In the News

Algorithm to rule in or rule out acute MI, feedback and daily lab orders, fecal transplant for Clostridium difficile, and more.

Novel algorithm may allow for rapid rule-in/rule-out of acute MI

A novel 1-hour algorithm to rule in or rule out acute myocardial infarction (MI) by incorporating high-sensitivity cardiac troponin T baseline values and changes may have substantially accelerated management, a study found.

As part of the Advantageous Predictors of Acute Coronary Syndromes Evaluation (APACE) Study, researchers conducted a prospective 6-center study in 3 European countries among 1,320 patients presenting to the ED with suspected acute MI. They had high-sensitivity cardiac troponin T measured at presentation and after 1 hour. All patients were also assessed by medical history, physical examination, 12-lead electrocardiography (EKG), continuous EKG monitoring, pulse oximetry, standard blood test, and chest radiography. Patients with ST-elevation MI were excluded from the analysis.

To rule out acute MI, baseline high-sensitivity cardiac troponin T levels had to be under 12 ng/L and change less than 3 ng/L within the first hour. To rule in acute MI, the criterion was either a baseline troponin T value of 52 ng/L or greater or an absolute change within the first hour of 5 ng/L or greater. Patients ruled neither out nor in were classified in an observational zone.

The algorithm was validated against the final diagnosis, which was then adjudicated by 2 independent cardiologists using coronary angiography, echocardiography, follow-up data, and serial measurements of high-sensitivity cardiac troponin T levels at 3 hours, 6 hours, and thereafter. Results were published in the May 19 CMAJ.

Acute MI was diagnosed in 17.3% of patients. The 1-hour algorithm ruled out 786 (59.5%) of the total patients and ruled in 216 (16.4%), with the remaining 318 (24.1%) classified to the observational zone.

The algorithm's sensitivity for ruling out acute MI was 99.6% (95% CI, 97.6% to 99.9%), and the negative predictive value for MI was 99.9% (95% CI, 99.3% to 100%). The specificity for ruling in acute MI was 95.7% (95% CI, 94.3% to 96.8%), and the positive predictive value for MI was 78.2% (95% CI, 72.1% to 83.6%).

The researchers noted that the 1-hour algorithm provided higher negative and positive predictive values than the standard interpretation (both P<0.05), and that cumulative 30-day mortality was 0.0% in the rule-out group, 1.6% in the observational group, and 1.9% in the rule-in group (P=0.001).

The researchers concluded that a quicker rule-in could result in faster initiation of antiplatelet, anticoagulant, and anti-ischemic medication, as well as more rapid transfer to coronary angiography and, if feasible, coronary revascularization. A more rapid rule-out could result in quicker relief of patient anxiety and quicker identification of an alternative cause of acute chest pain without the need for continued rhythm monitoring. In addition, the algorithm could reduce the time to discharge from the ED by about 50%.

Feedback reduced daily lab orders in a community hospital

An audit-and-feedback intervention in a community hospital successfully reduced lab ordering and costs without affecting quality of care, a recent study found.

The study was conducted in 2013 in a large community hospital group, beginning with an e-mail to hospitalists recommending that they stop ordering common lab tests to be done daily and instead order labs no further than 24 hours into the future. The 5 clinicians who had historically ordered the most daily labs received another e-mail informing of their relatively high use. Then, monthly group e-mails reported how often each clinician ordered daily labs and gave an example of a patient who had at least 1 common lab ordered for 5 days in a row with no apparent impact on his or her care according to the medical record.

In the 10 months before the intervention, a mean of 2.06 common labs were ordered per patient-day. During the 7-month intervention, that mean decreased by 0.22 (95% CI, 0.34 to 0.11; P<0.01) or 10.7%, adjusted for age, sex, and principal discharge diagnosis. The decline in lab costs reduced hospital direct costs by an estimated $16.19 per admission or $151,682 per year. During the same time period, hospital mortality and the volume of blood transfused in patients receiving a transfusion also dropped, but not statistically significantly. Length of stay and readmission rates didn't change.

Similar projects have been conducted at academic medical centers, but this study shows that a community-based hospitalist group can implement such an intervention to safely reduce health care waste without compromising quality of care, the study authors said. They speculated that hospitalists' aversion to displaying worse performance than their peers was a contributor to the intervention's success, in addition to their support of reducing unnecessary labs and improving quality generally.

The study was limited by its before-after design, especially considering that the Choosing Wisely campaign released a recommendation for hospitalists against performing repetitive complete blood count and chemistry testing in the face of clinical and lab stability in 2013, the authors noted. The study was published in the June Journal of Hospital Medicine.

Fecal transplants for recurrent C. diff may resolve symptoms with few adverse events

Low-strength evidence shows fecal microbiota transplantation (FMT) effectively treats recurrent Clostridium difficile infections (CDIs), with few short-term adverse events, a review found.

