Journal of hospital medicine : an official publication of the Society of Hospital Medicine
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Severe sepsis and septic shock are common and associated with a 30-50% mortality rate. Evidence-based therapies for severe sepsis supported by international critical care and infectious disease societies exist, but are inconsistently employed. ⋯ Compelling observational data supports the importance of early, effective antibiotics. Well-designed randomized controlled trials and/or meta-analyses demonstrate the impact of activated protein C, early goal-directed therapy, stress-dose steroids, and intensive insulin in well-defined subgroups of patients. These therapies reduce the absolute mortality risk associated with severe sepsis by 9.5-16%; the corresponding numbers needed to treat to save one life are 6.25-10.5. While major trials are ongoing and the evidence for several sepsis therapies are limited to single trials, the available evidence indicates that appropriate use of these treatments can substantially reduce mortality from severe sepsis.
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Restrictions in the hours residents can be on duty have resulted in increased sign-outs, that is, transfer of patient care information and responsibility from one physician to a cross-coverage physician, leading to discontinuity in patient care. This sign-out process, which occurs primarily in the inpatient setting, traditionally has been informal, unstructured, and idiosyncratic. Although studies show that discontinuity may be harmful to patients, this is little data to assist residency programs in redesigning systems to improve sign-out and manage the discontinuity. ⋯ We provide recommendations and strategies for best practices to design safe and effective sign-out systems for residents that may also be useful to hospitalists working in academic and community settings.
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Palliative care is medical care focused on the relief of suffering and support for the best possible quality of life for patients facing serious, life-threatening illness and their families. It aims to identify and address the physical, psychological, and practical burdens of illness. Palliative care may be delivered simultaneously with all appropriate curative and life-prolonging interventions. ⋯ The field of hospital palliative care has grown rapidly in recent years in response to patient need and clinician interest in effective approaches to managing chronic life-threatening illness. The growth in the number and needs of seriously and chronically ill patients who are not clearly terminally ill has led to the development of palliative care services outside the hospice benefit provided by Medicare (and other insurers). This article reviews the clinical, educational, demographic, and financial imperatives driving this growth, describes the clinical components of palliative care and the range of service models available, defines the relation of hospital-based palliative care to hospice, summarizes the literature on palliative care outcomes, and presents practical resources for clinicians seeking knowledge and skills in the field.