Originally published Spring Newsletter 2023. Written by Nick Patino, PA-C, Director At Large.
From the very moment a patient is admitted to a Hospitalist service, preparation for discharge begins. Stabilizing the patient to the point where they can be discharged from the hospital is the main goal of any hospitalist service, and a lot of thought goes into determining when that point is. A mantra can often be heard among Hospitalist clinicians: It is unlikely that we are going to get this patient better than their baseline. But what exactly do we mean by baseline? And how do we know what a patient’s baseline is? After all, as I am sure you are all aware, we certainly use the term a lot. My hope is to stress the importance of baseline as a central focus in the hospitalized patient. It is too often we find ourselves caught saying the following phrases:
What do you mean Ms. Smith is on 2 L of oxygen at baseline? Why have we been working up her respiratory failure this whole time?
Mr. Marks has chronic kidney disease? His baseline creatinine is 2.9? It was 2.4 this morning!!
Oh, Mrs. Freeman normally doesn’t know where she is? That’s why she said she was at the train station this morning!
In the hospitalized patient, baseline should be the goal we strive for, and it should be at the forefront of clinical decision making. I will share some important baselines to consider in the hospitalized patient, and some tips and tricks to determine and manage baseline from the mind of a Hospitalist PA, and hopefully be able to save a few headaches down the road in your clinical journey. Sometimes you have to do some digging and commit time to find these, but it often saves you a workup and resources.
Baseline Oxygen Requirement: This one is fairly easy to find, patients usually know their baseline oxygen at home, so start by asking them. If they don’t know, try their family members, visiting nurse agency or staff at a skilled nursing facility (SNF). You can also check medical records and W10s to see if orders exist for home oxygen. You also want to find out why they are on oxygen – COPD, lung cancer, heart failure and interstitial lung disease are among the most common reasons. Consider searching for the most recent pulmonology note, and read recent discharge summaries to see if they left on O2 last time.
Baseline Blood Pressure: Blood pressure is a little tricky because it obviously varies quite a bit. Really, you just want to get a sense of where their blood pressure usually runs by asking the patient or family members. You can also try to do a synopsis view in the electronic medical record (EMR) that can graph BP values over a period of time, but use caution with this method especially if most of their care has been in the hospital. If they run in the 150s/90s normally, while that is not a good thing, it isn’t something that can likely be fixed in the hospital setting. Of note, if a patient has orthostatic hypotension, always search the chart for a chronic history, especially if you suspect it is not a volume problem.
Baseline Weight: Dry weight is of utmost importance in hospitalized patients with disorders prone to volume overload: heart failure, cirrhosis, CKD. Baseline weight is
often difficult to determine, especially if the patient is not aware of the baseline weight. If the patient does not know, I suggest trending their weight back over time and getting a sense of their average weight and the lowest weights you see. You can also take a look at the most recent notes from the specialists in their area of disease, often they will write the patient’s “dry weight” in progress notes. A good tip is to find the date that a stand-alone weight was recorded and go to that day in the patient’s notes – it’s probably from an office visit and you can find some details about where the clinician thinks they are weight wise.
Baseline Lab Values: Unlike vital signs, it is unlikely that patients will know their baseline labs values. All labs can have baselines, but the most important ones to consider are the following: sodium, creatinine, B-type natriuretic peptide (BNP), hemoglobin/hematocrit, blood glucose, hemoglobin A1C. I suggest you use the power of the EMR to trend the lab data back in a graph or list format. Most often, if there is enough data you can get a pretty good idea of baseline this way. There are two pitfalls to consider with this method, however. First, more data is going to be present from hospitalizations, use of a graph method that incorporates time may be helpful to avoid error. If you see outlier data, it isn’t a bad idea to travel to the date that value is from and see what was going on with the patient at that particular time. The second pitfall would be lack of data / crossing health systems. I strongly suggest requesting records from other health systems if possible.
Baseline Mental Status: I cannot stress enough the important of knowing a patient’s baseline mental status. Altered mental status is an extremely common complaint among hospitalized patients. Often the methodology here is simple, but it takes time – it’s about collateral, collateral, collateral. If you are questioning if a patient is at their baseline, innately they are not going to be a reliable resource. You need to talk to someone else, and you can get creative. Start with anyone listed in the patient contacts section – spouse, children, siblings, nieces, nephews, friends – anyone that knows them. If relatives don’t know (which is unfortunately the case in some estranged families), call other healthcare workers. Their PCP, visiting nurses, staff at SNF, social workers, etc likely can give you some information about their mental status baseline. The absolute best thing would be to have the family member come in and see their relative if possible. Often that is not possible, so it has to be done over the phone.
My technique for the phone is the following: I will see the patient, have as best a conversation I can with them, and ask the normal orientation questions as well as some higher order thinking questions if they can answer them (Why are you in the hospital? What would you do if there was a fire in your home? A leak in your sink?). I will then call the relative or healthcare worker for collateral and ask them to describe the patient’s baseline. I ask specific questions about activities of daily life and mobility. Think of it like a conversation or a story where you are trying to get a mental image of what your patient is like outside of the hospital. This gives me a pretty good idea of their baseline. I will then describe what the patient is like right now and ask the person if they think they are at baseline.
Hopefully, I have stressed the importance of baseline as a central focus in the hospitalized patient and provided my methods for determining a few different baselines. As a Hospitalist PA, my goal is to get the patient out of the hospital as soon as it is safe to do so. Efficiently determining baseline is an important part of that clinical decision, but also incredibly important in saving the patient from unnecessary testing and extended hospital stays. Sometimes, the best care you can provide to a patient is taking the time to explore how they normally are.
Photo Credit: Photo by Joshua Chehov on Unsplash