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The widespread use of complementary products poses a challenge to clinicians in the perioperative period and may increase perioperative risk. Because dietary supplements are regulated differently from traditional pharmaceuticals and guidance is often lacking, the Society for Perioperative Assessment and Quality Improvement convened a group of experts to review available literature and create a set of consensus recommendations for the perioperative management of these supplements. Using a modified Delphi method, the authors developed recommendations for perioperative management of 83 dietary supplements. We have made our recommendations to discontinue or continue a dietary supplement based on the principle that without a demonstrated benefit, or with a demonstrated lack of harm, there is little downside in temporarily discontinuing an herbal supplement before surgery. Discussion with patients in the preoperative visit is a crucial time to educate patients as well as gather vital information. Patients should be specifically asked about use of dietary supplements and cannabinoids, as many will not volunteer this information. The preoperative clinic visit provides the best opportunity to educate patients about the perioperative management of various supplements as this visit is typically scheduled at least 2 weeks before the planned procedure.

We performed a MEDLINE search and found 6 studies published February 2018 through January 2019 that should influence perioperative cardiovascular medicine, specifically in preoperative cardiac risk assessment, perioperative medication management, and postoperative cardiac complications.

Key Points Question What is the frequency with which patients hospitalized with COVID-19 are treated with venous thromboembolism (VTE) prophylactic- and treatment-dose anticoagulation, and what is the association of anticoagulation with in-hospital and 60-day mortality? Findings In this cohort study of 1351 patients hospitalized with COVID-19 in which 1127 patients received anticoagulation, 34.8% missed 2 or more days of VTE prophylaxis. Use of only prophylactic-dose or treatment-dose anticoagulation was associated with lower in-hospital mortality vs no anticoagulation; however, only prophylactic-dose anticoagulation remained associated with lower mortality at 60 days. Meaning These findings suggest that prophylactic-dose VTE anticoagulation may be optimal therapy for patients hospitalized with COVID-19., This cohort study of patients hospitalized with COVID-19 examines the association of anticoagulation treatment with mortality rates, and assesses differences between prophylactic- and treatment-doses in in-hospital and 60-day mortality., Importance Venous thromboembolism (VTE) is a common complication of COVID-19. It is not well understood how hospitals have managed VTE prevention and the effect of prevention strategies on mortality. Objective To characterize frequency, variation across hospitals, and change over time in VTE prophylaxis and treatment-dose anticoagulation in patients hospitalized for COVID-19, as well as the association of anticoagulation strategies with in-hospital and 60-day mortality. Design, Setting, and Participants This cohort study of adults hospitalized with COVID-19 used a pseudorandom sample from 30 US hospitals in the state of Michigan participating in a collaborative quality initiative. Data analyzed were from patients hospitalized between March 7, 2020, and June 17, 2020. Data were analyzed through March 2021. Exposures Nonadherence to VTE prophylaxis (defined as missing ≥2 days of VTE prophylaxis) and receipt of treatment-dose or prophylactic-dose anticoagulants vs no anticoagulation during hospitalization. Main Outcomes and Measures The effect of nonadherence and anticoagulation strategies on in-hospital and 60-day mortality was assessed using multinomial logit models with inverse probability of treatment weighting. Results Of a total 1351 patients with COVID-19 included (median [IQR] age, 64 [52-75] years; 47.7% women, 48.9% Black patients), only 18 (1.3%) had a confirmed VTE, and 219 (16.2%) received treatment-dose anticoagulation. Use of treatment-dose anticoagulation without imaging ranged from 0% to 29% across hospitals and increased over time (adjusted odds ratio [aOR], 1.46; 95% CI, 1.31-1.61 per week). Of 1127 patients who ever received anticoagulation, 392 (34.8%) missed 2 or more days of prophylaxis. Missed prophylaxis varied from 11% to 61% across hospitals and decreased markedly over time (aOR, 0.89; 95% CI, 0.82-0.97 per week). VTE nonadherence was associated with higher 60-day (adjusted hazard ratio [aHR], 1.31; 95% CI, 1.03-1.67) but not in-hospital mortality (aHR, 0.97; 95% CI, 0.91-1.03). Receiving any dose of anticoagulation (vs no anticoagulation) was associated with lower in-hospital mortality (only prophylactic dose: aHR, 0.36; 95% CI, 0.26-0.52; any treatment dose: aHR, 0.38; 95% CI, 0.25-0.58). However, only the prophylactic dose of anticoagulation remained associated with lower mortality at 60 days (prophylactic dose: aHR, 0.71; 95% CI, 0.51-0.90; treatment dose: aHR, 0.92; 95% CI, 0.63-1.35). Conclusions and Relevance This large, multicenter cohort of patients hospitalized with COVID-19, found evidence of rapid dissemination and implementation of anticoagulation strategies, including use of treatment-dose anticoagulation. As only prophylactic-dose anticoagulation was associated with lower 60-day mortality, prophylactic dosing strategies may be optimal for patients hospitalized with COVID-19.

