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HospitalistWeekly 7-16-08
Highlights
- President Bush vetoes bill on physician payment cuts; legislators plan an override
- Noninvasive ventilation improves symptoms but not mortality in cardiogenic pulmonary edema
- Joint Commission targets unprofessional behavior in the workplace
Patient safety
- Staff shortcuts undermine safety aim of bar code technology, study finds
Annals of Internal Medicine
- Low-molecular-weight heparin may prevent clots after knee arthroscopy
- Disconnect found between patient-reported hospital errors, medical record review
FDA updates
- Boxed warning on fluoroquinolones for tendon ruptures, tendinitis
- Contaminated antiseptic cloths recalled
- Mycophenolate mofetil poses risk of progressive multifocal leukoencephalopathy
- Wireless insulin pump, genetic test for cancer treatment approved
From ACP Hospitalist
- Last chance to suggest a colleague as a Hospitalist of the Year
From ACP Internist
Cartoon caption contest
- Put words in our mouth
Highlights
.President Bush vetoes bill on physician payment cuts; legislators plan an override
On Tuesday, President Bush vetoed the Medicare Improvements for Patients and Providers Act of 2008 (H.R. 6331), legislation that would reverse the 10.6% physician payment cut that went into effect July 1. The Act also allows for a 1.1% increase in payment rates for 2009 instead of the rate cut that had been anticipated. At press time, Congress is expected to override the veto late Tuesday or Wednesday.
Although the Senate and the House of Representatives passed the legislation with margins large enough to overcome a presidential veto, ACP cautioned that a veto override cannot be taken for granted and will not necessarily occur in time to stop the cut from going into effect later this week.
In addition to the payment measures, the Act contains several other measures championed by ACP that will benefit hospitalists and their patients. One will require that Medicare cover preventive services recommended by the U.S Preventive Services Task Force. Another, which was added to the bill specifically at ACP's request, will substantially increase payments for hospital and office visits by Medicare and other payers that use the Medicare relative value scale.
ACP will keep you updated as the situation progresses on the ACP Advocacy Web site.
For information about what you can do encourage your legislators to overcome the veto, visit ACP's Legislative Action Center.
.Noninvasive ventilation improves symptoms but not mortality in cardiogenic pulmonary edema
Noninvasive ventilation methods help improve symptoms but have no effect on mortality compared with standard therapy in patients with cardiogenic pulmonary edema, according to a new study.
British researchers conducted a large, multicenter, randomized controlled trial in 1,069 patients with acute cardiogenic pulmonary edema to determine whether continuous positive airway pressure (CPAP) or noninvasive intermittent positive-pressure ventilation (NIPPV) yields more benefit than standard oxygen therapy and whether CPAP is inferior to NIPPV. The study's primary end points were death within seven days after the start of treatment for standard therapy versus noninvasive ventilation, and death or endotracheal intubation within seven days for CPAP versus NIPPV. Secondary end points were physiologic variables, dyspnea, intubation within seven days, length of stay, admission to the ICU, and death within 30 days. The study results appear in the July 10 New England Journal of Medicine.
The average age of the study population was 78 years, and approximately 57% were women. Three hundred sixty-seven patients were assigned to receive standard oxygen therapy, 346 were assigned to receive CPAP and 356 were assigned to receive NIPPV. At seven days, the authors found no significant difference in mortality between patients in the standard oxygen group and those in the noninvasive ventilation groups (9.8% vs. 9.5%; P = 0.87). Likewise, death or intubation at seven days did not differ between the CPAP and NIPPV groups (11.7% vs. 11.1%; P= 0.81). One hour after treatment began, greater improvement was seen in patient-reported dyspnea, heart rate, acidosis and hypercapnia in patients in the noninvasive ventilation groups.
The authors concluded that patients who receive noninvasive ventilation improve more quickly than those who receive standard oxygen therapy but that the former methods do not affect rates of short-term mortality. In addition, they found no evidence to suggest that NIPPV is safer or more effective than CPAP. "Noninvasive ventilation (CPAP or NIPPV) [should] be considered as adjunctive therapy in patients with acute cardiogenic pulmonary edema who have severe respiratory distress or whose condition does not improve with pharmacologic therapy," they recommended.
The New England Journal of Medicine is online.
.Joint Commission targets unprofessional behavior in the workplace
The Joint Commission issued an alert last week aimed at reducing abusive and disruptive behavior in the workplace.
