Vol 26, Issue 10
UNC Division of Hospital Medicine¶
Hospitalist Happenings¶
VIEW FROM THE NINTH FLOOR¶
View from the Ninth Floor November 14,2025¶
As I was thinking about writing this piece, my thought process took me on a winding path that reminded me of a relevant truth worth sharing. First, I thought about Thanksgiving approaching and that I have previously used this entry to discuss things I'm grateful for. But I don't like to repeat things too closely, so I looked back at 2024's entry to remind myself and found it was mostly about how much more productive we were year-to-date after the addition of MCAT and Bluebird and had little about the holiday. 'Maybe it was 2023…'
David Hemsey, MD Division Chief, Hospital Medicine¶
I then opened the other November entries all the way back to 2016 which served as a perfect bookend as it was also about productivity which was lower than expected that time. I was still putting famous quotes in my entries - a holdover from the previous style -and it was from Charles-Guillaume Etienne: "On n'est jamais servi si bien que par soi-même" usually translated as "If you want something done right, do it yourself". Dropping the French may have been a bit pretentious but served the message of billing our own notes to deal with under-coding related to the use of contracted coders.
The journey through time captured by these November missives is surprisingly relevant to things we are dealing with today and reminded me of the many other quotes that all emphasize the importance of understanding history, especially in historic times. My favorite for the current moment: Howard Zinn: "If you don't know history, it's as if you were born yesterday. If you were born yesterday then any leader can tell you anything". So, here's a quick lesson:
2017 featured the work of a few familiar faces on the Complex Care committee and offered an opportunity to participate in the first scheduling task force leading into initiation of Lightning Bolt. This week, a slightly older Andy reviewed the progress of a 3 rd iteration of this work.
2018 introduced 3 largely external efforts to improve the status quo: the Well Being program, a DOM -ER initiative to improve admissions and the Hospital Medicine specialty program. The first 2 were frankly failures (although we have renewed efforts to make headway with the ER), but the third continues today and has allowed us the forum to more rapidly improve order sets, to add Pathways and other clinical support, to both provide and receive focused education and to have meaningful collaborations with hospitalists across UNC Health.
1-2
View from the 9th Floor¶
Medicine Procedure Updates¶
Coding Corner 4¶
DHM Announcement 4¶
2019 was centered on feedback and our efforts to get peer input on how we can improve. I said similar things then as I did at the meeting on Wednesday: 'Negative feedback that is not actionable does not drive meaningful change and can hurt collegiality and morale. That being said, with how interdependent the care
Continued on page 2¶
Hospitalist Happenings¶
hospitalists provide is on all members of the team and how limited the quality metrics are for inpatient medicine, I continue to believe our peers are one of the best sources for opportunities to improve for our faculty.'
2020 was about changes brought by the COVID-19 pandemic including the adjusted caps related to the switch from our previous MD-APP model to the current workflow and weekend coverage. Looking back, this period was the start of the increased demand and resulting capacity concerns that create such challenges today.
2021 was still focused on COVID-19 but gave an accounting of things I was grateful for during that challenging period, including clinical excellence in the care of those patients, meaningful improvements towards our own wellbeing, and impactful collaborations with other divisions and departments. Odd but true that many of us look back at that time fondly.
2022 was back to productivity and coding/billing opportunities, like critical care time and attention to the missing elements of resident H&Ps (which thankfully became obsolete with the 2023 CMS billing changes). As Allen used to say, clinical work was and is our 'blocking and tackling' and has always been at the forefront of our conversations.
2023 highlighted some of the academic progress we had enjoyed that calendar year, including increased roles in the DOM, SOM, external grant funding, and our remarkable success at SHM Converge with 2 finalists in the research category, and how that dovetailed with Dr. Falk's emphasis on what makes us an ACADEMIC hospital medicine program.
History is cyclical and the recurrent themes of these newsletters remind us that the life of the DHM is no different. Clinical excellence, productivity, collaboration across UNC Hospitals and UNC Health, provider well-being, academic and professional development are all key pieces of our mission on which we have and should focus. We can also see some of the progress we have made and areas where previous efforts have fallen short or not achieved 'ideal state' despite iterative improvements.