The widespread use of complementary products poses a challenge to clinicians in the perioperative period and may increase perioperative risk. Because dietary supplements are regulated differently from traditional pharmaceuticals and guidance is often lacking, the Society for Perioperative Assessment and Quality Improvement convened a group of experts to review available literature and create a set of consensus recommendations for the perioperative management of these supplements. Using a modified Delphi method, the authors developed recommendations for perioperative management of 83 dietary supplements. We have made our recommendations to discontinue or continue a dietary supplement based on the principle that without a demonstrated benefit, or with a demonstrated lack of harm, there is little downside in temporarily discontinuing an herbal supplement before surgery. Discussion with patients in the preoperative visit is a crucial time to educate patients as well as gather vital information. Patients should be specifically asked about use of dietary supplements and cannabinoids, as many will not volunteer this information. The preoperative clinic visit provides the best opportunity to educate patients about the perioperative management of various supplements as this visit is typically scheduled at least 2 weeks before the planned procedure.

Periprocedural medication management is one of the most common tasks performed by the perioperative provider. But as surgery has become more frequently offered to patients with several medical comorbidities and taking multiple medications, this task can be difficult. This is further made challenging due to the limited published data on many, if not most, of the available medications. This article is based on a presentation given at the 12th Annual Perioperative Medicine Summit on March 9, 2017 in Fort Lauderdale, Florida. The medications discussed in this presentation were selected by the following criteria: availability of published data (i.e. statins), commonly prescribed agents (i.e. psychiatric and neurologic medications, oral diabetes agents), controversial perioperative medications (i.e. angiotensin-converting enzyme inhibitors and angiotensin receptor blockers), and high-risk medications (i.e. immunomodulators). To avoid redundancy, medications discussed at other meeting sessions (i.e. anticoagulants, antiplatelet agents, beta-blockers, opioids, and insulin) were not included.

Essentials How best to quantify thrombosis risk with peripherally inserted central catheters (PICC) is unknown. Data from a registry were used to develop the Michigan Risk Score (MRS) for PICC thrombosis. Five risk factors were associated with PICC thrombosis and used to develop a risk score. MRS was predictive of the risk of PICC thrombosis and can be useful in clinical practice. SummaryBackground Peripherally inserted central catheters (PICCs) are associated with upper extremity deep vein thrombosis (DVT). We developed a score to predict risk of PICC-related thrombosis. Methods Using data from the Michigan Hospital Medicine Safety Consortium, image-confirmed upper-extremity DVT cases were identified. A logistic, mixed-effects model with hospital-specific random intercepts was used to identify factors associated with PICC-DVT. Points were assigned to each predictor, stratifying patients into four classes of risk. Internal validation was performed by bootstrapping with assessment of calibration and discrimination of the model. Results Of 23 010 patients who received PICCs, 475 (2.1%) developed symptomatic PICC-DVT. Risk factors associated with PICC-DVT included: history of DVT; multi-lumen PICC; active cancer; presence of another CVC when the PICC was placed; and white blood cell count greater than 12 000. Four risk classes were created based on thrombosis risk. Thrombosis rates were 0.9% for class I, 1.6% for class II, 2.7% for class III and 4.7% for class IV, with marginal predicted probabilities of 0.9% (0.7, 1.2), 1.5% (1.2, 1.9), 2.6% (2.2, 3.0) and 4.5% (3.7, 5.4) for classes I, II, III, and IV, respectively. The risk classification rule was strongly associated with PICC-DVT, with odds ratios of 1.68 (95% CI, 1.19, 2.37), 2.90 (95% CI, 2.09, 4.01) and 5.20 (95% CI, 3.65, 7.42) for risk classes II, III and IV vs. risk class I, respectively. Conclusion The Michigan PICC-DVT Risk Score offers a novel way to estimate risk of DVT associated with PICCs and can help inform appropriateness of PICC insertion.

