SPEAKER_00 0:18

Hello, and welcome to Inpatient Update. I'm your host, Mason Turner, and this is your podcast for practice changing evidence for the working hospitalist. Today on the show, I'm joined by Nick Lindy, as we discuss quicker de-escalation of broad spectrum antibiotics in sepsis, and whether we're leaving in too many peripheral IVs. Nick Lindy is a hospitalist PA working in the division with me. He's an excellent clinician, an excellent teacher, an excellent coworker. Thanks so much for joining me, Nick.

SPEAKER_01 0:52

Yeah, thanks for having me. It's really uh a pleasure to join you here on the pod and um can't wait to hear more of the future pods and talk about some updates in medicine.

SPEAKER_00 1:03

Uh in way of introduction, is there anything else you think the audience needs to know about you?

SPEAKER_01 1:09

No, um hospital medicine is all I've known over the last nine years. It's been the only thing that I've practiced, despite being able to potentially change in the future. And um, I enjoy teaching, enjoy spending time with my family, and really just um learning new things um and trying to improve my practice.

SPEAKER_00 1:29

Well, I'm so excited to have you. I um this is a first for our non-MD guest. And so I've said in my requests and my intros anyone with uh value-added expertise and management of hospitalized patients come aboard. And so I'm so glad we're living it, we're doing it, and particularly glad it's you because honestly, uh Nick is one of those people that in the workroom is just one of the best practical clinicians. And like, you know, if you're a hospitalist doing direct patient care, you know, everyone just works side by side, and you have no idea whether anyone else is doing anything good or anything bad or if they're good at their job or not. But when Nick has a student with him and is teaching and explaining things, I think, oh my gosh, I want to be following it on around someday and just like soak up some of it in because uh you have a way of like really breaking things down and explaining things. I'm talking you up way too much. You're gonna be like, oh my god, this is too much pressure. Uh, but really break things down in a way that like makes sense, but also is thorough. And so very impressed, very happy to have you. Um, and so it's exciting. Uh, this is also our first uh podcast after dark recording. So uh uh Nick and I both have similar family situations, and both were just putting babies to sleep and are now having a nightcap.

SPEAKER_01 3:04

Yeah. The um the time for pods and discussions of medicine after work, uh that window is slowly just getting smaller and smaller as you add children, but it's exciting, and that's what we're here to do talking about it.

