%), and ensure the patient receives a meal or snack.

Perioperative Glucose Management

NPO patients: hold prandial insulin, continue basal insulin at 75–80% of the usual dose (prevents fasting hyperglycemia while reducing hypoglycemia risk). Monitor BG q4–6h. If BG >180: use correction insulin. Resume prandial insulin when eating. Target perioperative glucose 140–180 mg/dL. Hold metformin 48 hours before procedures using IV contrast and for 48 hours after (lactic acidosis risk). Hold SGLT2 inhibitors 3–4 days before surgery (euglycemic DKA risk).

15 VTE Prophylaxis

Venous thromboembolism is the most common preventable cause of hospital death. Every hospitalized patient should undergo VTE risk assessment on admission and receive appropriate prophylaxis. Failure to provide prophylaxis is a never event for surgical patients and a key CMS quality measure.

Padua Prediction Score (Medical Patients)

Score ≥4 = high risk (11% VTE rate without prophylaxis) — pharmacologic prophylaxis indicated. Score <4 = low risk (0.3% VTE rate) — early ambulation, consider mechanical prophylaxis.

Caprini Score (Surgical Patients)

The Caprini RAM assigns 1–5 points per risk factor. 1 point each: age 41–60, minor surgery, BMI >25, swollen legs, varicose veins, pregnancy/postpartum, history of unexplained stillbirth, oral contraceptives/HRT, sepsis <1 month, serious lung disease (including pneumonia <1 month), COPD, abnormal pulmonary function, MI, CHF <1 month, inflammatory bowel disease, bed rest. 2 points each: age 61–74, major surgery (>45 min), laparoscopic surgery (>45 min), malignancy, bed rest >72 h, immobilizing cast, central venous access. 3 points each: age ≥75, history of VTE, family history of VTE, Factor V Leiden, prothrombin 20210A, lupus anticoagulant, anticardiolipin antibodies, elevated homocysteine, HIT. 5 points each: stroke <1 month, elective arthroplasty, hip/pelvis/leg fracture, acute spinal cord injury <1 month.

Score 0–1: very low risk (early ambulation). 2: low (mechanical prophylaxis). 3–4: moderate (pharmacologic + mechanical). ≥5: high (pharmacologic + mechanical + extended prophylaxis post-discharge for high-risk surgery).

Pharmacologic Prophylaxis Options

Mechanical Prophylaxis

Sequential compression devices (SCDs) are the primary mechanical option. Indications: all patients with contraindications to pharmacologic prophylaxis (active bleeding, severe thrombocytopenia <50,000, recent neurosurgery, epidural catheter in place) or as adjunct to pharmacologic prophylaxis in high-risk patients. Graduated compression stockings (TED hose) provide modest benefit but are less effective than SCDs. Mechanical prophylaxis should be applied on admission and worn continuously except during ambulation and bathing.

DOAC Perioperative Management

For elective procedures: apixaban/rivaroxaban — hold 48 hours before high-bleeding-risk procedures, 24 hours before low-risk. Dabigatran — hold 48–72 hours (longer if CrCl 30–50: hold 72–96 hours for high-risk). No bridging with heparin is generally needed for DOACs (PERIOP2 and PAUSE trials). Resume 48–72 hours postoperatively once hemostasis is confirmed. For warfarin: hold 5 days before procedure (INR target <1.5); bridge with LMWH only for high-risk patients (mechanical mitral valve, recent VTE <3 months, high-risk thrombophilia).

16 Anticoagulation Management

Anticoagulation is one of the highest-risk medication classes in the hospital, accounting for a disproportionate share of adverse drug events. The hospitalist must master heparin dosing, warfarin management, DOAC selection, reversal strategies, and the recognition and management of heparin-induced thrombocytopenia.

Heparin Nomogram (Weight-Based)

Check aPTT 6 hours after any rate change. Once two consecutive therapeutic values are achieved, extend monitoring to q12–24h. Anti-Xa monitoring (target 0.3–0.7 IU/mL) may be more reliable than aPTT in patients with lupus anticoagulant, elevated factor VIII, or liver disease.

Warfarin Initiation & INR Targets

Start warfarin 5 mg daily (lower starting dose of 2–3 mg for elderly, liver disease, malnourished, CYP2C9/VKORC1 polymorphisms, or concurrent interacting drugs). Bridge with heparin/LMWH for ≥5 days AND until INR ≥2.0 for ≥24 hours. INR targets: 2.0–3.0 for DVT/PE, atrial fibrillation, bioprosthetic valve; 2.5–3.5 for mechanical mitral valve or mechanical aortic valve with additional risk factors. Supratherapeutic INR management: INR 4.5–10 without bleeding — hold warfarin, no vitamin K needed (unless high bleeding risk); INR >10 without bleeding — hold warfarin + vitamin K 2.5–5 mg PO; serious/life-threatening bleeding — hold warfarin + 4-factor PCC (Kcentra) 25–50 IU/kg + vitamin K 10 mg IV.