Background Hospitalists have long been involved in optimizing perioperative care for medically complex patients. In 2015, the Society of Hospital Medicine organized the Perioperative Care Work Group to summarize this experience and to develop a framework for providing optimal perioperative care. Methods The work group, which consisted of perioperative care experts from institutions throughout the United States, reviewed current hospitalist-based perioperative care programs, compiled key issues in each perioperative phase, and developed a framework to highlight essential elements to be considered. The framework was reviewed and approved by the board of the Society of Hospital Medicine. Results The Perioperative Care Matrix for Inpatient Surgeries was developed. This matrix characterizes perioperative phases, coordination, and metrics of success. Additionally, concerns and potential risks were tabulated. Key questions regarding program effectiveness were drafted, and examples of models of care were provided. Conclusions The Perioperative Care Matrix for Inpatient Surgeries provides an essential collaborative framework hospitalists can use to develop and continually improve perioperative care programs. Journal of Hospital Medicine 2017;12:277-282.

Hospitalized patients with acute medical illnesses are at risk for venous thromboembolism (VTE) during and after a hospital stay. Risk factors include physical immobilization and underlying pathophysiologic processes that activate the coagulation pathway and are still present after discharge. Strategies for optimal pharmacologic VTE thromboprophylaxis are evolving, and recommendations for VTE prophylaxis can be further refined to protect high-risk patients after hospital discharge. An early study of extended VTE prophylaxis with a parenteral agent in medically ill patients yielded inconclusive results with regard to efficacy and bleeding. In the Acute Medically Ill VTE Prevention with Extended Duration Betrixaban (APEX) trial, extended use of betrixaban halved symptomatic VTE, decreased hospital readmission, and reduced stroke and major adverse cardiovascular events compared with standard enoxaparin prophylaxis. Based on findings from APEX, the Food and Drug Administration approved betrixaban in 2017 for extended VTE prophylaxis in acute medically ill patients. In the Reducing Post-Discharge Venous Thrombo-Embolism Risk (MARINER) study, extended use of rivaroxaban halved symptomatic VTE in high-risk medical patients compared with placebo. In 2019, rivaroxaban was approved for extended thromboprophylaxis in high-risk medical patients, thus making available a new strategy for in-hospital and post-discharge VTE prevention. To address the critical unmet need for VTE prophylaxis in medically ill patients at the time of hospital discharge, the North American Thrombosis Forum (NATF) is launching the Anticoagulation Action Initiative, a comprehensive consensus document that provides practical guidance and straightforward, patient-centered recommendations for VTE prevention during hospitalization and after discharge.

Recent studies have shed light on preoperative risk assessment, medical therapy to reduce postoperative cardiac complications (beta-blockers, statins, and angiotensin II receptor blockers [ARBs]), perioperative management of patients with coronary stents on antiplatelet therapy, and perioperative bridging anticoagulation.

Background The optimal approach to assess risk of venous thromboembolism in hospitalized medical patients is unknown. We examined how well the Caprini risk assessment model predicts venous thromboembolism in hospitalized medical patients. Methods Between January 2011 and March 2014, venous thromboembolism events and risk factors were collected from non-intensive care unit medical patients hospitalized in facilities across Michigan. After calculation of the Caprini score for each patient, mixed logistic spline regression was used to determine the predicted probabilities of 90-day venous thromboembolism by receipt of pharmacologic prophylaxis across the Caprini risk continuum. Results A total of 670 (1.05%) of 63,548 eligible patients experienced a venous thromboembolism event within 90 days of hospital admission. The mean Caprini risk score was 4.94 (range, 0-28). Predictive modeling revealed a consistent linear increase in venous thromboembolism for Caprini scores between 1 and 10; estimates beyond a score of 10 were unstable. Receipt of pharmacologic prophylaxis resulted in a modest decrease in venous thromboembolism risk (odds ratio, 0.85; 95% confidence interval, 0.72-0.99; P = .04). However, the low overall incidence of venous thromboembolism led to large estimates of numbers needed to treat to prevent a single venous thromboembolism event. A Caprini cut-point demonstrating clear benefit of prophylaxis was not detected. Conclusions Although a linear association between the Caprini risk assessment model and the risk of venous thromboembolism was noted, an extremely low incidence of venous thromboembolism events in non-intensive care unit medical patients was observed. The Caprini risk assessment model was unable to identify a subset of medical patients who benefit from pharmacologic prophylaxis.