SPEAKER_00 3:23

Nick, have you ever inherited a patient from the ICU? Maybe say a 70-something year old man who came in a few days ago, lactate, five and change, blood pressure low, tachycardic, fever, no clear infectious source. Maybe they were briefly on pressers, and either the ICU team's talking to you, or our admitting doc of the day, our admitting officer of the day is talking to you and says, yeah, they need to be in the hospital. Probably the ICU's plan is just a seven-day course of ZOCIN, and you're like, Okay, but I don't really know why, or what we're treating. And so this article specifically looked at that. And so this is about the patient who has community onset sepsis and is admitted to the hospital, I see you or not, that part's not particular, but de-escalating from those broad spectrum antibiotics we put everybody on, and when is it safe to do that? Um, I do think a lot of us at baseline are kind of our our feeling is like you need a longer course of that broad spectrum antibiotics when someone's been really sick. And so this study looked can we be uh pairing that back sooner? So this was a article entitled Antibiotic De-escalation in adults hospitalized for community onset sepsis, just as I said. Um, it was published in JAMA internal medicine in um was recent. It was published this year. This is another, just like an article I did in the next last episode, was a target trial emulation, which is basically just a fancy retrospective cohort study where they try to do all they can from a statistical standpoint to give it the rigor of a randomized controlled trial. Um, but what they looked at is these patients on broad spectrum antibiotics with um community onset sepsis, as I said, they go to day four of their care and then they branch off that there's the control group, which is continue that broad spectrum antibiotics, and then there's the intervention group, which is de-escalating from the broad spectrum antibiotics at that time. So they looked at a ton of patients because like as you know, like you see this patient all the time, I see this patient all the time. So they're in and the patients they looked at was over, excuse me, over 36,000 uh patients. And they were on empiric anti-mersal coverage or empiric anti-pseudomonal coverage, uh, and or and so classic vanxophin, vanxepapine, whatever that you're throwing at a real sick person to make sure you're covering whatever might be hidden down. Um, and then the patients also still have to be on that therapy at three days and then not be growing any multi-drug resistant organism that obviously we're gonna want to keep treating. Um, and so looking at this study, uh, the primary outcome was 90-day all-cause mortality. Um, I love a good catch-all. Like, did the patients do okay or did they die? Um, but the odds ratios were right at one for um both the de-escalating the MRSA coverage and de-escalating the pseudomonal coverage, um, showing no difference in mortality between the groups at all. Um, looking at some secondary outcomes, no surprise. The I think most important one here is that the length of stay is shorter. Um, that was statistically significant. And basically you saved uh a day on average of hospitalization if you were covering for MRSA and you de-escalated, and then two days um for pseudomonal coverage. Um looked at some other secondary outcomes, nothing that I thought honestly really worth talking about too much. There were some like signals that maybe 90-day readmission rate is actually better if you de-escalate pseudomonal, which is cool. Um, but I don't really have a causal mechanism for that. So just um the big headline, obviously, being that you hit day four of your antibiotics, and you're just as good for keeping your patients alive standpoint if you de-escalate, you come off that vankinzocin as you would be if um if you continued those antibiotics. And so this is pretty powerful and um of note. They weren't specific in this trial of whether you de-escalate to uh just more targeted IV therapy or less broad IV therapy, or if you um actually go down to to oral antibiotics. Um well, Nick, any any initial thoughts on this study? What was are you convinced?

SPEAKER_01 9:00

Yes, so uh what I immediately pictured is that patient coming out of the ICU, and basically you've been left with an unclear picture in a patient where you might not even know the source, the culture results are either not growing anything or growing something entirely different, not even Pseudomonas or MRSA, and you're trying to figure out well, they're the ICU, should we just continue this or should we switch them to something else? And so a lot of times I'll admit, you know, I just continue because that's what's already being done. But this definitely gives me a little bit more um courage to de-escalate, knowing that 90-day mortality is decreased. Um but another thing that I wanted to point out is I think something that wasn't addressed is knowing which antibiotic you de-escalate to is very important. And they didn't really address that. You could de-escalate to something also fairly broad that is not typic, you know, anti-pseudomonal or anti-MERSA. Um, and just keeping in mind that what you do de-escalate to is important. Um and then one thing that really stands out because I've had multiple patients with this, is complications from continuing broad spectrum antibiotics. So um, I'm not sure what your thoughts are on that, but um, I just recently had a patient um CKD stage three going on for encephaline for fevers and signs of sepsis while in the hospital. And lo and behold, several days later, he's totally lethargic, not responsive. And so you get into that. Okay, this patient's been on a broad spectrum for several days. We have negative cultures. What are we doing here? Um, and just briefly basically um ended up calling neurology, called ID. There was concern for cefapine-induced neurotoxicity, took the patient off cefapine much better within 24 hours. So um, that's something that I immediately thought about when it comes to continuing versus de-escalating.