DOAC Dosing by Indication

Reversal Agents

Heparin-Induced Thrombocytopenia (HIT) — 4T Score

Score 0–3: low probability (<5% chance of HIT) — HIT unlikely, continue heparin. Score 4–5: intermediate (14%) — send HIT antibody (PF4/heparin ELISA); if positive, confirm with serotonin release assay (SRA). Score 6–8: high probability (64%) — stop all heparin immediately (including flushes), start alternative anticoagulation (argatroban for hepatic metabolism, bivalirudin for short procedures, fondaparinux off-label). Do NOT start warfarin until platelets recover >150,000 (warfarin depletes protein C faster than clotting factors, causing a transient hypercoagulable state that can cause venous limb gangrene).

17 Electrolyte Management

Electrolyte disorders are ubiquitous in hospitalized patients and can cause life-threatening arrhythmias, seizures, and neuromuscular dysfunction. The hospitalist must know correction rates, treatment protocols, and the critical ECG changes that demand emergent intervention.

Hyponatremia

Serum Na <135 mEq/L. Most common electrolyte abnormality in hospitalized patients. Classification by volume status: hypovolemic (GI losses, diuretics, adrenal insufficiency — treat with NS), euvolemic (SIADH, hypothyroidism, adrenal insufficiency, psychogenic polydipsia — fluid restrict to <1 L/day, consider salt tabs, demeclocycline, or tolvaptan for refractory SIADH), hypervolemic (CHF, cirrhosis, nephrotic syndrome — fluid restrict, diuretics). Correction rate: do not exceed 8 mEq/L in any 24-hour period (6 mEq/L in patients at high risk for osmotic demyelination syndrome: alcoholism, malnutrition, hypokalemia, liver disease). Overcorrection treatment: desmopressin (DDAVP) 2–4 mcg IV to halt free water excretion, plus D5W infusion to re-lower sodium.

Severe Symptomatic Hyponatremia

Seizures or obtundation from hyponatremia: 3% hypertonic saline 100 mL IV bolus over 10 minutes, may repeat twice at 10-minute intervals (total 300 mL). Goal: raise Na by 4–6 mEq/L in the first few hours to stop symptoms, then slow correction to stay within 8 mEq/L in 24 hours. Check Na q2h during active correction.

Hypernatremia

Serum Na >145 mEq/L. Almost always due to free water deficit (impaired thirst, restricted access to water, diabetes insipidus, osmotic diuresis). Calculate free water deficit: FWD = TBW × [(Na/140) − 1], where TBW = 0.6 × weight (kg) for men, 0.5 for women. Replace half the deficit in the first 24 hours and the remainder over the next 24–48 hours using D5W or free water via feeding tube. Correction rate: do not exceed 10 mEq/L per 24 hours (faster correction risks cerebral edema).

Hypokalemia

K <3.5 mEq/L. Causes: GI losses, diuretics, alkalosis, refeeding syndrome, insulin, beta-agonists, hypomagnesemia. ECG changes: flattened/inverted T waves, prominent U waves, ST depression, prolonged QT, risk of torsades de pointes. Treatment: Mild (3.0–3.5): oral KCl 40–80 mEq/day in divided doses. Moderate (2.5–3.0): IV KCl 10–20 mEq/h via central line (max 40 mEq/h for emergencies via central line with continuous monitoring) + oral supplementation. Severe (<2.5 or symptomatic): IV KCl 20–40 mEq/h via central line with continuous cardiac monitoring. Always check and replace magnesium — hypomagnesemia makes hypokalemia refractory to treatment (Mg is required for ROMK channel function in the distal nephron). 10 mEq IV KCl raises serum K by approximately 0.1 mEq/L.

Hyperkalemia

K >5.0 mEq/L. Causes: AKI/CKD, acidosis, cell lysis (rhabdomyolysis, tumor lysis, hemolysis), medications (ACEi/ARB, spironolactone, TMP-SMX, NSAIDs, heparin), pseudohyperkalemia (hemolyzed sample, tourniquet, thrombocytosis). ECG progression: peaked T waves (earliest, K ~5.5–6.5) → PR prolongation → loss of P waves → widened QRS → sine wave → V-fib/asystole.

Treatment ladder:

Hypocalcemia & Hypercalcemia

Hypocalcemia (corrected Ca <8.5 or ionized Ca <4.0): causes include hypoparathyroidism (post-thyroidectomy), vitamin D deficiency, CKD, hypomagnesemia, massive transfusion (citrate chelation), pancreatitis. Symptoms: perioral/extremity paresthesias, Chvostek sign, Trousseau sign, QT prolongation. Treatment: symptomatic or ionized Ca <3.2 — calcium gluconate 1–2 g IV over 10–20 min, then 0.5–1.5 mg/kg/h infusion; mild — calcium carbonate 1–2 g PO TID with vitamin D. Hypercalcemia (Ca >10.5): causes — primary hyperparathyroidism and malignancy account for >90%. Treatment: IV NS 200–300 mL/h (volume expansion and calciuresis), then furosemide 20–40 mg once euvolemic (not first-line), calcitonin 4 IU/kg SC/IM q12h (rapid onset, tachyphylaxis in 48 h), zoledronic acid 4 mg IV over 15 min (peak effect 2–4 days, lasts weeks; avoid if CrCl <35), denosumab 120 mg SC for refractory/renal failure.