Important articles in perioperative medicine published and indexed on MEDLINE from February 2019 to February 2020 were compiled and reviewed. Three experts in perioperative medicine reviewed a total of 55 articles and independently voted on the most relevant studies that either had the potential to change clinical practice, confirm current practice, or bring attention to promising new areas in perioperative medicine. The top articles were chosen by consensus and presented at the “Clinical Update in Perioperative Medicine” session at the 15th Annual Perioperative Medicine Summit on March 12th, 2020 in Orlando Florida sponsored by The Society for Perioperative Assessment and Quality Improvement (SPAQI).

A MEDLINE search was performed from January 2017 to February 2018, and articles were selected for this update based on their significant influence on the practice of perioperative cardiovascular medicine.

This chapter guides the reader on the approaches and considerations for perioperative medication management in hospitalized patients.

This chapter guides the reader on preoperative cardiovascular risk reduction for noncardiac surgery in hospitalized patients.

This chapter guides the reader on the approaches and considerations in managing preoperative pulmonary risk assessment and reduction strategies in hospitalized patients.

This chapter guides the reader on the approaches and considerations in managing preoperative cardiovascular risk assessment for noncardiac surgery in hospitalized patients.

As the field of hospital medicine moves into its third decade, it is worthwhile to reflect on the evolution of perioperative cardiovascular risk stratification and risk reduction measures, and to l...

Computerized provider order entry systems commonly contain alerting mechanisms for patient allergies, incorrect doses, or drug-drug interactions when ordering medications. Providers have the option to override (bypass) these alerts and continue with the order unchanged. This study examines the effect of customizing medication alert override options on the appropriateness of override selection related to patient allergies, drug dosing, and drug-drug interactions when ordering medications in an electronic medical record.In this prospective, randomized crossover study, providers were randomized into cohorts that required a reason for overriding a medication alert from a customized or non-customized list of override reasons and/or by free-text entry. The primary outcome was to compare override responses that appropriately correlate with the alert type between the customized and non-customized configurations. The appropriateness of a subset of free-text responses that represented an affirmative and active acknowledgement of the alert without further explanation was classified as "indeterminate." Results were analyzed in three different ways by classifying indeterminate answers as either appropriate, inappropriate, or excluded entirely. Secondary outcomes included the appropriateness of override reasons when comparing cohorts and individual providers, reason selection based on order within the override list, and the determination of the frequency of free-text use, nonsensical responses, and multiple selection responses.Twenty-two clinicians were randomized into 2 cohorts and a total of 1829 alerts with a required response were generated during the study period. The customized configuration had a higher rate of appropriateness when compared to the non-customized configuration regardless of how indeterminate responses were classified (p0.001). When comparing cohorts, appropriateness was significantly higher in the customized configuration regardless of the classification of indeterminate responses (p0.001) with one exception: when indeterminate responses were considered inappropriate for the cohort of providers that were first exposed to the non-customized list (p=0.103). Free-text use was higher in the customized configuration overall (p0.001), and there was no difference in nonsensical response between configurations (p=0.39).There is a benefit realized by using a customized list for medication override reasons. Poor application design or configuration can negatively affect provider behavior when responding to important medication alerts.