SPEAKER_00 11:22

Oh, yeah, huge. Uh, in addition to what they looked at and just keeping the patients in the hospital themselves, which obviously, if you're on cefapine, you're in the hospital unless you're doing a pick and all that. But um, yeah, I thought you were gonna do the classic like vanxosin, AKI, maybe it's real, maybe it's not real, but that's way better. You know, cefopine neurotoxicity is very real, specifically in folks with bad renal function. And like a hundred percent. Like that's the things um that's our value added in getting that stuff off and de-escalate. And to your point, like if you de-escalate to uh fluoroquinolone and then they pop in Achilles, like you know, it's there's there's the good and the bad with everything, different antibiotic, but at least you're getting them out of the hospital. And I kind of agree with you. This this study isn't one of those where I'm like, wow, bang, this is huge. Um, this is it changes everything. This is more because it is such a just sort of broad strokes look at things, this is more giving me that extra oomph to to do what I kind of wanted to do anyways, which is de-escalate the antibiotics. But you just don't know. It's one of those like a hundred little questions a day of like, this feels like this could be the right answer, but I don't have a hundred percent certainty. And so then maybe you waffle, and maybe some weeks when you're feeling brave, you do it. Some weeks when you're just like, I'm just gonna follow the ICU's plan, I don't care, you're gonna keep doing the antibiotics. But this definitely will give me sort of the courage to um to de-escalate in the future when I feel like it's clinically appropriate, um, and also give me something to put back, push back on if someone else is saying that maybe we shouldn't, I'll be able to give them a citation to look at that's gonna back me up. Yeah. Absolutely. Um, so what do you think? Uh if it was you or your loved one who was this patient coming in, sepsis, no clear source, in the ICU a bit, it's day four. Are you taking off the Vink and Zosin or the cefopime? Or and are you that confident based on this article that you do that for a loved one, or are you keeping them going?

SPEAKER_01 13:49

I think one of the other tools that this article briefly touched on that I would use is the MERSA nasal swab. Um, I think it's an extremely powerful tool. And actually, in this article, um, providers were faster to de-escalate MERSA antibiotic coverage uh than antomodal. And I think that might be due to some of the tools like a nasal swab and how um the specificity is so high, not only in pneumonia, but multiple other things. So I think I would at least check a MERSA swab, stop the vancomycin, and um, if cultures are negative or growing something different, I would de-escalate to something less to avoid some of the complications of broad spectrum antibiotics.

SPEAKER_00 14:36

Yeah, I'm with you. I mean, if all things being equal, and again, this is a big it's not gonna um subvert what would be my clinical judgment if someone seems really sick or they have in my mind some risk factors, and I know they control for some of these factors in the study, but if they have significant risk factors for multi-drug-resistant organisms, then then maybe I'm keeping it on, but I can, you know, de-escalate them and just have them on about mittens that's kind of getting some of that good broad coverage, um, uh, and just and that is also oral and potentially even getting them out of the hospital. So I definitely would would push to de-escalate as long as they're doing clinically great.