Researchers conducted a literature search to find 2 randomized, controlled trials (RCTs); 28 case-series studies; and 5 case reports (included only for reporting harms) assessing FMT. Results of their analysis, which was funded by the Department of Veterans Affairs, appeared in the May 5 Annals of Internal Medicine.

Across all studies of FMT for recurrent CDI, symptom resolution was seen in 85% of cases. In the 2 RCTs, totaling 36 patients with recurrent CDI, 27 (75%) had resolution of CDI symptoms without recurrence. One RCT comparing FMT with 2 control groups reported resolution of symptoms in 81% of patients who received FMT, 31% of patients who received vancomycin, and 23% of patients who received vancomycin plus bowel lavage (P<0.001 for both control groups vs. FMT). An RCT comparing different FMT routes of administration for CDI recurrence reported no difference between groups (60% had their symptoms resolved in the nasogastric tube group, as did 80% in the colonoscopy group; P=0.63). Among the 480 patients in 21 case-series studies who received FMT for recurrent CDI, 85% had resolution of symptoms without recurrence.

There were 7 studies reporting on patients with refractory CDI treated with FMT, and they used various methods and did not compare FMT with standard therapy. Reported resolution of symptoms ranged widely (0% to 100%; overall resolution rate, 55%).

Case-series studies included 7 patients treated with FMT for initial CDI, with mixed results. Six cases were part of a series of 14 patients with refractory CDI, and 1 case was part of a series of 4 patients. Among the 6 cases, 1 was cured after FMT. The other, single case received FMT as initial treatment of an episode of postantibiotic-associated colitis and had symptom resolution within 48 hours.

“[L]ow-strength evidence supports FMT as having a substantial effect and few short-term adverse events for adults with recurrent CDI,” the authors wrote. “There is insufficient evidence about FMT for patients with refractory CDI or for initial treatment of CDI. Evidence is insufficient about whether treatment effects vary by FMT donor, preparation, or delivery method.”

The author of an accompanying editorial stated that FMT is effective, provides durable cures, and can result in a cost savings of $17,000 per patient in recurrent cases. Remaining issues include the need for regulations to standardize the treatment, which is currently considered a drug and biologic by the FDA, and the potential effects of transplanting a microbiome from one patient to another.

“The excitement about FMT is justified given its high efficacy in treating recurrent CDI, relative availability and simplicity, and favorable cost profile compared with other therapies,” the editorial stated.

Family presence during cardiopulmonary resuscitation doesn't appear to affect safety, outcomes, study finds

Allowing families to be present during cardiopulmonary resuscitation (CPR) doesn't appear to have negative effects on safety or outcomes, according to a recent study.

Researchers performed an observational cohort study at U.S. hospitals participating in Get with the Guidelines-Resuscitation. The study examined adult patients who were in cardiac arrest, with the goal of evaluating patterns of care at facilities that had policies allowing family presence during CPR and those that didn't. Primary outcomes were return of spontaneous circulation, defined as restoration of a pulse for at least 20 minutes during the arrest, and survival to discharge; neurological outcomes among survivors were also evaluated. Secondary outcomes were resuscitation quality and aggressiveness, as well as potential resuscitation systems errors (e.g., potential errors in airway deployment, vascular access, or chest compression quality) as reported by the facilities. Study results were published in the May Circulation: Cardiovascular Quality and Outcomes.

Overall, 252 hospitals and 41,568 patients were included in the study, with 13,470 patients cared for at 80 hospitals that allowed families to be present during CPR. A statistically significant difference was seen in the rate of return of spontaneous circulation in hospitals with a policy allowing families versus those without (58.2% vs. 55.8%; P=0.045), but this difference was not seen after adjustment for patient and hospital characteristics. The researchers likewise found no significant differences in survival to discharge or survival to discharge with a favorable neurological status between hospitals that had a policy allowing families to be present during CPR and those that did not. However, a small and borderline statistically significant decrease was seen in mean time to defibrillation (mean difference, 0.32 minute; 95% CI, −0.01 to 0.64). No meaningful difference was seen in quality or aggressiveness of resuscitation or potential resuscitation systems errors.

The researchers noted that Get with the Guidelines-Resuscitation is a voluntary registry and may not represent all hospitals and that not many hospitals had a policy allowing families to be present during CPR. In addition, among other limitations, they noted that hospitals with such policies may apply them very differently. However, based on their results, they concluded that hospitals with a policy allowing families to be present during CPR do not appear to have statistically significant differences in outcomes or processes of care compared with hospitals that do not have a similar policy. While these results seem to indicate that such policies have no negative effect on care, additional study of the direct effects on patients and families is needed, the researchers said.