Time Management

Time management refers to the way you organize and plan how long you spend on specific activities.

Time management is a bit of a misnomer.  Really it is about managing your overall workload and productivity.

Trying to multi-task will cause you to be inefficient because you are constantly switching between different tasks.  The act of switching between tasks costs time and makes you less productive.  It will also lead to cognitive errors and fatigue.

Studies show people are more productive with short bursts of activity that last about 90 minutes followed by a break.

Practical Tips:

  • Minimize Multi-Tasking
  • Check email/Epic only once a day
  • Minimize interruptions
  • List your goals and organize/group the activities
    • Core responsibilities-admitting patients, phone calls to patients, etc
    • Personal Growth- projects, research, etc
    • Managing People- working with others
    • Urgent matters- crisis
    • Free Time
    • Administrative tasks

Grand Rounds-9/7/16

“Increasing Family Resilience To Improve Patient Outcomes”.

Presenter: Dr. Barry Jacobs.  Crozer-Keystone Family Medicine Residency

Link to presentation

  • Why Family Matters
    • Rapidly aging population (20% over 65 by 2030)
    • Rising incidence of chronic illnesses, functional limitations
    • Decreased hospital lengths of stay and emphasis on preventing bounce-backs
  • Family Caregiving in America
    • 43 million Americans engage in some form of caregiving activity
    • Heterogenous group.  E.g. 1/4 are Millenials (20s), 1/4 are Generation X-ers (30s)
    • 33% reported no strain, 49% some strain, 18% a lot of strain
  • Negative Effects
    • Dementia caregiving linked to 63% increased mortality, insomnia, depression, musculoskeletal, decreased use of preventative medical services
  • Positive Effects
    • Caregivers report personal and spiritual growth
  • Caregiver Intervention
    • Research from NYU Caregiver Intervention shows that it can forestall nursing home placement of Alzheimer’s patient for nearly 2 years
  • Elements of support programs
    • Frequent contact with multiple means (in-person, telephone, internet, etc)
    • Counseling
    • Acknowledgement
      • Identification of the caregiver in the patient’s chart
    • Communication
      • Ability to share observations, ask questions
    • Decision-making power
      • Include patient and family goals in care plans
    • Money
      • Payment incentives for healthcare providers to support faily caregivers
    • Assessment
      • Asking if the caregiver is willing and able to perform the tasks
    • Care management
      • Will need additional help when a patient is being transitioned from one care to another
    • Training and support
      • Better preparing the caregiver for complex medical tasks
    • Technology

Spirometry

Pulmonary Function Testing (PFT) is a broad term to describe several tests.  It requires specification by the prescribing physician for the individual components:

  • Spirometry- FEV1 and FVC.
    • FEV1 is the forced expiratory volume in 1 second.   A normal person would be able to expire 80% of their forced vital capacity in 1 second.  Individuals with obstruction will have a reduced FEV1 volume.  Forced vital capacity is the volume an individual can expire in 6-8 seconds.  An FEV1/FVC ratio <0.70 signifies obstruction.
  • Lung volumes- TLC, RV, ERV.
    • At Temple this is measured by body plethysmography.  RV and TLC are normal if values are between 80-120%.  RV and TLC percentages >120% signify gas trapping and hyperinflation, respectively.  Percentages <80% signify restriction.
  • Diffusion capacity- DLCO, DLCO/VA
    • Diffusion capacity is measured through inhalation of carbon monoxide.  DLCO/VA will correct for the patients alveolar volume.
  • Methacholine challenge
    • Increasing amounts of methacholine will be given to a patient to see if it will cause a reduction in FEV1.  FEV1 drop of 20% will lead to immediate discontinuation of the test.  Patients cannot take their bronchodilator the day of the test.
  • 6 minute walk test

 

Approach to Abdominal Pain

Abdominal Pain History:

  • Position/palliating and provoking factors
  • Quality (sharp, dull, sore, burning, cramping)
  • Region, radiation, referral
    • Ask patient to use one finger to confirm location
    • Referred pain: Kehr’s sign (diaphragmatic irritation can cause shoulder pain), Ipsilatral scapula (biliary disease)
  • Severity
  • Temporal factors (time/mode of onset, progression, previous episodes)
    • Remember to ask about recent surgeries or procedures, new medications, social history (tobacco use in AAA, ob/gyn history)

Physical Exam:

  • Palpation strategies/questions: Work from least to most painful areas, do not be afraid to push, care the complaints out of proportion to exam, when did they get pain meds?
  • Peritonitis: Perforation, malignancy, mesenteric ischemia, strangulated hernia
    • Evaluation Techniques: Cough test, Inspiration test, peritoneal irritation (tapping heel, bumping bed)
    • Specific Maneuvers:
      • Murphy’s Sign- Inspiratory arrest during pressure to RUQ while patient taking a deep breath.
      • Psoas Sign- pain with passive hip extension
      • Obturator Sign- pain with passive internal/external rotation of right hip
      • Rovsing Sign- pain in RLQ when there is pressure exerted in LLQ

Smoking Cessation

Stats:

480,000 Premature deaths per year with 3-5 times increase in all-cause mortality in smokers vs non-smokers

$289 billion in extra costs

17.8% of adults smoke

Quitting smoking before 40 years old reduced smoking-related mortality by 90%.