Catheter exchange over a guidewire is frequently performed for malfunctioning peripherally inserted central catheters (PICCs). Whether such exchanges are associated with venous thromboembolism is not known.We performed a retrospective cohort study to assess the association between PICC exchange and risk of thromboembolism. Adult hospitalized patients that received a PICC during clinical care at one of 51 hospitals participating in the Michigan Hospital Medicine Safety consortium were included. The primary outcome was hazard of symptomatic venous thromboembolism (radiographically confirmed upper-extremity deep vein thrombosis and pulmonary embolism) in those that underwent PICC exchange vs those that did not.Of 23,010 patients that underwent PICC insertion in the study, 589 patients (2.6%) experienced a PICC exchange. Almost half of all exchanges were performed for catheter dislodgement or occlusion. A total of 480 patients (2.1%) experienced PICC-associated deep vein thrombosis. The incidence of deep vein thrombosis was greater in those that underwent PICC exchange vs those that did not (3.6% vs 2.0%, P .001). Median time to thrombosis was shorter among those that underwent exchange vs those that did not (5 vs 11 days, P = .02). Following adjustment, PICC exchange was independently associated with twofold greater risk of thrombosis (hazard ratio [HR] 1.98; 95% confidence interval [CI], 1.37-2.85) vs no exchange. The effect size of PICC exchange on thrombosis was second in magnitude to device lumens (HR 2.06; 95% CI, 1.59-2.66 and HR 2.31; 95% CI, 1.6-3.33 for double- and triple-lumen devices, respectively).Guidewire exchange of PICCs may be associated with increased risk of thrombosis. As some exchanges may be preventable, consideration of risks and benefits of exchanges in clinical practice is needed.

1. Papilledema is defined as bilateral optic disc swelling caused by increased intracranial pressure. 2. Papilledema is most commonly caused by intracranial mass lesions, idiopathic intracranial hypertension, hydrocephalus, intracranial hemorrhage, venous thrombosis or obstruction, meningitis, and cerebral edema. 3. Emergent neuroimaging of the brain is critical in diagnosis of the patient with papilledema. 4. Vision loss caused by giant cell arteritis should be treated immediately with corticosteroids to prevent involvement of the second eye. 5. In complete third cranial nerve palsy with pupil involvement, the affected eye is turned out and slightly down, with a paralysis of adduction, elevation, and depression, ptosis, and a dilated unreactive pupil. 6. Third nerve palsy may be an early sign of a neurologic emergency, such as an intracranial aneurysm, pituitary apoplexy, uncal herniation, or giant cell arteritis. 7. In third nerve palsy, computed tomography (CT) and CT angiography should be performed emergently to rule out aneurysm.

Hospital-acquired venous thromboembolism (VTE) is a leading cause of preventable death in hospitalised patients and its prevention with pharmacological prophylaxis has been rated a top patient safety practice.1 Furthermore, the rate at which VTE prophylaxis is administered to ‘at-risk’ patients along with the rate of ‘potentially preventable’ VTE events are national performance measures for US hospitals.2 As a result, many hospitals have spent considerable time and effort implementing processes designed to increase rates of VTE prophylaxis. Missed doses due to patient refusal of VTE prophylaxis is a commonly encountered barrier. Strategies to minimise anticoagulant refusal in patients who would otherwise benefit from prophylaxis are needed. Baillie et al 3 describe a multifaceted approach designed to increase adherence to pharmacological VTE prophylaxis in hospitalised patients. By standardising the nursing response to patient refusal of heparin injections (which included a strong focus on patient education), assessing successful administration of VTE prophylaxis on a daily basis via a multidisciplinary rounding checklist, and receiving regular feedback on patient refusal rates, the authors were able to demonstrate a reduction in missed doses in over 20 000 patient admissions to medical and oncology units. Much of the improvement was due to reductions in patient refusal. The fact that the reduction in missed doses was not seen in several units serving as the control group further supports the effectiveness of the intervention. As the authors highlight, which aspects of the multifaceted intervention primarily …

Perioperative medicine is an increasing area of research focus that brings together internists, anesthesiologists, surgeons, and hospitalists. A medical team approach to ensure the best possible patient outcomes has fostered collaborative strategies across areas of patient care. We review 8 seminal articles in the field of perioperative medicine. Each article was published in either 2011 or 2012 and adds to care strategies in the areas of perioperative cardiac medicine, pulmonary care, blood transfusion decision making, and medication management.

First, I am pleased Dr. Cohn described how the writing committee of the new guidelines handled the well-publicized breaches of scien-tific integrity by Dr. Don Poldermans, a prolif-ic perioperative-medicine researcher at Eras-mus University in the Netherlands who has contributed an abundance of literature that influenced clinical practice. Although some of his key publications were excluded by the ACC/AHA committee in its overall analysis, it remains unclear to me if simply ignoring

Perioperative management of patients receiving systemic anticoagulation for atrial fibrillation or flutter can be challenging. This commentary discusses why clinicians should reconsider the need to...