Hypomagnesemia

Mg <1.8 mg/dL. Common in hospitalized patients (up to 65% of ICU patients). Causes: diuretics (loop and thiazide), alcoholism, PPIs (chronic use), diarrhea, refeeding syndrome. Makes hypokalemia and hypocalcemia refractory to correction. Treatment: mild (1.2–1.8) — magnesium oxide 400–800 mg PO daily; moderate/severe (<1.2 or symptomatic) — magnesium sulfate 1–2 g IV over 1 hour (can give up to 4–6 g/day); for torsades de pointes — magnesium sulfate 2 g IV push over 1–2 min.

Hypophosphatemia & Refeeding Syndrome

Phosphate <2.5 mg/dL. Refeeding syndrome occurs when malnourished patients (alcoholism, anorexia nervosa, prolonged NPO, cancer cachexia) are refed. Insulin surge drives phosphate, potassium, and magnesium intracellularly, causing severe hypophosphatemia (can cause respiratory failure from diaphragmatic weakness, cardiac dysfunction, rhabdomyolysis, seizures). Prevention: start nutrition at 10–15 kcal/kg/day, advance slowly over 5–7 days; supplement thiamine 200–300 mg IV before feeding (prevents Wernicke encephalopathy); check and replace PO₄, K, Mg BID. Treatment of hypophosphatemia: mild (2.0–2.5) — sodium or potassium phosphate 30–40 mmol PO daily; severe (<1.0 or symptomatic) — potassium phosphate or sodium phosphate 20–40 mmol IV over 4–6 hours; monitor Ca (IV phosphate can cause hypocalcemia and metastatic calcification).

18 Pain Management in Hospitalized Patients

Effective pain management improves patient outcomes, mobility, and satisfaction while reducing complications. The hospitalist must employ multimodal analgesia, understand opioid equivalencies, and anticipate opioid side effects.

Multimodal Analgesia Approach

The multimodal strategy uses agents from different drug classes to target multiple pain pathways, reducing opioid requirements by 30–50%. The foundation: scheduled acetaminophen (650–1000 mg PO/IV q6h, max 3 g/day in liver disease or elderly, 4 g/day otherwise) + NSAID/COX-2 inhibitor (ketorolac 15–30 mg IV q6h, max 5 days; or ibuprofen 400–600 mg PO q6h; avoid in AKI, GI bleed, heart failure, post-CABG) + adjuncts as appropriate (gabapentin 100–300 mg PO TID for neuropathic pain, lidocaine patch 5% topical for localized pain, muscle relaxants for musculoskeletal spasm). Add opioids only when non-opioid multimodal therapy is insufficient.

Opioid Equivalency Table

When converting between opioids, calculate the total 24-hour dose in morphine milligram equivalents (MME), then reduce by 25–50% for incomplete cross-tolerance.

IV-to-PO Conversion

When transitioning from IV to PO opioids: calculate the total IV dose in 24 hours, convert to oral morphine equivalents using the ratios above, reduce by 25% for safety, and divide into appropriate dosing intervals. Example: patient receiving morphine 2 mg IV q4h (12 mg IV/day) → 12 × 3 = 36 mg PO morphine/day → reduce by 25% = 27 mg → morphine IR 5 mg PO q4h PRN (30 mg/day available).

PCA Protocols

Patient-controlled analgesia (PCA) delivers small opioid doses on patient demand. Standard settings: demand dose (morphine 1–2 mg or hydromorphone 0.2–0.4 mg), lockout interval (6–10 minutes), 4-hour limit (to prevent excessive dosing), and optional continuous/basal rate (use with caution — increases sedation and respiratory depression risk; generally avoid in opioid-naive patients). PCA requires: patient ability to understand and operate the button, no cognitive impairment, continuous pulse oximetry monitoring, and a bowel regimen.

Bowel Regimen with Opioids

Opioid-induced constipation (OIC) occurs in 40–80% of patients on opioids. Prophylactic bowel regimen for all patients on scheduled opioids: senna 8.6–17.2 mg PO BID (stimulant) + docusate 100 mg PO BID (stool softener). If no BM in 48 hours: add bisacodyl 10 mg PO or PR. If refractory: polyethylene glycol (MiraLAX) 17 g PO daily, or lactulose 15–30 mL PO q6h. For severe OIC in patients on chronic opioids: methylnaltrexone (Relistor) 12 mg SC every other day (peripherally acting mu-opioid receptor antagonist, does not cross BBB, does not reverse analgesia) or naloxegol 25 mg PO daily.