SPEAKER_01 15:23

The article that I'm bringing to the table is uh more of a discussion piece, uh less of a clinical trial. And what this article does is make us really think about something that we do in our practice every single day that is extremely common and it is challenging that. So this article is called Things We Do for No Reason: Routinely Maintaining Intravenous Access in Hospitalized Patients, Journal of Hospital Medicine 2026. So brand new article. Um, I thought this article was really interesting, and it really makes you think about the peripheral IV and why we keep it, the harm of potentially keeping it, and um how do we know when we can stop it? Um, so this article starts out with a clinical scenario, uh, a scenario that we all know very well. Elderly patient comes in, nausea, vomiting, diarrhea, diagnosed with gastroenteritis and AKI. Um as we should. We start them on IV fluids, we check their electrolytes, uh, we replace everything, give anti-ometics intravenously through a peripheral IV, and the next day the patient's doing so much better. Um the patient's tolerating oral intake, uh, the IV is working fine, and the patient, you get that page from the nurse that says, hey, patient doesn't want this IV anymore. It hurts, it's bothersome. Can we take it out? Um, and so this article forces us to think about why we continue IV and peripheral IVs in these patients. And really, it comes down to the fact that we keep them in case we need them, even in patients that are totally clinically stable and in which we are not actively using them. And so the the biggest thing is a patient that's gonna decompensate, right? So a patient that's gonna code or have a cardiac arrest, we want to have access, right? Um, and that is one of the main reasons of having them. Um, and so then it looks at well, what are the potential problems of keeping them in? And this is what I thought was extremely interesting. Um, as we all know, um there is a chance of uh a patient becoming bacteremic with something like Staphorus. And although it is much more common in central venous catheters, obviously, um, it's still due to the absolute number of peripheral IVs in hospitalized patients, uh, approximately one-third of MSSA bacteremia is actually caused or thought to be attributed to a peripheral IV. That's wild. Yeah. And uh and then of those, um, about 20% of all MSS MSSA bacteria is thought to be attributed to a peripheral IV. Um, so that's a huge risk for patients. Um, there's also the risk of them failing, uh ruining vascular access, especially in the frail old patients where they have to get you stuck a million times. Um pain, phlebitis and 10 to 20 percent. Um, and then they're not the most reliable access points. You know, some of these patients have two IVs with nothing get being given intravenously. And so this article really challenges that thought of do we continue them? Um and then, you know, when can we discontinue them? So, you know, it then goes on to discuss um who can we discontinue them in? And you know, it talks about the patient that is no longer getting the IV therapy, or in a patient that is clinically stable and we can switch to an oral option, such as uh IV opiates. Can we switch to oral if they're no longer vomiting? IV antibiotics, as we just talked about, de-escalation. When is it okay to de-escalate orally? Um is it reasonable to keep them? Um that high-risk patient, multiple comorbidities, that's a patient that I think we could keep them, um, and that it would be beneficial. Uh, another one is um the anticipated need for IV contrast, uh, anticipated need for a procedure, um, or just the patient that may need a little extra work. Let's say their labs are still not stable or you're still needing to replace electrolytes. Um, and so I think the highest yield takeaways for this were peripheral RVs, extremely common. Um almost every patient has them, but when do we truly need them? Think about that social admission that's been sitting there for a week that is getting no therapy. Yes, they're probably okay to discontinue that. And in it might even save them the issue of bacteremia or something different, pain, discomfort. Um in and then when to keep it, obviously, um, your higher risk patient, risk of decondensation, or the need that you, you know, the potential need of using it again. So um wanted to get your thoughts on it. Um, it's a little bit different than some of the other studies, but it's uh thought-provoking and um important, I think.

SPEAKER_00 21:09

Yeah, I like this article a lot, and I was excited you picked it because um there's the whole things to do for no reason series, and they'll occasionally come out with articles, but this one is really one that I honestly very rarely consider pulling out that IV. It's gotta be the most extreme case of Joe waiting for placement who has just been here for days on end. That like, I'm like, okay, this person definitely doesn't need an IV. I'm not even checking labs once a week. Um, but other than that, I'm just leaving them in people. Unless like they give me a good reason to take them out. Um, so it was this was a good thought experiment for me. And I I was impressed, as you mentioned, by the fact that it's really it's a numbers game. Like, yeah. Every single patient on my service, as I said, has an IV every single day, maybe multiple, often multiple. Um, and so based on that numbers game, that's it's a major risk for uh comorbidity, for morbidity in the hospital. Like the hospital is a dangerous place, and the IV is one of the things that's making that way. I mean, I was really impressed by the statistics you specifically mentioned about the um the rates of bacteremia, specifically staph aureus bacteremia from from peripheral IVs, like 20%. Like, this is bad bacteremia. This is bacteremia that uh got excluded from the trial we talked about a couple weeks ago. Great, you could de-escalate after seven days, like, but and 20% of the time it's from these peripheral IVs that I think almost nothing about. So I I found it pretty powerful. Uh yeah, I found it pretty persuasive. Are you are you persuaded?

