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HospitalistWeekly 7-2-08
Highlights
- New guidelines on antithrombotic therapy released
- Radiofrequency identification devices may interfere with critical care equipment
Quality improvement
- Quality scores may be inaccurate for low-volume hospitals, study reports
Cardiology
- Drug-eluting stents improved outcomes without increasing death rates, study finds
Patient safety
- WHO launches safe surgery initiative
Tools and resources
- PIER introduces interactive feature
From ACP Hospitalist
- Only two weeks left to recommend your colleagues as Hospitalists of the Year
From ACP Internist
- What they're saying on the blogs
Editorial notice: ACP HospitalistWeekly will not be published on July 9 in observance of Independence Day.
Highlights
.New guidelines on antithrombotic therapy released
The American College of Chest Physicians has issued new guidelines on antithrombotic therapy emphasizing prophylaxis and management in specific populations, including perioperative patients.
The guidelines, published as a supplement to the June issue of Chest, include the following strong recommendations:
- Every general hospital should develop a formal, active strategy to address the prevention of venous thromboembolism.
- Hospitals should not rely on passive methods to increase thromboprophylaxis adherence but should instead encourage use of computer decision support systems, preprinted orders and periodic audit and feedback.
- Thromboprophylaxis other than early and frequent ambulation is not recommended in low-risk general surgery patients
- Patients undergoing major general surgery should receive thromboprophylaxis until hospital discharge.
- Patients who are asymptomatic after major orthopedic surgery should not be routinely screened with duplex ultrasonography before discharge.
Additional recommendations address trauma, critical care, venous thromboembolic disease and prophylaxis in pregnant women and children, among other topics.
The guidelines are online.
A press release from the American College of Chest Physicians is online.
.Radiofrequency identification devices may interfere with critical care equipment
Radiofrequency identification devices (RFIDs) may cause critical care equipment to malfunction and may lead to adverse events, according to a new study.
RFIDs are increasingly used in medicine for tracking and patient safety purposes, but few if any studies have examined their potential impact on medical equipment. A group of Dutch authors assessed two types of RFIDs, a passive 868-MHz system and an active 125-MHz system, to determine how often they caused incidents of electromagnetic interference (EMI) with critical care equipment. Passive systems are activated by a reader, while active systems use batteries and can transmit information without requiring activation.
Incidents were defined as "every unintended change in the function of a medical device" and were classified as hazardous (a direct physical influence on a patient by unintentionally changing equipment function), significant (an influence on monitoring requiring a significant level of attention and substantial distraction from patient care) or light (an influence on monitoring not requiring a significant level of attention). Patients were not connected to the 41 critical care devices examined in the study during the EMI tests. The study was published in the June 25 Journal of the American Medical Association.
The authors conducted 123 EMI tests and found that RFIDs caused 34 reproducible EMI incidents. Of these, 22 were considered hazardous, two were considered significant and 10 were considered light. The passive RFID caused more incidents than the active RFID (26 in 41 tests [63%] vs. 8 in 41 tests [20%]). RFID incidents occurred at a median distance of 30 cm (range, 0.1 to 600 cm).
Although the authors cautioned that their study results apply only to the specific RFIDs tested at maximum power, they concluded that RFIDs can cause harm by interfering with medical equipment. RFIDs should be frequently tested in the health care setting and updated international standards should govern their use, the authors wrote.
The Journal of the American Medical Association is online.
Quality improvement
.Quality scores may be inaccurate for low-volume hospitals, study reports
Low-volume hospitals may be measured incorrectly during performance assessment efforts, according to a new study.
Researchers at Duke University examined performance data from the Hospital Quality Alliance on eight acute myocardial infarction process measures at 3,761 U.S. hospitals, with the goal of determining whether small case volumes affect the measures' accuracy. The study results appear in the June 23 Archives of Internal Medicine.
The authors found that sample sizes varied for each of the eight measures; fewer than 25 patients were eligible for each measure at almost a third of the hospitals. Although large-volume hospitals had better aggregate quality scores (e.g., 96% vs. 83% for aspirin given on arrival and 75% vs. 56% for percutaneous coronary intervention delivered within 120 minutes), small-volume hospitals were more likely to be classified as top performers because they saw fewer cases. For example, more than 30% of hospitals with a perfect score on administration of angiotensin-converting enzyme inhibitors treated only one eligible patient.