19 Hospital-Acquired & Ventilator-Associated Pneumonia

Hospital-acquired pneumonia (HAP) develops ≥48 hours after admission in non-intubated patients. Ventilator-associated pneumonia (VAP) develops ≥48 hours after endotracheal intubation. Together they are the leading cause of death from hospital-acquired infections, with mortality rates of 20–50% for VAP.

Definitions & Diagnosis

HAP: new or progressive pulmonary infiltrate on imaging plus clinical signs of infection (fever >38°C, purulent sputum, leukocytosis >12,000 or leukopenia <4,000, declining oxygenation) developing ≥48 hours after admission, without preceding intubation. VAP: same criteria, developing ≥48 hours after endotracheal intubation. Diagnosis requires: chest imaging showing new infiltrate, plus at least 2 of 3 clinical criteria (fever/hypothermia, leukocytosis/leukopenia, purulent secretions). Send sputum or endotracheal aspirate (or BAL) for Gram stain and culture before starting antibiotics (but do not delay treatment while awaiting results).

Empiric Coverage

HAP/VAP empiric therapy must cover MRSA + Pseudomonas aeruginosa + gram-negative bacilli. Recommended empiric regimen:

Add a second antipseudomonal agent (aminoglycoside or fluoroquinolone) only if: high risk of multidrug-resistant organisms, prior IV antibiotics within 90 days, structural lung disease, or >25% local Pseudomonas resistance to the primary agent. Obtain nasal MRSA PCR: negative result has >95% NPV — supports de-escalation off MRSA coverage within 48–72 hours.

De-escalation & Duration

Narrow antibiotics based on culture and sensitivity results at 48–72 hours. Standard duration: 7 days for uncomplicated HAP/VAP (2016 IDSA guidelines). Procalcitonin-guided de-escalation (discontinue antibiotics when procalcitonin decreases by ≥80% from peak or to <0.5 ng/mL) reduces antibiotic exposure without increasing mortality.

VAP Prevention Bundle

Evidence-based interventions that reduce VAP incidence by 40–70%: head of bed elevation 30–45°, daily sedation interruption and spontaneous breathing trials (SAT/SBT pairing), oral care with chlorhexidine 0.12% q12h (controversial — some recent data suggests possible harm; institutional variation), subglottic suctioning endotracheal tubes, peptic ulcer prophylaxis only when indicated (not universal), VTE prophylaxis, and daily assessment of readiness for extubation.

20 Clostridioides difficile Infection

Clostridioides difficile (formerly Clostridium difficile) is the most common cause of healthcare-associated infectious diarrhea. CDI rates have increased dramatically, with approximately 500,000 infections and 29,000 deaths annually in the US. The hospitalist must recognize risk factors, select appropriate testing, and tailor treatment to severity.

Risk Factors

Major risk factors: antibiotics (fluoroquinolones, clindamycin, cephalosporins, and carbapenems are highest risk; any antibiotic can cause CDI), age ≥65, hospitalization ≥4 days, proton pump inhibitors (controversial but listed in IDSA guidelines as risk factor), immunosuppression (chemotherapy, organ transplant), and prior CDI (recurrence rate 20–25% after first episode, >40% after second).

Diagnostic Testing

Test only patients with ≥3 unformed stools in 24 hours. The optimal strategy is a two-step algorithm: (1) GDH (glutamate dehydrogenase) antigen screen — sensitive but not specific (detects toxigenic and non-toxigenic strains), then (2) toxin EIA (detects toxins A and B) or NAAT/PCR if GDH positive. Alternatively, a NAAT (nucleic acid amplification test / PCR) alone is very sensitive (sensitivity >95%) but may detect colonization rather than active disease (positive PCR without clinical disease = carrier, not CDI). Toxin EIA alone is specific (99%) but less sensitive (75–85%). Do not test formed stools. Do not repeat testing within 7 days if initially negative. Do not use test of cure after treatment.

Severity Classification & Treatment

Recurrence Management

First recurrence: fidaxomicin 200 mg PO BID × 10 days (preferred — lower recurrence rate than vancomycin), or vancomycin pulse-taper (125 mg QID × 14 days, then BID × 7 days, then daily × 7 days, then every 2–3 days × 2–4 weeks). Second or subsequent recurrence: consider fecal microbiota transplant (FMT) — efficacy 80–90% for recurrent CDI; FDA-approved options include fecal microbiota live-jslm (Rebyota, rectal) and fecal microbiota spores live-brpk (Vowst, oral). Bezlotoxumab (monoclonal antibody against toxin B) 10 mg/kg IV single dose can be given with standard therapy to reduce recurrence (NNT ~10).

21 Catheter-Associated UTI & CLABSI

Catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI) are the two most common device-associated hospital-acquired infections and CMS-designated never events. Prevention is a core hospitalist responsibility.