SPEAKER_01 23:04

Yeah, um, there was one other thing I wanted to pick your brain about when it comes to these peripheral IVs and how they're being used not only for therapies, but in some cases, blood draws or phlebotomy. That is what I really thought about with this article. And um, it just made me think a little bit more how many times you've been called by the nurse and said, Hey, I've got this slab I'm gonna draw for you, but I'm getting it from the peripheral IV. And so I looked into that a little bit more, and there's actually some harm that could come of that. You know, nurses think it's okay to just draw from these peripheral IVs, not all of them, but a lot of times it's convenient. And what specifically when monitoring potassium and venous blood gases, it is actually shown to give um false numbers. Um, and how that could potentially be harmful. So when you've got these patients that are not getting any IV therapies, they're just sitting around, and you want to draw that BMP just before they before uh, you know, this little old lady goes to her nursing home. Um, think twice about drawing it through the peripheral, and maybe that's a reason another reason to discontinue is just to decrease that risk because we've all seen that potassium come back hemalized at six, and then we say, what do we do?

SPEAKER_00 24:21

Yeah. I'd love a nurse's perspective on on all of this, because I do think at the same time, it's like what percentage of the IVs even draw that they can get labs off. Exactly. I'm like, I feel like, and you know, I only hear what I hear, but I'm almost always hearing from nurses, oh, their IV doesn't draw, but it flushes, so I'm still using it. Like it's very rare that they're actually even, if there is any use to it of drawing labs, there's very rare that they're actually even able to get this, get that from it.

SPEAKER_01 24:50

Um but to answer your question, I'm definitely going to be thinking about when I should I remove a peripheral IV and when is it okay, when is it not okay? Um, actually, just had a patient that came in um schizophrenic patient from uh a group home, just waiting on a new group home, no issues at all. And the nurse calls me, hey, their IV failed. Do we need a new one? To be honest, I didn't even know that she had one in. And I said, Absolutely, you can keep it out. Um, and these are some of the patients we should be thinking about much earlier. Um, let's stop that, uh, or discontinue the peripheral IV if we're not using it at all.

SPEAKER_00 25:32

Yeah. My so uh I was also impressed by the numbers of like ED peripheral IVs, about a third of them go unused, and like 25% of inpatient uh IVs are just sit there and aren't used. And so it's um I'm impressed by that. And I'm tempted to have an ideology of like, don't put it in, and once you're not gonna use it, take it out. But at the same time, I do worry about the delays in care. And so they mentioned some, and you talked about like a like if it's a code, yeah, an I.O. is fine. And so I I do I feel covered in that situation, and it makes me a little, you know. I mean, I I it take it would take me a little getting used to to be like, I'm always relying on the I.O. for the code, but that's fine. The question is though, in the not a code situation where I want IV access, and maybe I want it fast, I'm like thinking, like, what if they have a seizure? How are we gonna give them IV meds? And like, how are you gonna abort the seizure with an IV benzo if they don't have an IV? And how are you gonna put an IV in on if they're seizing? And so, I mean, and obviously, like there are other options, and so, but I would put that in kind of this is all another one that it's all this is more clinical judgment, not gonna change um, not something concrete that you're gonna do different every time. But like, if I have a patient that I'm worried is seizing or has had a seizure, then I'm probably leaving in their IV for that reason.

SPEAKER_01 27:07

Um and then, yeah, just to go back real quick to that um IO versus IV, they actually cited a study in the article um showing patients that did have a cardiac arrest and uh were able to return to rhythm and without neurologic deficits, and there was no benefit difference. Um, the outcomes were the same and not clinically different, uh significantly different between using an I.O. and a peripheral IV. Um, and that's just something to think about, and maybe a change of mindset when it comes to um a cardiac arrest or resuscitation, but IOs are maybe underutilized in some of these patients.

SPEAKER_00 27:46

Oh yeah, I think you I think you're right. Uh that that part of it I am convinced by. Um, I worry about, and part of what's gonna give me pause is that how often do you have our typical patient population? Either they're ESRD, so their vessels are terrible, or they're frequently getting something else medical going on, chemo, whatever, um, or they're just little ladies who are just really hard sticks. That if I'm like, all right, now I want to start anything on them, whether it's antibiotics or fluids or whatever, I how often is it that the nurses are like, I can't get it, I have to call Vantine? And then you're waiting hours and hours before you get access. And so if I take, if I'm really aggressive and taking out all these IVs or not putting them in, I um I do worry a little bit that I'm gonna have those delays and cares of like we're waiting for hours or half a day or whatever before someone who like has the skill to put in the IV can put it in.