National guidelines1 recommend objective risk stratification for venous thromboembolism (VTE) in hospitalized medical patients. The Padua Prediction Score risk assessment model2 is recommended to categorize patients as high or low risk. The Michigan Hospital Medicine Safety Consortium (HMS), a statewide quality collaborative aimed at preventing adverse events in hospitalized medical patients, collects detailed data on VTE risk factors, prophylactic treatment, and outcomes. Using data from the HMS,3 we sought to determine whether patients in this cohort were receiving appropriate VTE prophylaxis.

The oral anticoagulant warfarin is a common medication that requires special consideration in the perioperative period. Although some procedures do not require warfarin interruption, the majority will necessitate its temporary cessation due to the risk of bleeding. Determining whether patients will benefit from the temporary use of a heparin product while warfarin is discontinued perioperatively (so-called "bridging" therapy) needs to take into consideration the risk of bleeding balanced with the risk of thromboembolism. Perioperative care also requires minimizing the risk of venous thromboembolism (VTE). Understanding the patient-specific and procedure-specific risks for VTE is paramount to employ optimal risk reduction strategies. This article uses a case-based approach to present the topics of perioperative warfarin management and postoperative VTE prevention.

Bariatric surgery has serious associated medical comorbidity and procedure-related risks and is thus considered an intermediate- to high-risk noncardiac surgery. Most patients referred for bariatric surgery have a low or very low functional capacity, making cardiac risk assessment imperative. Stress echocardiography has a high negative predictive value and can avoid some of the table weight and torso diameter problems associated with myocardial perfusion imaging. Echocardiograph contrast agents improve the ability to identify endocardial borders and assess ventricular wall motion and may be used with stress and nonstress imaging protocols. Single photon emission computer tomography (SPECT) imaging with attenuation correction, combined supine and prone imaging, use of technetium isotope, and positron emission tomography (PET) imaging may all provide some advantage for myocardial perfusion imaging for the obese patient.

Purpose To evaluate patterns and predictors of peripherally inserted central catheter (PICC)–related occlusion. Materials and Methods Data from a multihospital study were used to examine factors associated with PICC occlusion. Occlusion was defined if documented in the medical record or when tissue plasminogen activator was administered for occlusion-related concerns. Mixed-effects logistic regression was used to predict occlusion, controlling for patient-, provider-, device-, and hospital-level characteristics. Results A total of 14,278 PICCs placed in 13,408 patients were included. Of these, occlusion developed in 1,716 PICCs (12%) in 1,684 patients. The most common indications for PICC insertion were intravenous antibiotic therapy (32.7%), difficult intravenous access (21.5%), and central access (13.7%). PICCs placed in the right arm had decreased odds of occlusion compared with those in the left arm (odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.72–0.94). Verification of catheter tip position following insertion was associated with reduction in occlusion (OR = 0.75; 95% CI = 0.61–0.92). Although normal saline solution or heparin flushes did not reduce occlusion, PICCs flushed with normal saline solution and “locked” with heparin were less likely to become occluded (OR = 0.54; 95% CI = 0.33–0.88). Compared with single-lumen devices, double- and triple-lumen PICCs were associated with greater incidences of occlusion (double, OR = 3.07; 95% CI = 2.56–3.67; triple, OR = 3.72; 95% CI = 2.92–4.74). Catheter tip malposition was also associated with occlusion (OR = 1.46; 95% CI = 1.14–1.87). Conclusions Several patient, provider, and device characteristics appear associated with PICC occlusion. Interventions targeting these factors may prove valuable in reducing this complication.