The authors concluded that although a smaller proportion of patients at low-volume compared with high-volume hospitals received evidence-based care, low-volume hospitals were more likely to be classified as top performers due to the small number of patients treated for each measure. Analysis of quality measures must take case volume into account to truly assess hospital quality, they wrote.
An accompanying editorial pointed out that small case numbers could also lead to disproportionately poor quality ratings for low-volume hospitals. "The take home message…is not that small hospitals are unfairly crowned top performers—rather, it is that with limited information, small hospitals are more at risk of being misclassified at either extreme of performance," the editorialists wrote. They recommended reporting quality ratings from low-volume facilities more carefully, as well as explaining the data's inherent uncertainty.
The Archives of Internal Medicine article and editorial are online.
This week's Archives of Internal Medicine also includes a debate by two prominent physicians on whether hospitalists improve inpatient care.
Cardiology
.Drug-eluting stents improved outcomes without increasing death rates, study finds
Drug-eluting stents have decreased the need for revascularization compared with bare-metal stents without significantly increasing patients' risks for death or myocardial infarction, concluded a study in the June 25 Journal of the American Medical Association.
In the observational study, researchers looked at 38,917 Medicare patients who received bare-metal stents before drug-eluting stents became available and 28,086 patients who received stents later, with 61.5% getting drug-eluting stents and 38.5% bare-metal stents. After two years, patients in the drug-eluting stent era group had lower risks for repeat percutaneous coronary interventions (17.1% vs. 20.0%, P < 0.001) and coronary artery bypass surgery (2.7% vs. 4.2%, P < 0.01) than the bare-metal stent era group. There was no difference in mortality risks and only a small decrease in ST-elevation myocardial infarction (2.4% vs. 2.0%, P < 0.001).
The authors concluded that that while some previous data have indicated an incremental risk of stent thrombosis with the use of drug-eluting stents, their findings detected no adverse consequences compared with bare-metal stents. They speculated that any increased risk of stent thrombosis associated with drug-eluting stents would be more than offset by a decrease in the risk of developing restenosis.
The JAMA abstract is online.
Patient safety
.WHO launches safe surgery initiative
The World Health Organization launched an initiative last week to improve the safety of surgery worldwide.
The initiative, Safe Surgery Saves Lives, is a collaborative led by the Harvard School of Public Health and centers on a checklist that hospitals can use to improve surgical care. The checklist has been tested in eight pilot sites and has increased adherence to standards of care from 36% to 68% and close to 100% at some hospitals, according to a WHO press release.
The surgical safety checklist is divided into three sections: before induction of anesthesia (the sign-in phase), before skin incision (the time-out phase), and before the patient leaves the operating room (the sign-out phase). Surgery teams should not move on to a new phase until a checklist coordinator has verified that all steps in the current phase have been completed, the press release said.
Steps in the sign-in phase include having the patient confirm his or her identity and the procedure to be performed and making sure that the surgical site has been marked. In the time-out phase, steps include having all team members introduce themselves by name and role, and having the surgical, anesthesia and nursing teams review the possibility of any anticipated critical events. During the sign-out phase, steps include having the nurse verbally confirm instrument, sponge and needle counts with the team.
The current version of the checklist will be finalized by the end of the year, after the pilot evaluation has been completed, the press release said.
The WHO press release is online.
The first edition of the checklist is online.
Tools and resources
.PIER introduces interactive feature
PIER has introduced interactive user comment pages for 10 of its disease modules. Users can trade clinical insights and questions with colleagues, discuss important new data in the medical literature, and suggest additions and changes to PIER modules. The new feature is now available in the following areas (ACP membership required):
Acute coronary syndromes
Atrial fibrillation
Community acquired pneumonia
Deep venous thrombosis
Depression
Diabetes mellitus, type 2
Essential hypertension
Heart failure
Lipid disorders (dyslipidemia)
Stroke and transient ischemic attack
PIER invites general suggestions and opinions about this feature. Send your comments to gklaiman@acponline.org so that we can continue to adapt and improve it to best meet the needs of ACP members.
From ACP Hospitalist
.Only two weeks left to recommend your colleagues as Hospitalists of the Year
ACP Hospitalist is seeking candidates for its first annual Hospitalists of the Year issue. To recommend a colleague who made notable contributions to the field in 2008, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement, readers can fill out the online form. All recommendations should be received by July 14. Hospitalists of the Year will be profiled in our November 2008 issue.
From ACP Internist
.What they're saying on the blogs
Join ACP Internist's community on its blogs, featuring daily updates on news that just can't wait. Find popular features such as Medical News of the Obvious. Post your comments today.
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