Behavior such as physical threats and verbal outbursts have a detrimental effect on teamwork and communication that in turn impacts patient care, the agency said in a press release. Beginning Jan. 1, 2009, The Joint Commission will require hospitals and other health care facilities to create a code of conduct that defines acceptable and unacceptable behavior, as well as establish a formal process for handling clinicians who don't comply.
The agency recommends 11 steps that facilities can take to address this problem, including:
- Educating all health care team members about professional behavior;
- Holding all team members accountable for modeling desirable behaviors, and enforcing the code of conduct consistently and equitably;
- Determining how and when disciplinary actions should begin;
- Developing and implementing a system for assessing staff perceptions of the seriousness and extent of instances of unprofessional behaviors and the risk of harm to patients; and
- Documenting all attempts to address intimidating and disruptive behaviors.
The Joint Commission alert and a related press release are online.
Patient safety
.Staff shortcuts undermine safety aim of bar code technology, study finds
Practical problems surrounding the use of bar code medication administration (BCMA) technology in hospitals are prompting staff to develop shortcuts that may be undermining safety, according to a recent study.
In the study, researchers spent several years observing bar-code technology in five hospitals and analyzing medication scans. They identified several factors that led nurses to take shortcuts, including some related to difficulties with using the technology, such as unreadable or missing bar codes, and other problems related to workflow or efficiency, such as affixing extra copies of patient ID bar codes on desks or clipboards to avoid scanning the patient's actual ID wristband.
The authors identified several categories of causes for these "workarounds":
- Technological: Including problems with BCMA software or hardware, such as battery failures of handheld scanners or linked computers, difficult-to-read or -navigate screens, and alert beeps that sound like confirmation beeps.
- Task-related: For example, nurses may circumvent BCMA protections by carrying several patients' medications on one tray or by not scanning medication IDs or patient IDs.
- Organizational: For example, patients or medications without bar codes (due to organizational flaws), medication bar codes covered by a label reminding users to scan bar codes, or pharmacies sending only partial doses.
- Patient-related: For example, staff may not scan patient IDs or document administrations before medications are ingested due to special circumstances, such as patients refusing medications, vomiting medications, sleeping, agitated, receiving central lines, or in contact isolation.
- Environmental: For example, hospital areas without wireless BCMA connectivity (operating rooms, laboratories) and medications stored far away from the scanner (e.g., those that require refrigeration) necessitating multiple trips to scan, dispense, and return.
The study, published in the July/August 2008 Journal of the American Medical Informatics Association, includes a list of recommendations for hospitals to identify and correct problems associated with using BCMA technology.
The article is online.
Annals of Internal Medicine
.Low-molecular-weight heparin may prevent clots after knee arthroscopy
Researchers studied 1,761 patients undergoing knee arthroscopy, randomly assigning them to three groups. One wore a graduated compression stocking for seven days, the second group received injections of low-molecular-weight heparin (LMWH) for seven days, and the third group received LMWH injections for 14 days. Although blood clots were uncommon in all groups, fewer patients receiving LMWH developed blood clots compared with those wearing compression stockings (0.9% vs. 3.2%). Patients receiving LMWH for 14 days did not have fewer clots than those receiving LMWH for seven days. Blood thinners made the biggest difference in people having meniscectomy.
.Disconnect found between patient-reported hospital errors, medical record review
Among 998 patients who completed a questionnaire about their hospitalization experience, poor agreement about the occurrence of adverse hospital events exists between patient interviews and medical records. A study suggests that patients report serious and preventable events that are not documented in medical records. It also suggests that hospitals should consider monitoring patient safety by adding questions about adverse events to post-discharge interviews.
Annals of Internal Medicine is online.
FDA updates
.Boxed warning on fluoroquinolones for tendon ruptures, tendinitis
Fluoroquinolone antimicrobial drugs need boxed warnings and patient medication guides about their higher risk for tendinitis and tendon rupture, the FDA told drug manufacturers last week.
Patients at highest risk include those over age 60; kidney, heart or lung transplant recipients; and people taking corticosteroids. Patients should stop using fluoroquinolones at the first sign of tendon pain, swelling or inflammation; avoid using or exercising the area; and call their doctors about switching drugs.
The warning applies to fluoroquinolones for systemic use, like pills, capsules and injections, and not those for topical ophthalmic or otic use. Affected medications include ciprofloxacin (Cipro), gemifloxacin (Factive), levofloxacin (Levaquin), moxifloxacin (Avelox), norfloxacin (Noroxin), and ofloxacin.
The FDA alert and news release are online.