Cancer patients who quit at time of diagnosis reduce their risk of dying by 30-40%

 

Nicotine and addiction:

Physiologic withdrawal can last for 6 weeks

The physicians role- Ask, Advise, Assess (motivational interviewing), Assist (behavioral therapies, nicotine replacement, pharmacologic therapies), Arrange (bringing the patient back)

Endocarditis

Definition: Infection involving the inner lining of the heart, often involving the valves.

TUH In-Hospital Mortality- ~23%

5-Year Mortality- 40%

Risk Factors: Prosthetic valve, history of IE, intracardiac devices, rheumatic heart disease, age, hemodialysis, IV drug abuse, HIV (?), diabetes

Valves affected (TUH): Aortic 34%,Mitral 36%, Tricuspid 33%, Pulmonic 2%

Microbiology (TUH): S. aureus 58%, Viridans strep 9%, Coag. neg staph 5.5%, Enterococcus 6%

Clinical and Laboratory Findings on Admission (most common): Fever >38C, Elevated ESR/CRP, Worsening of old murmur, New murmur, Vascular embolic event, Hematuria

Complications: Cerebral (CVA, TIA, brain abscess, meningitis), Intracardiac abscess, CHF, conduction abnormalities, Osteomyelitis/Distant abscesses

Modified Duke Criteria:

Major-

  • Positive blood culture for typical IE
  • Echo with intracardiac mass, abscess, prosthetic valve dehiscence, new valvular regurgitation

Minor-

  • Predisposing heart condition
  • IV drug abuse
  • Temp >100.4
  • Vascular phenomena: arterial emboli, pulm infarcts, Janeway lesion
  • Immunologic phenomena: Osler nodes, Roth spots
  • Other positive blood cultures

Diagnosis:

  • Blood cultures (2 sets)
  • CXR
  • ECG
  • Echo (TTE vs. TEE)
    • Especially with S. aureus
  • CBC, Basic met, Coags
  • ID consult, +/- CT surgery and cardiology

Treatment:

Empiric coverage- Vancomycin

MRSA-

  • Vancomycin 30mg/kg BID x 4 weeks

Viridans strep-

  • Penicillin G q4h x 4 weeks
  • Ceftriaxone 2g daily x 4 weeks
  • Penicillin G q4h PLUS Gentamicin q8h x 2 weeks
  • Pen-Allergic Patients: Vancomycin 30mg/kg BID x 4 weeks

MSSA-

  • Oxacillin 2g q4h x 4-6 weeks
  • Cefazolin 2g q8h x 4-6 weeks
  • Pen-Allergic Patients: Cefazolin 2g q8h x 4-6 hour OR Vancomycin 30mg/kg BID x 4-6 weeks

Enterococcus-

  • Penicillin G q4h PLUS Gentamicin q8h x 2 weeks
  • Ampicillin 2mg q4h PLUS Gentamicin q8h x 4 weeks
  • Vancomycin 30mg/kg BID x 4 weeks PLUS Gentamicin q8h x 4 weeks
  • Ampicillin PLUS Ceftriaxone

HACEK-

  • Ceftriaxone 2g IV daily x 4 weeks
  • Ampicillin 2g q6h PLUS Gentamicin q8h x 4 weeks

Prosthetic Valve Endocarditis- Viridans Strep

  • Penicillin G x 6 weeks +/- Gentamicin x 2 weeks
  • Ampicillin x 6 weeks +/- Gentamicin x 2 weeks
  • Vancomycin 30mg/kg BID x 6 weeks

Prosthetic Valve Endocarditis- S. aureus

  • MSSA
    • Oxacillin 2g q6h x 6 weeks PLUS Gentamicin x 2 weeks PLUS Rifampin 300mg q8h x 6 weeks
  • MRSA
    • Vancomycin 30mg/kg BID x 6 weeks PLUS Gentamicin x 2 weeks PLUS Rifampin 300mg q8h x 6 weeks

Prosthetic Valve Endocarditis- Enterococcus

  • Ampicillin 2g q6h x 6 weeks PLUS Gentamicin x 6 weeks
  • Penicillin G x 6 weeks PLUS Gentamicin x 6 weeks
  • Vancomycin 30mg/kg BID x 6 weeks PLUS Gentamicin x 6 weeks

Valve Replacement Indications

  • Major
    • Heart Failure
    • Uncontrolled Infection
    • Prevention of Embolic Events
  • Other Indications
    • Fungal
    • Pseudomonas species
    • Perivalvular abscess
    • Valve Dehiscence

Prophylaxis

  • Prosthetic cardiac valve
  • Previous episode of IE
  • Unrepaired cyanotic congential heart disease
  • Heart transplant recipients with cardiac valvulopathy