Clinical pearls from Hospital Medicine 2017 that you can apply tomorrow

Hospital Medicine 2017, hosted by the Society of Hospital Medicine at Mandalay Bay in Las Vegas from 1 to 4 May 2017, drew hospitalists eager to convert conference slides into bedside change. The event blended plenary evidence reviews with practical workshops on sepsis, anticoagulation, heart failure, pneumonia, glycaemia, delirium, and antimicrobial stewardship, with continuing medical education credits attached. The perennial challenge for attendees is to carry useful updates home without leaving them on a hard drive.

The ten clinical updates below focus on practical, evidence-based shifts that can be adopted on a ward without waiting for committee approval. They cover sepsis bundles, anticoagulation reversal, heart failure decongestion, pneumonia severity, inpatient glycaemia, venous thromboembolism prophylaxis, delirium prevention, antimicrobial stewardship, and procedural sedation. The aim is for each item to be usable on a Tuesday morning round at Royal Prince Alfred, the Royal Melbourne, or a regional service in Townsville.

Australian clinicians usually receive American guidance filtered through local frameworks such as the Therapeutic Guidelines, the Pharmaceutical Benefits Scheme, and the Australian Commission on Safety and Quality in Health Care. These realities shape how conference evidence lands here, so the commentary below pairs each update with Australian prescribing notes, resource suggestions, and implementation tips for multidisciplinary teams.

Recognising sepsis earlier and resuscitating smarter

Sepsis remained a dominant theme, and the operational message from the Sepsis-3 definitions has matured into a clear bedside approach. The qSOFA score, with its emphasis on altered mentation, systolic pressure under 100 mmHg, and respiratory rate of 22 or higher, functions as a quick triage screen rather than a diagnostic label. SIRS criteria still identify infection-related inflammation, yet prognostic weight has shifted toward qSOFA and lactate trends. The Hour-1 bundle from the Surviving Sepsis Campaign reinforced that antibiotics, cultures, lactate measurement, fluids, and vasopressors belong in the first hour, an approach that aligns with ANZICS guidance for intensivists in Adelaide and Brisbane.

Lactate clearance has emerged as a more useful resuscitation target than a single absolute value, with a repeat sample at two hours that drops by at least twenty percent signalling adequate tissue perfusion. Slide decks and recorded sessions from Hospital Medicine 2017 remain accessible through the official conference portal, which makes it easy for staff in Perth to refresh local sepsis pathways without travel.

Anticoagulation reversal in the era of direct oral anticoagulants

The proliferation of direct oral anticoagulants has changed how hospitalists manage bleeding and urgent surgery. Idarucizumab for dabigatran and andexanet alfa for apixaban and rivaroxaban are now part of formulary discussions in tertiary centres, though smaller hospitals in Hobart or Cairns may not stock them routinely. Prothrombin complex concentrate remains the standard for warfarin reversal and can bridge the gap when a specific antidote is unavailable. The IMPROVE score stratifies medical inpatients for VTE prophylaxis, with extended courses reserved for high-risk groups such as those with active cancer.

In Australia, NOAC prescribing is shaped by the Pharmaceutical Benefits Scheme, and discharge plans should match the PBS indication to avoid out-of-pocket costs. A recurring conference theme was to simplify handover language by writing specific dose, timing, and renal function details rather than the single word "anticoagulated".

Heart failure decongestion and the four pillars of therapy

Acute decompensated heart failure dominated the cardiovascular sessions, with particular focus on diuretic strategy. Intermittent bolus dosing remains the standard, but high-dose bolus therapy at two and a half times the home oral dose has evidence for faster decongestion in selected patients. Common diuretic approaches used in Australian inpatient settings are summarised below.

Beyond decongestion, the four pillars of guideline-directed medical therapy, namely an ARNI or ACE inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor, were emphasised for stabilised inpatients. Starting low and titrating before discharge reduces thirty-day readmission, a metric closely watched by hospital executives in Perth and Adelaide, and the Heart Foundation's guidance should be referenced in the discharge summary to align community follow-up.