CAUTI

Definition: patient with an indwelling urinary catheter (or catheter removed within 48 hours) who develops urinary symptoms (fever, suprapubic tenderness, costovertebral angle tenderness, urgency, frequency, dysuria) plus urine culture ≥10⁵ CFU/mL of ≤2 organisms. Critical distinction: asymptomatic bacteriuria (ASB) — positive urine culture without urinary symptoms — should NOT be treated in catheterized patients (except in pregnancy or before urologic procedures). Treating ASB drives antibiotic resistance and CDI without clinical benefit.

Prevention bundle: (1) Avoid unnecessary catheter insertion — appropriate indications: urinary retention/obstruction, accurate I&O measurement in critically ill patients, perioperative use for selected surgeries, open sacral/perineal wounds in incontinent patients, comfort care at end of life. (2) Daily assessment of catheter necessity with prompt removal (nurse-driven removal protocols reduce CAUTI by 50%). (3) Aseptic insertion technique. (4) Maintain closed drainage system. (5) Keep bag below bladder. (6) Consider alternatives: condom catheter, intermittent straight catheterization, bladder scanner.

CLABSI

Definition: laboratory-confirmed bloodstream infection in a patient with a central venous catheter in place for ≥2 calendar days (day 1 = insertion day), with no other identified source of infection. Common organisms: coagulase-negative Staphylococci (most common), S. aureus, Enterococcus, Candida, gram-negative bacilli.

Prevention bundle (central line insertion): hand hygiene, maximal sterile barrier precautions (cap, mask, sterile gown, sterile gloves, full-body sterile drape), chlorhexidine skin antisepsis (allow to dry), optimal site selection (subclavian preferred over IJ or femoral for lowest infection risk — but ultrasound-guided IJ is often preferred to avoid pneumothorax), sterile dressing. Maintenance bundle: daily assessment of line necessity, scrub the hub (alcohol swab for 15 seconds before access), chlorhexidine-impregnated dressing or sponge, standardized tubing changes.

Blood Culture Interpretation

Distinguishing true bacteremia from contamination is essential. Likely contaminants (single positive culture): coagulase-negative Staphylococci, Corynebacterium spp., Bacillus spp., Propionibacterium acnes. True pathogens (even single positive): S. aureus, Streptococcus pneumoniae, E. coli and other Enterobacteriaceae, Pseudomonas aeruginosa, Candida spp. When a potential contaminant is isolated, repeat cultures before initiating treatment. S. aureus bacteremia always requires a minimum 2 weeks of IV antibiotics (4–6 weeks if endocarditis, osteomyelitis, or metastatic infection) and a transthoracic or transesophageal echocardiogram to rule out endocarditis.

Line Removal Decision

Remove the central line for: S. aureus (always), Candida (always), tunnel infection or port pocket infection, septic shock, persistent bacteremia after 72 hours of appropriate antibiotics, and complicated infection (endocarditis, septic thrombosis). Line salvage (antibiotic lock therapy + systemic antibiotics) may be attempted for coagulase-negative Staphylococci in patients with limited venous access and uncomplicated infection, provided the patient defervesces within 72 hours.

22 Falls, Delirium & Pressure Injuries

Falls, delirium, and pressure injuries are the triad of preventable hospital-acquired conditions that disproportionately affect elderly and critically ill patients. All three are CMS-reportable quality measures and are tied to reimbursement penalties.

Morse Fall Scale

Score 0–24: no risk; 25–44: low risk (standard fall precautions); ≥45: high risk (intensive fall prevention — bed alarm, non-slip socks, low bed, sitter if needed, PT consult, medication review).

Delirium — CAM (Confusion Assessment Method)

The CAM is the gold standard bedside delirium screening tool. Diagnosis requires features 1 AND 2, plus either 3 OR 4:

CAM sensitivity 94–100%, specificity 90–95% when performed correctly. For ICU patients, use the CAM-ICU (modified for non-verbal patients on ventilators).

Delirium Prevention — HELP Protocol

The Hospital Elder Life Program (HELP) reduces delirium incidence by 40% (Inouye et al., NEJM 1999). Components: daily reorientation (calendar, clock, familiar objects, windows), cognitive stimulation (conversation, word games), early mobilization (PT/OT, ambulation 3×/day), sleep promotion (minimize nighttime vitals/medications, reduce noise, warm milk, relaxation techniques, avoid benzodiazepines for sleep — use melatonin 1–3 mg instead), nutritional support (assistance with meals, hydration), vision and hearing aids (ensure glasses and hearing aids are at the bedside). Non-pharmacologic prevention is far more effective than pharmacologic treatment.