SPEAKER_01 28:57

Um and I think if that's your thought process, that's probably not the patient you want to take it out. I mean, those are the patients that you're thinking twice about. Um, you maybe have some hesitancy, and uh that's probably the patient you might want to keep in.

SPEAKER_00 29:09

Yeah. But the the patient awaiting placement, like you mentioned, like at any given time, what percentage of your census is awaiting placement?

SPEAKER_01 29:19

Yeah. At least one to two, usually.

SPEAKER_00 29:22

Yeah, yeah, totally. Like it's a solid 20% of my patients on on the list to weigh more than that at times. Like 20% is part of my minimum.

SPEAKER_01 29:32

Um if we could decrease risk of bacteremia or other complications or even just discomfort and stress, it mentions, then that would be huge, I think, for the patients.

SPEAKER_00 29:42

I think I reading it going through, I was a little tempted, like I said, to have the ideology of like, don't put it in until you need it and take it out if you're not gonna use it in the next 24 hours. And I think I've kind of like walked back a little bit, and this is maybe me just being like too much too fast, of like, you know, maybe we put them in on everyone when they come in, but if we don't expect we're gonna need in the next 24 hours aggressively start pulling these out.

SPEAKER_01 30:14

Um and that's actually um that's funny that you mentioned that because in the clinical scenario, they mentioned an 80-year-old man, probably bad veins. He's feeling better and his labs look better, but is that someone that you necessarily want to just take it out? Like, is that someone that's not a 25-year-old with some nausea and vomiting that feels better? Like um, maybe that is the person that you keep it in, and that's a not the example you want to use. Yeah.

SPEAKER_00 30:42

But I think that's the patient that I think it's it's worthwhile and thinking about in that patient and pushing in that patient. Because if I've got the 20-something year old and they're like, Can I take this out? Then I'm like, Yeah, sure, we I'll yeah, we'll we'll have the nurse take your IV out. That's no big deal. Um, but in that patient, I'd be like, I don't know. But I do feel heartened uh to pull those IVs out more often based on um all the stuff they cited here. And and probably that same guy is this he's more likely to have complications or at least to compensate if he's the guy who gets the Staph aureus bacteria, he's gonna be the guy who gets really sick from it rather than his 20-something, like they're gonna ultimately probably be fine.

SPEAKER_02 31:26

Yeah.

SPEAKER_00 31:26

Um, so what do you think? If you're do you think this is just for Nick Lindy? Every day you're gonna kind of think about it. It's gonna be more on your radar, or if you were the boss of the world, the boss of the hospital, there'd be a protocol of some sort about pulling them out or not putting them in, or what are your thoughts?

SPEAKER_01 31:50

I think you and I both know that when you start making a protocol for everything, it gets more complicated. You're gonna miss things. I think just having it being on your radar or something, you know, we think about enough, we make enough clinical decisions per patient in a day that this shouldn't, you know, cloud a more important thing. But if you have that patient um that is a waiting placement, or maybe you just have a box on your list that says, should I remove the peripheral IV? I think that might be beneficial and um maybe even lead to some improved uh satisfaction scores. You pulled that peripheral IV out. That was driving them nuts in their AC.