Importance Hospitalization for acute medical illness is associated with increased risk of venous thromboembolism (VTE). Although efforts designed to increase use of pharmacologic VTE prophylaxis are intended to reduce hospital-associated VTE, whether higher rates of prophylaxis reduce VTE in medical patients is unknown. Objective To examine the association between pharmacologic VTE prophylaxis rates and hospital-associated VTE. Design, Setting, and Participants Retrospective, multicenter cohort study conducted at 35 Michigan hospitals participating in a statewide quality collaborative from January 1, 2011, through September 13, 2012. Trained medical record abstractors at each hospital collected data from 31 260 general medical patients. Use of VTE prophylaxis on admission, VTE risk factors, and VTE events 90 days after hospital admission were recorded using a combination of medical record review and telephone follow-up. Hospitals were grouped into tertiles of performance based on rate of pharmacologic prophylaxis use on admission for at-risk patients. Main Outcomes and Measures Association between hospital performance and time to development of VTE within 90 days of hospital admission. Results A total of 14 563 of 20 794 patients (70.0%) eligible for pharmacologic prophylaxis received prophylaxis on admission. The rates of pharmacologic prophylaxis use at hospitals in the high-, moderate-, and low-performance tertiles were 85.8%, 72.6%, and 55.5%, respectively. A total of 226 VTE events occurred during 1 765 449 days of patient follow-up. Compared with patients at hospitals in the highest-performance tertile, the hazard of VTE in patients at hospitals in moderate-performance (hazard ratio, 1.10; 95% CI, 0.74-1.62) and low-performance (hazard ratio, 0.96, 95% CI, 0.63-1.45) tertiles did not differ after adjusting for potential confounders. Results remained robust when examining mechanical prophylaxis, prophylaxis use throughout the hospitalization, and subsequent inpatient stays after discharge from the index hospitalization. Conclusions and Relevance The occurrence of 90-day VTE in medical patients after hospitalization is low. Patients who receive care at hospitals that have lower rates of pharmacologic prophylaxis do not have higher adjusted hazards of VTE, even after accounting for individual receipt of pharmacologic prophylaxis. Efforts to increase rates of pharmacologic VTE prophylaxis in hospitalized medical patients may not substantively reduce this adverse outcome.

Background Patients hospitalized for acute medical illness are at increased risk for venous thromboembolism. Although risk assessment is recommended and several at-admission risk assessment models have been developed, these have not been adequately derived or externally validated. Therefore, an optimal approach to evaluate venous thromboembolism risk in medical patients is not known. Methods We conducted an external validation study of existing venous thromboembolism risk assessment models using data collected on 63,548 hospitalized medical patients as part of the Michigan Hospital Medicine Safety (HMS) Consortium. For each patient, cumulative venous thromboembolism risk scores and risk categories were calculated. Cox regression models were used to quantify the association between venous thromboembolism events and assigned risk categories. Model discrimination was assessed using Harrell's C-index. Results Venous thromboembolism incidence in hospitalized medical patients is low (1%). Although existing risk assessment models demonstrate good calibration (hazard ratios for "at-risk" range 2.97-3.59), model discrimination is generally poor for all risk assessment models (C-index range 0.58-0.64). Conclusions The performance of several existing risk assessment models for predicting venous thromboembolism among acutely ill, hospitalized medical patients at admission is limited. Given the low venous thromboembolism incidence in this nonsurgical patient population, careful consideration of how best to utilize existing venous thromboembolism risk assessment models is necessary, and further development and validation of novel venous thromboembolism risk assessment models for this patient population may be warranted.

The field of perioperative medicine continues to mature as evidenced by the growing number of high-quality articles published each year. This is encouraging given the increasingly complex patient population that routinely undergoes major surgery. Furthermore, as surgeons have become more sub-specialized, there is increased reliance on the generalist to perform consultative medicine for the preoperative patient, as well as co-manage patients throughout the hospitalization.

Given the increasing complexity of hospitalized patients and the increasing specialization among surgeons, there is greater reliance on hospitalists for preoperative assessment. Several institutions have developed surgery/medicine comanagement teams that jointly care for patients in the perioperative setting. Despite a growing body of evidence, it is important to recognize there are many gaps in the perioperative literature. This has led to considerable dependence on consensus statements and expert opinion when evaluating patients perioperatively. This review focuses on the preoperative cardiovascular and pulmonary evaluation of the hospitalized patient: the two systems responsible for the greatest morbidity and mortality. Prevention of postoperative venous thromboembolism and management of perioperative hyperglycemia are also discussed.

Bariatric surgery has serious associated medical comorbidity and procedure-related risks and is, thus, considered an intermediate-to-high-risk non-cardiac surgery. Altered respiratory mechanics, obstructive sleep apnea (OSA), and less often, pulmonary hypertension and postoperative pulmonary embolism are the major contributors to poor pulmonary outcomes in obese patients. Attention to posture and positioning is critical in patients with OSA. Suspected OSA patients requiring intravenous narcotics should be kept in a monitored setting with frequent assessments and naloxone kept at the bedside. Use of reverse Tredelenburg position, preinduction, maintenance of positive end-expiratory pressure, and use of continuous positive airway pressure can help improve oxygenation in the perioperative period.