Pressure Injuries — Braden Scale

The Braden Scale predicts pressure injury risk. Six subscales, each scored 1–4 (except friction/shear, scored 1–3):

Total score range 6–23. Score ≤12: high risk; 13–14: moderate risk; 15–18: mild risk; ≥19: no significant risk. High-risk patients should receive: repositioning q2h, pressure-redistribution mattress, moisture management, nutritional optimization (protein 1.25–1.5 g/kg/day, vitamin C, zinc), skin inspection every shift, and heel elevation off the bed surface.

Pressure Injury Staging (NPUAP/EPUAP)

23 Bedside Procedures

Hospitalists perform and interpret several core bedside procedures. Proficiency in these procedures allows rapid diagnosis and therapeutic intervention without waiting for subspecialty availability.

Paracentesis

Indicated for: new-onset ascites (diagnostic), suspected spontaneous bacterial peritonitis (SBP), and symptomatic relief of tense ascites (therapeutic — remove up to 5 L; if >5 L, give albumin 6–8 g per liter removed to prevent post-paracentesis circulatory dysfunction). Site: left lower quadrant, lateral to rectus muscle (use ultrasound guidance to confirm fluid pocket and avoid inferior epigastric vessels). Send fluid for: cell count and differential (PMN ≥250 = SBP), albumin (calculate SAAG = serum albumin − ascites albumin), total protein, culture (inoculate blood culture bottles at bedside).

Thoracentesis — Light’s Criteria

Indicated for: new pleural effusion of unknown etiology, suspected empyema/parapneumonic effusion, or symptomatic relief. Perform under ultrasound guidance (reduces pneumothorax risk to <2%). Therapeutic thoracentesis: remove up to 1–1.5 L (excessive removal risks re-expansion pulmonary edema). Send fluid for: cell count, protein, LDH, glucose, pH, Gram stain, culture, cytology (if malignancy suspected).

Light’s Criteria classify an effusion as exudative if ANY ONE of the following is met:

Transudates (meet none of the above): CHF (most common), cirrhosis (hepatic hydrothorax), nephrotic syndrome, atelectasis. Exudates: infection (pneumonia, empyema, TB), malignancy, PE, autoimmune (RA, lupus), pancreatitis, chylothorax. Note: Light’s criteria misclassify ~25% of CHF transudates as exudates (especially after diuresis) — if the fluid is near the cutoff and CHF is suspected, check serum-pleural fluid albumin gradient >1.2 to confirm transudate.

Lumbar Puncture

Indicated for: suspected meningitis/encephalitis, subarachnoid hemorrhage (after negative CT), normal-pressure hydrocephalus evaluation, CNS malignancy. Position: lateral decubitus (most accurate opening pressure) or seated. Opening pressure: normal 10–20 cmH₂O; elevated >25 cmH₂O (infection, idiopathic intracranial hypertension, mass lesion). CSF analysis: cell count (normal WBC <5; bacterial meningitis: 1,000–5,000+ with >80% neutrophils; viral: 50–1,000 with lymphocyte predominance; TB/fungal: 50–500 with lymphocyte predominance), protein (normal 15–45 mg/dL; elevated in bacterial >250, viral 50–200, TB 100–500), glucose (normal 60–70% of serum glucose; low <40 in bacterial, TB, fungal; normal in viral). Always get CT before LP if: papilledema, focal neurologic deficit, new seizure, altered consciousness, or immunocompromised (rule out mass lesion).

Central Line Placement

Site selection: Internal jugular (IJ) — most common for temporary access, lowest mechanical complication rate with ultrasound guidance, preferred for dialysis catheters. Subclavian — lowest infection rate, but highest pneumothorax risk (5%) and should be avoided in coagulopathy (non-compressible). Femoral — easiest landmark access, used in emergencies, but highest infection and DVT risk. All central lines should be placed with ultrasound guidance (real-time visualization reduces complications by ~70%), maximal sterile barrier precautions, and chlorhexidine skin prep. Post-placement CXR to confirm tip position (IJ/subclavian: at cavoatrial junction) and rule out pneumothorax.

Arthrocentesis

Indicated for: acute monoarthritis (mandatory to rule out septic arthritis), crystal arthropathy evaluation, and symptomatic relief of large effusions. Send fluid for: cell count (WBC >50,000 with >90% PMNs = septic until proven otherwise; 2,000–50,000 = inflammatory; <2,000 = non-inflammatory/OA), Gram stain and culture, crystal analysis under polarized microscopy (negatively birefringent = monosodium urate/gout; positively birefringent = calcium pyrophosphate/pseudogout). Anticoagulation is NOT a contraindication to arthrocentesis of an acutely inflamed joint — septic arthritis is an emergency that cannot be excluded without joint aspiration.

24 Consultation & Comanagement

Effective consultation is a core hospitalist skill. Knowing when to consult, how to frame the clinical question, and how to comanage complex patients with other specialties improves outcomes and efficiency.

When to Consult

Consult when: the patient has a condition outside the hospitalist’s scope of practice, a procedure is needed that the hospitalist does not perform, the diagnosis is uncertain despite thorough workup, the patient is not responding to standard therapy, or medicolegal risk is high and specialist input is warranted. Avoid "courtesy consults" with no clinical question — they waste specialist time and fragment care.

