AAFP Guidelines on ‘Hospitalists’

The American Academy of Family Physicians (AAFP) has released the following statement and guidelines concerning interaction between the receiving inpatient care management physician and the referring primary care physician:

Family physicians are participating on both sides of the new models of health care delivery, which use a dedicated inpatient physician (or “hospitalist”) to manage the inpatient care of general adult medicine patients referred by primary care physicians in the community. AAFP believes that family physicians are well trained and highly qualified to serve in these roles and that participation in such arrangements should be voluntary for the referring physicians and the patient involved.

Because “continuity of care” has been a hallmark of the specialty of family practice, the AAFP is especially concerned about safeguarding continuity in these new models through adequate communication. The following guidelines are intended to support quality care to patients and their families and to clarify expectations for communication between physicians participating in such systems.

1. The overarching objective for all should be the best possible care for the patient.

2. At the request of the family physician (or other primary care physician), the inpatient care physician (who may also be a family physician) should admit and coordinate the care of all patients admitted to the hospital regardless of the admitting diagnosis or type of insurance coverage.

3. If patients present to the emergency department and the emergency department physician assesses them, that physician should then contact the patient's family physician to determine if admission is necessary or if close follow-up or outpatient work-up is more appropriate.

4. If admission is necessary, the family physician should communicate information on prehospital treatment, work-up, comorbidities and ongoing specialty consultations, along with family and social concerns, advance directives, etc., to the inpatient care physician who is assuming management of the patient's care.

5. The inpatient care physician will assess the patient at admission and determine the best course of treatment. This may include treat and release, admit for general medical management or admit for medical or surgical subspecialty care, while providing general medical oversight.

6. During the period of hospitalization, decisions regarding care, consultation, admission, transfer and discharge should be the sole responsibility of the inpatient care physician in consultation with the patient and, as appropriate, the patient's family physician and/or family members.

7. The inpatient care physician should be readily available to discuss the patient's medical problems and hospital course with the family and should provide timely updates to the family physician designated by the patient. Communication with the family physician is extremely important at the time of any changes in the patient's status, complications or new diagnoses (e.g., cancer).

8. The inpatient care physician should communicate the treatment plan and follow-up recommendations to the patient's family physician or the covering physician on the day of discharge. This may be best accomplished by having the discharge summary dictated and faxed to the family physician.

9. When family physicians refer their hospitalized patients to the care of an inpatient physician, the AAFP strongly encourages them to maintain ongoing communication with the patients and their families throughout the hospitalization. Family physicians should also provide written communication to the inpatient care physician after the first posthospital visit at the office where there may be an educational benefit.

Health care systems that use inpatient care management models should seek to constantly monitor and improve their processes through the use of ongoing surveys for patient and physician satisfaction with the system. Data on health care outcomes are essential to the ultimate evaluation of these models.

New Warning for Parkinson's Drug

The U.S. Food and Drug Administration (FDA) has issued a warning to physicians about reports of fatal liver injury associated with the use of tolcapone (Tasmar). Tolcapone was originally approved as an adjunct to levodopa and carbidopa for the treatment of idiopathic Parkinson's disease.

The labeling on the drug now states that tolcapone should be reserved for use only in patients who do not have severe movement abnormalities and who do not respond to or who are not appropriate candidates for other available treatments. The warning on the label also calls for increased liver monitoring (every two weeks) in patients who receive tolcapone. Physicians should also advise their patients to be alert for the classic signs of liver disease, such as jaundice, and nonspecific ones, such as fatigue and loss of appetite.

The FDA continues to monitor the liver injury rate in patients receiving tolcapone. All cases of serious liver injury occurring in patients with Parkinson's disease, whether they are receiving tolcapone or any other drug, should be reported to the FDA through MedWatch. Reports to MedWatch should be made by telephone: 800-FDA-1088; by fax: 800-FDA-0178; by mail: MedWatch, FDA HF-2, 5600 Fishers Lane, Rockville, MD 20857; or through the Web site at http://www.FDA.gov/medwatch. Physicians may also contact Roche Laboratories at 800-526-6367 to report adverse events for Tasmar or to receive further information.

Practice Guidelines for Preoperative Fasting

Changing the standard “nothing after midnight rule,” the American Society of Anesthesiologists (ASA) has issued new guidelines on preoperative fasting that state that patients may safely drink clear liquids with permission from their physicians up to two hours before receiving anesthesia or being sedated.

According to the ASA, clear liquids include water, fruit juices without pulp, carbonated beverages, clear tea and black coffee. Studies show that patients, especially children, are less anxious, better hydrated and may have fewer headaches and nausea following surgery when allowed to drink clear liquids up to two hours before surgery. The ASA notes that clear liquids are digested quickly, so the amount of liquid a patient drinks before receiving anesthesia is not as important as what the patient drinks.

The guidelines also discuss consumption of milk and solid food before surgery. Breast milk should not be given to infants less than four hours before surgery. Surgical patients should not have solid food, nonhuman milk and infant formula for at least eight hours before surgery.

The new guidelines, released at the annual meeting of the ASA, can be found on the ASA Web site at http://www.ASAhq.org.

Anti-Theft Systems and Medical Electronic Devices

In the past 10 years, the U.S. Food and Drug Administration (FDA) has received 44 reports of adverse events in which anti-theft systems and metal detectors may have interfered with the routine function of implantable pacemakers, implantable cardioverter/defibrillators and spinal cord stimulators. The Center for Devices and Radiological Health (CDRH) believes that these anti-theft systems or metal detectors can potentially interact with other electronic medical devices as well. The CDRH has issued a statement requesting that physicians advise their patients with these medical devices about this risk.

The CDRH emphasizes that interactions with medical devices are unlikely to cause clinically significant symptoms in most patients. However, physicians should advise their patients to take the following precautions:

• Be aware that anti-theft systems may be hidden in entrances and exits in many commercial establishments.

• Do not stay near an anti-theft system or metal detector longer than is necessary and do not lean against the system.

• If scanning with a hand-held metal detector is necessary, warn the security personnel that you have an electronic medical device and ask them not to hold the metal detector near the device any longer than is necessary, or ask for an alternate form of personal search.

Questions about this information can be directed to Nancy Pressly, CDRH, Office of Surveillance and Biometrics, HFZ-510, 1350 Piccard Dr., Rockville, MD 20850; fax: 301-594-2968; e-mail: nap@cdrh.fda.gov. Incidences of adverse events involving medical electronic devices should be reported to MedWatch by telephone: 800-FDA-1088; by fax: 800-FDA-0178; by mail: MedWatch, FDA, HF-2, 5600 Fishers Lane, Rockville, MD 20857; or through the Web site at http://www.FDA.gov/medwatch.