Pneumonia severity, antibiotic selection, and local resistance

Community-acquired pneumonia still drives a major share of admissions, and the 2017 update reinforced the use of severity scoring to decide on ward versus intensive care placement. CURB-65 and the Pneumonia Severity Index help triage, but clinical judgement remains essential for elderly patients or those from remote communities. The Therapeutic Guidelines provide an Australian-adapted pathway that recommends amoxicillin for uncomplicated cases and adds doxycycline or a macrolide when atypical pathogens are suspected.

For hospital-acquired pneumonia, the message was to review anti-pseudomonal coverage after forty-eight hours and de-escalate once cultures return. Local antibiograms, published by state health departments, should be the first reference before finalising an empirical regimen, particularly in regional Western Australia where Pseudomonas patterns can differ from metropolitan Melbourne.

Inpatient diabetes management without sliding scale

The discrediting of sliding-scale monotherapy has accelerated, and basal-bolus regimens now define best practice for non-critically ill inpatients. A long-acting insulin analogue paired with rapid-acting prandial doses achieves better glycaemic control and lowers hypoglycaemia rates. The hospitalist's role is to write a clear subcutaneous insulin order, document meal intake expectations, and adjust doses daily. For patients on metformin, the priority is to confirm renal function and withhold the drug when the eGFR drops below thirty.

Australia's National Diabetes Services Scheme supports patients with consumables and education, and discharge summaries should connect inpatients with community follow-up, particularly for those in rural Queensland. Insulin pumps should be left running during admission where possible, with endocrinology input for perioperative management to avoid loss of glycaemic control.

Delirium prevention and sleep-friendly wards

Delirium affects up to a third of older medical inpatients and is closely tied to length of stay, falls, and mortality. The Hospital Elder Life Program and similar multicomponent interventions were showcased as evidence-based bundles that can reduce incidence by up to forty percent, with orientation cues, early mobilisation, sleep hygiene, hearing and vision support, and avoidance of deliriogenic medications as key elements. Australian data from the Royal Commission on Aged Care Quality and Safety highlighted the need for consistent delirium screening using tools such as the 4AT.

Pharmacological treatment remains controversial. Low-dose haloperidol or risperidone can be used for distressing symptoms, but they do not shorten delirium duration and carry cardiac and extrapyramidal risks. The most useful bedside action is to review the medication chart at admission and deprescribe agents that contribute to confusion, particularly in older patients transferred from residential aged care in Geelong or Wollongong.

Antimicrobial stewardship and bedside procedures

Antimicrobial stewardship sessions reinforced the hospitalist's influence on prescribing patterns. Reviewing every antibiotic order at forty-eight to seventy-two hours, documenting the indication, and switching from intravenous to oral therapy when clinically appropriate remain core practices. Australian data from the AURA surveillance system show that reducing unnecessary vancomycin and ceftriaxone use is a national priority, and for Clostridioides difficile infection oral vancomycin or fidaxomicin are now preferred over metronidazole for non-severe disease.

Procedural updates included ultrasound-guided paracentesis and thoracentesis, lumbar puncture, and central venous access, with informed consent, sterile technique, and routine use of bedside ultrasound as core safety elements. Procedural sedation with ketamine, often paired with propofol, was discussed as a safe option for short painful procedures in selected patients, with monitoring standards aligned to the Australian and New Zealand College of Anaesthetists guidelines.

The practical takeaway for the week ahead is to schedule a fifteen-minute review of antibiotic orders and procedural logs during the next ward round, share findings with the local stewardship committee, and use that conversation to refine the next set of orders. Pair that with one printed sepsis bundle at triage, one updated NOAC reversal card in the drug chart, and one conversation with the night team about delirium screening. Three small changes, repeated consistently, are how conference evidence becomes ward routine.