The 5 C’s of an Effective Consult Request

Surgical Comanagement

The hospitalist comanages surgical patients by handling: perioperative medical optimization (cardiac risk assessment — RCRI, medication management), postoperative medical complications (AKI, delirium, glycemic control, VTE prophylaxis, electrolytes, pain management), and discharge planning. Clear delineation of responsibilities between surgical and medical teams is essential. Common comanagement models: advisory (hospitalist provides recommendations), collaborative (shared order writing), and primary medical (hospitalist writes all medical orders while surgeon manages surgical issues).

Rapid Response & Code Blue

Rapid Response Teams (RRT) are activated for acute clinical deterioration before cardiac arrest. Common activation criteria: RR <8 or >28, HR <40 or >130, SBP <90, SpO₂ <90% despite O₂, acute change in mental status, new-onset seizure, or nursing concern ("worried" criterion). The hospitalist is typically part of the RRT and must rapidly assess, stabilize, and determine disposition (remain on floor, transfer to ICU). Code Blue (cardiac arrest): follow ACLS algorithms — high-quality CPR (rate 100–120, depth 2–2.4 inches, full recoil, minimize interruptions), early defibrillation for shockable rhythms (V-fib/pulseless V-tach: 200 J biphasic), epinephrine 1 mg IV q3–5 min, and identify/treat reversible causes (H’s and T’s: hypovolemia, hypoxia, hydrogen ion, hypo/hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, thrombosis pulmonary, thrombosis coronary).

Palliative Care Consultation

Trigger criteria for palliative care consult: ICU stay >7 days with no improvement, advanced cancer with declining functional status, end-stage organ disease (HFrEF EF <20%, COPD on home O₂, ESRD on dialysis with declining function), frequent readmissions (≥3 in 6 months), surrogate decision-making conflicts, uncontrolled symptoms despite treatment, or patient/family requesting goals of care discussion. Early palliative care involvement reduces ICU LOS, healthcare costs, and improves quality of life without shortening survival (Temel et al., NEJM 2010).

25 Geriatric Hospital Medicine

Patients aged ≥65 account for over 35% of hospitalizations and are at disproportionate risk for medication adverse events, delirium, falls, functional decline, and iatrogenic complications. Geriatric-specific principles should guide every aspect of hospital care for this population.

Beers Criteria Highlights

The AGS Beers Criteria (updated 2023) identify potentially inappropriate medications in older adults. Key drugs to avoid:

Polypharmacy & Deprescribing

Polypharmacy (≥5 medications) affects >40% of older adults and is the single strongest risk factor for adverse drug events. Hospitalization is an opportunity to deprescribe. Systematic approach: (1) list all medications, (2) identify drugs with no current indication, (3) identify drugs where risks outweigh benefits (Beers criteria, STOPP criteria), (4) identify drug interactions, (5) discuss with patient/family and taper/discontinue. Common targets: PPIs (taper after 8 weeks unless Barrett’s or chronic NSAID), bisphosphonates (drug holiday after 5 years oral / 3 years IV), statins (questionable benefit in limited life expectancy <1–2 years), and duplicative medications.

Functional Decline Prevention

Up to 35% of hospitalized older adults experience functional decline during hospitalization. Prevention strategies: early mobilization (PT/OT within 24 hours, ambulate in hallway TID), minimizing unnecessary bed rest orders, limiting tethers (remove Foley, telemetry, IVs as soon as possible), ensuring nutritional adequacy, and maintaining normal sleep-wake cycles. The ACE (Acute Care for Elders) unit model bundles these interventions and has been shown to reduce functional decline, LOS, and institutionalization.

26 Palliative Care & Goals of Care

Palliative care focuses on relief of suffering and improvement of quality of life for patients with serious illness, regardless of prognosis. It is not synonymous with hospice or end-of-life care. Every hospitalist should be competent in primary palliative care skills: symptom management, goals-of-care conversations, and advance care planning.

Symptom Management

Hospice Eligibility

Medicare hospice benefit requires: (1) two physicians certify a prognosis of ≤6 months if the disease follows its natural course, and (2) the patient elects comfort-focused care (forgoing curative treatment for the terminal diagnosis). General indicators of hospice-appropriate prognosis: recurrent hospitalizations, progressive functional decline (PPS ≤50%), unintentional weight loss >10% over 6 months, albumin <2.5, increasing dependence in ADLs. Disease-specific criteria exist for heart failure (EF <20%, NYHA IV despite optimal therapy), COPD (FEV1 <30%, O₂-dependent, cor pulmonale), dementia (FAST scale ≥7, unable to ambulate/dress/bathe/speak >6 words per day), and renal disease (not pursuing dialysis, CrCl <10 or Cr >8).

