- Current Issue
- ACP Hospitalist Weekly
- Supplements
- Blog
- Archives
- Career Connection
- Subscribe
- RSS Feeds
HospitalistWeekly 10-15-08
Highlights
- Groups issue consensus guidelines on preventing hospital-acquired infections
- End-of-life talks lead to less aggressive care, higher quality of life
Critical care
- Movement instead of bed rest may improve prognosis after ICU stay
Vascular medicine
- Whole-leg and two-point ultrasound equal in DVT diagnosis
Tools and resources
- Online toolkit offers chronic care business model
From ACP Internist
- ACP Internist's Web site combines best of its features online
- On the blog: New government guidelines on physical activity
Cartoon caption contest
- Put words in our mouth
Highlights
.Groups issue consensus guidelines on preventing hospital-acquired infections
The Joint Commission and the American Hospital Association along with three major epidemiological organizations last week released evidence-based guidelines for preventing the most common types of healthcare associated infections (HAIs).
"The Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals" addresses two organism-specific HAIs: methicillin-resistant Staphylococcus aureus and clostridium difficile, and four device and procedure-oriented infections: central line-associated bloodstream infection, ventilator-associated pneumonia, catheter-associated urinary tract infection and surgical site infection, according to an Oct. 8 news release. For each type of HAI, the authors recommend several basic prevention strategies and list special procedures when basic steps fail to control an infection.
Most strategies outlined in the new guidelines are not new, but they represent the first professional consensus on a basic set of prevention strategies, the authors said. The compendium also includes proposed performance measurements for internal monitoring, in light of Medicare's recently adopted policy of withholding reimbursement for costs related to treating certain HAIs.
Other societies that helped develop the compendium included the society for Healthcare Epidemiology for American (SHEA), the Infectious Diseases Society of America (IDSA) and the Association for Professionals in Infection Control and Epidemiology. SHEA and IDSA will assume responsibility for updating the strategies as science evolves.
.End-of-life talks lead to less aggressive patient care, higher quality of life
Patients who had end-of-life discussions with physicians received less aggressive medical care and had higher quality-of-life scores in their final weeks of life, a new study found.
The prospective longitudinal cohort study involved 332 patients with advanced cancer, and their informal caregivers, at multiple sites from September 2002 through February 2008. Patients were followed from enrollment until death, with outcomes being aggressive medical care (like resuscitation and ventilation), hospice in the final week of life and mental health. Caregivers were also assessed about six months after death for mental illness and quality of life. The study was published in the Oct. 8 Journal of the American Medical Association.
About 37% of patients reported having end-of-life discussions, which were associated with lower rates of ventilation (adjusted OR, 0.26; 95% CI 0.08-0.83), resuscitation (OR, 0.16; CI 0.03-0.80), ICU admission (OR, 0.35, CI 0.14-0.90) and earlier hospice enrollment (OR, 1.65, CI 1.04-2.63). Adjusted analyses showed more aggressive medical care was associated with lower patient quality-of-life scores (6.4 vs. 4.6, P =0.1) and higher risk of major depressive order for caregivers (OR, 3.37, CI 1.12-10.13). Better patient quality of life was associated with better caregiver quality of life at follow-up, as well.
End-of-life discussions between patients and physicians may make patients more realistic about the benefits of aggressive therapies, thus reducing the chances that they will opt for such therapies, the authors said. More than 60% of patients didn't recall having end-of-life conversations, especially if they were at major academic centers, so there is an apparent need to step up these discussions, the authors concluded.
Critical care
.Movement instead of bed rest may improve prognosis after ICU stay
Getting ICU patients out of bed and moving soon after admission leads to shorter hospital stays and may reduce long-term complications, according to a recent review.
Deep sedation and bed rest have recently become common practice for patients on mechanical ventilators. However, there is evidence to suggest that bed rest might be contributing to prolonged neuromuscular complications experienced by many patients following an ICU stay. To examine that question, researchers at Johns Hopkins University looked at 24 studies focusing on ICU patients with sepsis, multiorgan failure or prolonged mechanical ventilation and found that the mean duration of mechanical ventilation after awakening was longer in patients with vs. without weakness (18 vs. 8 days; P =0.03).
The review found that some ICUs introduced aspects of physical medicine and rehabilitation within days of admission and that early rehabilitation therapy appeared to help patients regain their ability to ambulate and conduct activities of daily living. One study included in the review suggested that some activity, such as sitting, is feasible and safe in mechanically ventilated patients with an endotracheal tube. Minimizing sedation and focusing on recovery and rehabilitation issues were key success factors for early mobilization, the review found. However, the authors noted that early rehabilitation in the acute ICU setting is relatively new and that large, randomized trials are needed to evaluate the safety and benefits of these strategies.
The author noted that Johns Hopkins has instituted a new model of care within its medical ICU that includes stopping bed rest as a default order with admission; establishing reduced sedation and bed rest guidelines for consultation with physical and occupational therapists as well as physical medicine, rehabilitation and neurology; and adding multidisciplinary training and education regarding reductions in heavy sedation and improved attempts at rehabilitation for ICU patients.