As Thanksgiving approaches, I am thankful to each of you for being part of this journey as we continue to work together towards our long-term goals.
People¶
Clinician-educatorswith an academicniche Full staffingand sustainableclinical workload
Clinical¶
Servicesthatprovide¶
consistentexcellence Data-drivenassessmentof quality,valueand productivity Leadershipincaredelivery improvementsacrossUNc Health
Education¶
Topratedinpatient educatorsatUNC Opportunitieswith learmersatalllevels UNCDHMwithregional andnationalreachin education Culture ofcontinuous improvementwithwork thatimprovesscienceof hospitalmedicine Intentionaldesignof projectsfrominitiationto sustainmentand publication UNCDHM knownas leadingdivisionofhospital medicine
Hospitalist Happenings¶
Weekly Review November 2025¶
Things the Medicine Procedure Service wants you (and your resident teams) to know about procedures -The LP edition¶
- LPs, believe it or not, are our highest risk procedure with respect to bleeding. This may be surprising to anyone who has witnessed a dialysis line, for example, but bleeding into the canal is very difficult to stop.
- In the past year, we have been able to decrease our platelet threshold to 30,000 platelets (prior was 50,000), which has allowed us to become better stewards of platelets. This was agreed upon by us, neuroradiology, and VIR.
- All services will LP a patient on ASA, clopidogrel, prasugrel, ticagrelor, etc.
- We still wait 12 hours after prophylactic enoxaparin and because there is still a black box warning on apixaban, will still require a wash-out period for patients on DOACs.
- Please be cognizant that we will likely be more successful. in the sitting position, rather than side lying, particularly in obese patients. If an opening pressure isn't absolutely necessary and the patient can sit up, this is generally our preferred position.
- When discussing with patients, the procedure will not 'only be a few minutes'. Depending on the body habitus and prior spine surgeries it may be difficult to get into the canal. Depending on the flow of CSF and how many studies you've ordered, collecting an adequate volume may take up to an hour.
- Head imaging is needed for patients > 60 years old, immunocompromised, have had a seizure within one week of presentation, has an abnormal level of consciousness, abnormal neurologic exam, or papilledema.
- The most common complication after an LP is post-dural puncture headache, whose hallmark is its positional nature. We will usually remember to ask about headache before the LP, but both primary team and the MPS should ask about headaches before and after the procedure.
Jessica Fuller -Dec 4¶
Erin Finn - Dec 11¶
Ria Dancel, MD Director of Medicine Procedure Service & Point of Care Ultrasound Education
Hospitalist Happenings¶
Coding Corner:¶
Hello everyone and happy almost Thanksgiving! For this week's Coding Corner, we are going to briefly review AKI and ATN.
Remember that, by definition, not all elevated creatinine is an AKI. We follow KDIGO Criteria which defines AKI as one (or more) of the following:
- Increase in SCr by ≥ 0.3 mg/dl within 48 hours
- Increase in SCr to ≥1.5 times baseline, which is known or presumed to have occurred with the prior 7 days
- Urine volume < 0.5 ml/kg/h for 6 hours
In addition to AKI, don't forget about ATN! While AKI is coded as a CC, ATN is more severe and is an MCC. Consider a diagnosis of ATN if there is a significant rise in creatinine (especially >1 above baseline), the creatinine is less responsive to fluids, slower recovery, and of course muddy brown casts.
Announcements¶
Save the Date: Hospital Medicine White Elephant
Holiday Party¶
Wednesday, December 17¶
12:00 PM-1:30 PM
Location: Bondurant room 2030
DHM Operations Weekly Huddle¶
Mondays, 12:30-1:00 | Zoom
Grand Rounds¶
Nov 20 -Jason Mock, MD -Update in ARDS and Lessons Learned from COVID -19
Dec 4 -Barbara LeVarge, MD -Invasive Cardiopulmonary Exercise in the Evaluation of Dyspnea Dec 11 -Brian Jensen, MD -Topic TBD
Upcoming DHM Faculty Meeting¶
Noon -1:00 | PECR1 & Webex Dec 10
Hospital Medicine Grand Rounds¶
Dec 9 , 12:00-1:00