Advance Directive Documentation

Key documents: Advance directive / Living will — written instructions about desired medical treatment if the patient cannot communicate (varies by state). Healthcare Power of Attorney (HCPOA) / Healthcare proxy — designates a surrogate decision-maker. POLST/MOLST (Physician/Medical Orders for Life-Sustaining Treatment) — portable, actionable medical orders signed by both physician and patient; more specific than an advance directive (specifies code status, hospitalization preferences, artificial nutrition). Document the presence of these forms in the EMR, scan copies, and ensure orders match the patient’s expressed wishes.

Code Status Discussions — REMAP Framework

27 Medical-Legal & Documentation

Hospitalists carry substantial medicolegal risk due to the volume and acuity of patients they manage. Thorough documentation is the single most important defense against liability and ensures accurate coding, reimbursement, and quality reporting.

Medical Necessity Documentation

Every note should support the medical necessity for the hospitalization. Document: why the patient cannot be safely managed at a lower level of care, what services are being provided that require inpatient resources, and the expected length of stay. Use language such as "The patient requires inpatient hospitalization due to [specific clinical reasons]. Outpatient management is not appropriate because [specific barriers]." This documentation protects against RAC audits and denial of claims.

Clinical Decision-Making Levels (E&M 2021)

Under the 2021 CMS E&M guidelines, the level of service is determined by either total time OR medical decision-making (MDM) complexity. MDM has three components:

Two of three components must meet the level to qualify. For hospital inpatient E&M: 99221 (straightforward/low), 99222 (moderate), 99223 (high) for initial; 99231 (low), 99232 (moderate), 99233 (high) for subsequent days.

Incident Reporting

Incidents requiring reporting: medication errors (wrong drug, wrong dose, wrong route, wrong patient), falls with injury, wrong-site/wrong-patient procedures, equipment malfunction causing harm, sentinel events (death or serious harm from a hospital-acquired cause), and near-misses. Incident reports are internal quality improvement documents. In the medical record, document the objective clinical facts (what happened, what was found, what was done) but do NOT reference the incident report itself (it is a privileged quality document in most jurisdictions).

AMA Discharge — Capacity Assessment & Documentation

When a patient wishes to leave against medical advice (AMA), the hospitalist must: (1) Assess decision-making capacity — the patient understands the diagnosis, the proposed treatment, the risks of leaving (including death), and the alternatives; this is a clinical assessment, not a legal determination (capacity is task-specific). (2) Clearly explain the risks of leaving. (3) Document the conversation thoroughly: "Patient was informed of [specific risks including death], understands and can articulate these risks, and still wishes to leave." (4) Offer alternatives: "You may return at any time. I would be happy to provide prescriptions for [medications] and arrange follow-up in [timeframe]." (5) Provide discharge medications, instructions, and follow-up information even if the patient leaves AMA. Do NOT withhold prescriptions or follow-up as "punishment." AMA discharge does NOT automatically void insurance coverage — this is a common myth.

Informed Consent

Required elements of valid informed consent: (1) nature of the procedure/treatment, (2) benefits, (3) risks (including common and serious/life-threatening), (4) alternatives (including no treatment), (5) opportunity to ask questions. The patient must have capacity, be free from coercion, and sign voluntarily. For patients lacking capacity, consent is obtained from the surrogate decision-maker (HCPOA, or next of kin per state hierarchy). In emergencies where consent cannot be obtained, the emergency exception doctrine allows treatment to prevent death or serious harm.

28 Scoring Systems Master Table

This section consolidates every major scoring system referenced in hospital medicine. Each score is fully enumerated with thresholds and interpretation.

CURB-65 (Pneumonia Severity)

Wells PE Score Interpretation

Wells DVT Score Interpretation

PESI Score Classes

4T Score for HIT

LACE Index (Readmission Risk)

LRINEC Score (Necrotizing Fasciitis)

Braden Scale (Pressure Injury Risk)

Morse Fall Scale

CAM (Confusion Assessment Method) — Summary

MELD Score (Model for End-Stage Liver Disease)

MELD = 3.78 × ln(bilirubin mg/dL) + 11.2 × ln(INR) + 9.57 × ln(creatinine mg/dL) + 6.43. MELD-Na incorporates serum sodium (improves prognostic accuracy). Used for: liver transplant organ allocation priority, predicting 90-day mortality in cirrhosis (MELD 10 = 6%, 20 = 20%, 30 = 53%, 40 = 80%), and guiding decisions about TIPS and other interventions. Minimum values are set to 1.0 for each variable; maximum creatinine is capped at 4.0 (and 4.0 if on dialysis).

29 Medications Master Table

This table lists the most commonly used inpatient medications by class, with dosing, indications, and clinical pearls relevant to hospitalist practice.

Antibiotics

Cardiovascular

Endocrine

GI / Antiemetics

Sedation / Psychiatry

30 Abbreviations Master List

Comprehensive list of abbreviations used throughout hospital medicine documentation, orders, and communication.