SHM Converge Scientific Abstract ePoster Gallery-To Obs or Not to Obs? The Role of Hospitalists as Advocates

Pdf Summary

This case describes a 25-year-old woman with right fibular hemimelia and a history of multiple limb-lengthening surgeries complicated by prior Staphylococcus aureus infection requiring hardware removal. She presented to the ED with several weeks of worsening acute-on-chronic leg pain after outpatient orthopedics had recommended a nonurgent MRI. In the ED, she was afebrile and hemodynamically stable, but inflammatory markers were elevated (ESR, CRP) and x-rays showed only postsurgical changes without acute abnormalities.<br /><br />She was initially admitted under observation for pain control, as she required IV opioids. An MRI was attempted but had to be stopped early because of pain. Based on this incomplete study, inpatient orthopedics initially recommended outpatient follow-up. However, because she continued to need IV pain medication and was expected to have a prolonged hospital stay, her status was upgraded to inpatient.<br /><br />A repeat MRI was later completed and showed acute-on-chronic osteomyelitis of the femur. Orthopedics was reengaged, Infectious Disease was consulted, and she was started on IV vancomycin. Bone culture ultimately grew MSSA, so antibiotics were narrowed to cefadroxil. She was discharged on an oral pain regimen.<br /><br />The presentation highlights the challenges of determining observation versus inpatient status in complex cases. It also notes the broader policy context: CMS introduced the two-midnight rule in 2013, but surveys have shown that many providers feel it adds administrative burden without improving care. The authors argue that hospitalists often bear the responsibility of navigating these status decisions while managing complex patients, and that further discussion is needed to streamline care and improve efficiency.

Asset Subtitle

Robert Vargas

Meta Tag

Author List Manya Gupta, Robert Vargas

Category Clinical Vignettes

Concept Observation Status

Concept Hospital Admission

Concept Postoperative Bone Infection

Concept Two-Midnight Rule

Concept Culture

Distinguished Non-Finalist

Presenter Organization Rush University Medical Center

Presenting Author Robert Vargas

Track Adult

Keywords

fibular hemimelia

osteomyelitis

acute-on-chronic leg pain

MRI

inpatient status

observation status

IV opioids

Staphylococcus aureus

MSSA

CMS two-midnight rule

Observation Status

Hospital Admission

Postoperative Bone Infection

Two-Midnight Rule

Culture