Vascular medicine
.Whole-leg and two-point ultrasound equal in DVT diagnosis
Diagnosis of deep vein thrombosis (DVT) is as effective via two-point ultrasound as it is with whole-leg ultrasound, according to a prospective study.
In the study, researchers randomized 2,098 patients to either two-point (n=1,045) or whole-leg (n=1,053) ultrasonography. Symptomatic venous thromboembolism occurred in 7 of 801 patients (incidence, 0.9%; 95% confidence interval [CI], 0.3%-1.8%) in the two-point group and in 9 of 763 patients (incidence, 1.2%; 95% CI, 0.5%-2.2%) in the whole-leg group. The three-month incidence of objectively confirmed VTE in patients with an initial normal diagnostic ultrasound was similar in the two groups. The findings appear in the Oct. 8 Journal of the American Medical Association.
Researchers said two observations were particularly noteworthy. First, detecting isolated calf DVT may not be as relevant as previously thought, since the long-term outcomes of the groups were similar even though isolated calf DVT was initially more prevalent in the whole-leg group. Secondly, proximal DVT always involved the common femoral vein, the popliteal vein, or both, suggesting that the superficial and deep femoral veins are usually not worth investigating.
The authors concluded that either strategy can be appropriate depending on the circumstances. Two-point ultrasound is simple, convenient and widely available but requires repeat testing in one-quarter of patients. Whole-leg ultrasound provides results in one day but may be more expensive and may expose patients to the risk of anticoagulation because the procedure often is not available after hours or on weekends.
An editorial said the results of the trial show that whole-leg ultrasonography has little advantage, unless anticoagulant therapy for isolated calf DVT is preferable to repeating two-point ultrasonography a week later.
Tools and resources
.Online toolkit offers chronic care business model
A free, online toolkit to help safety-net hospitals improve their care of chronically ill patients as well as their financial returns is now available online from the Agency for Healthcare Research and Quality.
The toolkit Integrating Chronic Care and Business Strategies in the Safety Net, is designed to improve patient satisfaction and loyalty; increase staff satisfaction and retention; streamline workflow; enhance efficiency; position practices to capture pay-for performance and quality improvement bonuses; and improve financial return. The kit also includes flow charts, worksheets, slides, fact sheets, and other forms developed by AHRQ, the Institute for Healthcare Improvement, the California Healthcare Foundation, the American Medical Association, and others.
From ACP Internist
.ACP Internist's Web site combines best of its features online
ACP Internist has relaunched its Web site as a landing area for all of the exciting content offered in our print and electronic editions, including ACP InternistWeekly, the blog, and polls and surveys (including our cartoon caption contest). Look over the site and use the quick contact links to tell us your opinions.
In our October issue, online and in your mailbox:
Two-pronged approach to attack prediabetes. Until recently, internists had very little guidance on how to treat prediabetes and reduce the risk of the full-blown disease. The most recent advice: Treat it early, with simple lifestyle changes.
Alaska primary care crisis the tip of the iceberg. When primary care doctors are already stretched, losing even one internist can leave a community in crisis.
Ethical Dilemmas. Harvard ethicist Lachlan Forrow, FACP, reviews how a sexual relationship with a former patient, however brief the doctor’s visit, raises issues after a romantic break-up.
On the blog: New government guidelines on physical activity
The government released what is meant to be the definitive word on how much exercise adults and kids need to stay healthy. Read more on the blog, plus check out this week's installment of Medical News of the Obvious.
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 us by Oct. 17. ACP staff will choose three finalists and post them in the Oct. 21 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the Oct. 28 issue.
Pen the winning caption and $50 gift certificate good for any ACP program, product or service.
Subscribe online
Are you involved in hospital medicine? Then you should be getting ACP Hospitalist and ACP HospitalistWeekly. Subscribe now.
Test Yourself
This week's quiz asks readers to evaluate a 60-year-old woman with a 12-week history of pruritic hives.
ACP Career Connection
Looking for a new hospitalist position?
ACP Career Connection can help you find your next job in hospital medicine. Search hospitalist positions nationwide that suit your criteria and preferences. Jobs are posted about two weeks before print publication of Annals of Internal Medicine, ACP Internist, and ACP Hospitalist. Exclusive “Online Direct” opportunities are updated weekly. Check us out online.
ABIM Maintenance of Certification for Hospitalists
Hospital-based internists have the option of maintaining their certification in either Internal Medicine or Internal Medicine with a Focused Practice in Hospital Medicine. Learn more about resources from ACP and the Society for Hospital Medicine to complete both MOC programs.
Internal Medicine 2012
Earn Hospitalist CME credits at Internal Medicine 2012. The hospital medicine track and several pre-courses offer a collection of CME courses designed for hospitalists. Register early and reserve your spot today.
Prepare with the Experts: Live Recert Prep Courses from ACP
Upcoming dates and locations include:
|
ACP Launches Depression Care Guide
This evidence-based, free online resource provides concise, practical information and strategies to enable health professionals to reduce the treatment gaps that exist for depression care.
Access the Guide now.