SPEAKER_00 32:29

Yeah, a lot of the the literature, the study or the journals were nursing journals. Because I do think this is the kind of thing, and I'd love a nurse's perspective because it's easy for us as providers to sit here and be like, yeah, this is something to put on the nurse's plate. And we we did that a lot. Um uh, but I do think it's the kind of thing they are would be so good at owning, like bugging me about a foley, bugging me about other things that are those like day-to-day patient risk things. And whether it's by design or just by nurses and who they are, um they do they do a great job of being sort of the the watchers of those risk things in a patient. And so if we had, you know, a nursing protocol of some port where we put this on their radar, and if it, you know, if the IV hasn't been used within 24 hours, they page the provider and ask to remove it or something like that. I think that could be a great thing. Because then you can use your clinical judgment and call them back and be like, oh no, this guy like is probably gonna have a seizure, like um but or you can be like, oh yeah, definitely. I didn't think about it because it's just another thing to be thinking about that you're not thinking about, I haven't been thinking about, definitely will some now. But unless I create a a structure to my workflow, it's gonna be so hard to to keep these peripheral IVs in the front of my mind. I'll definitely be more likely to pull them if someone else brings them up. I can't guarantee me being the poster child for laziness. Um, and so like I know what what's gonna be the path of least resistance because like I'm I if things can get forgotten, I'll I could potentially forget them. And I'm like, I don't I don't know. I I just don't think I'm gonna think about the peripheral IV every day.

SPEAKER_01 34:30

I think I think a 24-hour uh 48-hour removal from um protocol from a nurse would could be good, but that is every 24 to 48 hours on every patient, uh whatever protocol comes, it's uh down to that.

SPEAKER_00 34:47

I guess gosh, and god forbid the uh the 24 hours comes up overnight and the our nocturne's calories are getting paged. They would I I'd like their perspective too, because I'm sure they would say, like, no, no more things that need a 24-hour renewal. No problem. You day jerks are terrible at the foliage already, and anything else, the restraints, all of that stuff. So don't don't give me more pages for this. Um cool. Any other any other thoughts on this?

SPEAKER_01 35:20

No, I think um, you know, bottom line, routine maintenance of idle IVs or non- you know, IVs not being used, low value care, regular reassessment, early removal, if it's the appropriate patient, could lead to um decreased infections and improved patient satisfactions.

SPEAKER_00 35:41

Yeah. I like that uh one thing is I like that this article kind of dovetails in with our first article because after those four days, if you're de-escalating to something oral, yeah, pull that IV out too. Overall takeaway points. Um at day four of a patient who's admitted with community acquired sepsis, reevaluate whether or not they need that broad spectrum antibiotics. Uh de-escalating it is shown to not increase their risk of mortality. And when it comes to IVs, use it or lose it. If you haven't been using it for 24 hours, then seriously consider pulling it out and uh kind of kind of think on that one a little bit and decide do we need institutional protocols for this or not? It's been a great discussion. It's been great. Thanks so much for joining me, Nick.

SPEAKER_01 36:42

Yeah, yeah. Uh shout out to all the APPs out there and um hope you guys learned something from this.

SPEAKER_00 36:48

A couple things I'll mention is uh the next show I plan to post is going to be an SHM primer i slash inpatient updates go into SHM. So I'll just drop a short episode about things I'm excited about seeing and then a recap episode afterwards. But as always, um if anyone, if anyone else is going to SHM and has anything that uh I should be alert to and mention on the show, please reach out. Um and if anyone wants to give their two cents and come on the show and talk about SHM either before or after, I would love to have you. Um and if you're a provider, a pharmacist, a nurse, a resident, a student, or anyone with some value-added insight into the manage of hospitalized patients, reach out to me directly, contact me on social media or email me at podcast at impatientupdate.com if you'd like to come on the show. I'd love to have you. Um, and as always, uh subscribe to the show if you like it. But most importantly, if honestly, if you're enjoying the show, if you find it valuable, share it with other people that you think might actually also find it valuable. Because if this is something people are listening to and getting value out of, I'll certainly continue to do it. And so far, I've had a good response, but keep sharing it around. Thank you so much, Nick. Thank you. We'll have to pour ourselves uh another drink and have a toast uh to science to the evidence.

SPEAKER_01 38:19

The science to the listeners, and uh yeah, Dr. Turner is doing a phenomenal job at this. I've already learned so much uh from his first couple sessions, so yeah, please continue to tune in and subscribe, and um, you'll learn a lot.

SPEAKER_00 38:31

All right, thank you so much. Thank you for joining us, listeners. This has been Inpatient Update.