.Contaminated antiseptic cloths recalled
Limited lots of 2% chlorhexidine gluconate cloth patient preoperative skin preparation product are being recalled because some lots tested positive for Burkholderia cepacia, the FDA said.
Patients with weakened immune systems or chronic lung diseases like cystic fibrosis may be especially susceptible to B. cepacia respiratory infections. The cloths were shipped to hospitals and medical centers nationwide between April 28 and June 19.
The lots being recalled are numbers 10722, 10729, 10718, 10357, 10365, 10641, 10672, 10753, 10755, 10944.
The FDA recall notice is online.
.Mycophenolate mofetil poses risk of progressive multifocal leukoencephalopathy
Mycophenolate mofetil (CellCept) may carry a heightened risk of progressive multifocal leukoencephalopathy (PML) for transplant recipients, the FDA said last week.
Postmarketing reports indicate 17 patients treated with CellCept developed PML; six of them died from the disease. The patients usually had risk factors for PML, including immune function impairment and treatment with immunosuppressant therapies.
The most common clinical features of PML were hemiparesis, apathy, confusion, cognitive deficiencies and ataxia. Doctors should consider PML as a cause if patients develop neurologic symptoms and possibly consult a neurologist, manufacturer Roche said in a letter to health care professionals.
Novartis, manufacturer of Myfortic, sent a similar letter to health professionals, because mycophenolate mofetil is metabolized to make the active ingredient of Myfortic (mycophenolic acid). Both companies are changing their prescribing information to reflect the risks, they said.
The FDA alert is online.
Copies of the letters sent to health care professionals by the manufacturers are online here![[PDF]](/i/pdf.gif){kind=small}
and here.
Wireless insulin pump, genetic test for cancer treatment approved
The FDA last week approved the first insulin pump that wirelessly communicates with a remote blood glucose meter, and a genetic test to determine if patients with breast cancer are good candidates for treatment with trastuzumab (Herceptin).
The SPOT-Light HER2 CISH genetic test counts the number of HER2 genes in a tumor sample. If there are more than two copies of the HER2 gene, they may overproduce HER2 protein and the breast cells will grow and divide too quickly. Trastuzumab helps retard growth by targeting HER2 protein production.
Separately, the newly approved OneTouch Ping Glucose Management System allows patients to calculate and deliver insulin doses without touching their pumps.
The press releases for the gene test and insulin pump are online.
From ACP Hospitalist
.Last chance to suggest a colleague as a Hospitalist 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. Recommendations received by July 18 are eligible to be included. Hospitalists of the Year will be profiled in our November 2008 issue.
From ACP Internist
.The latest issue is online and in your mailbox
The latest issue of ACP Internist is online and in your mailbox. Check out this month's issue for stories on:
- Internal Medicine 2008. A complete wrap-up of clinical and Leadership Day coverage from the College's annual meeting in Washington, D.C.
- Practice management. It's not too late to recoup bonus payments from Medicare for reporting quality measures. Practice Rx lays out simple steps to garner more reimbursement. Also, ways to recoup money for filling out patient's forms.
- Mindful Medicine. The case of a young woman mistakenly diagnosed with asthma illustrates the danger of confusing correlation and causation. Commentary by Jerome Groopman, FACP, and Pamela Hartzband, FACP.
The July/August issue of ACP Internist is online.
.What they're saying on the blog
Join ACP Internist's community on its blog, featuring daily updates on news that just can't wait. Find popular features such as entries on the effectiveness of food diaries, expert commentary on direct-to-consumer genetic tests, and the latest Medical News of the Obvious. Post your comments today.
Cartoon caption contest
.Put words in our mouth
ACP HospitalistWeekly wants readers to create captions for this cartoon and help choose the winner.
E-mail all entries to acphospitalist@acponline.org by July 25. ACP staff will choose three finalists and post them in the July 30 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the Aug. 6 issue.
Pen the winning caption and win a $50 gift certificate good for any ACP product, program or service.
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Test Yourself
A 52-year-old woman is evaluated for a 6-week history of generalized malaise and fatigue. She received a kidney transplant 15 years ago for hypertension-related renal failure. What type of infection is the most likely cause of this patient’s worsening kidney function?
ACP Career Connection
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Is Your Practice Ready For Meaningful Use?
ACP and AmericanEHR Partners are holding a free Webinar, “Meaningful Use and Its Implications For Your Practice,” featuring Dr. David Blumenthal, National Coordinator for Health Information Technology. Sign up now for this national Webinar on August 4 at 7p.m. ET
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The American College of Physicians introduces the essential book set for medical students. Get both titles for one low price!