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ACP HospitalistWeekly 8-26-09

Highlights

• Studies evaluate discharge summaries for test result documentation, satisfaction
• Study reports drop in Rx for respiratory infections, but use of quinolones on the rise

Palliative care

• Palliative care program improves mood but not symptoms

Critical care

• Early exercise training in the ICU could aid functional recovery

FDA update

• Hospira devices recalled

Cartoon caption contest

• Vote for your favorite entry

Physician editor: A. Scott Keller, FACP

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Highlights

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Studies assess discharge summaries for test result documentation, satisfaction

Hospital discharge summaries were found to be grossly inadequate in a recent analysis of pending test result documentation.

The retrospective study, published in the September Journal of General Internal Medicine, examined discharge summaries for 696 patients released from two academic medical centers. All of the patients had pending test results, but only 25% of their discharge summaries mentioned the tests and only 13% listed all pending results. In all, only 16% of the 2,927 pending test results were recorded in a discharge summary. The transmission of test results was also hampered by failure to include a follow-up clinician in the summary; only 67% of the discharge summaries made it possible to discern what clinician or clinic should receive the pending results.

The study authors concluded that discharge summaries have large deficiencies in their documentation of pending test results and they suggested some strategies for improvement, including using a checklist, enforcing documentation of pending tests, or having an electronic system automatically query all parts of the hospital's computer system to identify pending tests. The same strategies could improve documentation of follow-up physicians as well, the authors said.

Another study published in the same journal compared electronic and dictated hospital discharge summaries. The 209 studied summaries, generated by four medical teams of an academic general medicine service, were assessed for overall quality by primary care physicians, the level of satisfaction they provided for housestaff, patient understanding of discharge details, and adverse outcomes after discharge.

Housestaff found the electronic system to be easier to use than the phone dictation system (mean rating 86.5 vs. 49.2; P=0.03). They were also slightly more satisfied with the electronic process although it was more time-consuming, but both differences were statistically insignificant. There was no difference in primary care physician satisfaction, patient satisfaction or follow-up or patient outcomes within 30 days. The study authors concluded that electronic discharge systems have a similar level of quality to traditional methods and therefore, given the other benefits they provide, can play a key role in efforts to computerize patient care and enhance discharge.

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Study reports drop in Rx for respiratory infections, but use of quinolones on the rise

Antibiotic prescription rates for acute respiratory tract infection declined between 1995-2006 in the U.S., especially among young children and for non-otitis media infections, but rates for broad-spectrum antibiotics rose sharply during the same period, a study found.

Using data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, researchers examined trends in prescribing by antibiotic indication and class. Annual acute respiratory tract infection (ARTI) visit rates fell by 17% and ARTI-associated prescriptions decreased by 36% among children younger than five years, while among those five years or older, ARTI prescriptions dropped by 18% while ARTI-related visits remained stable. The decrease in antibiotic prescriptions in children younger than five was largely related to a decrease in otitis media visit rates.

In addition, researchers reported that antibiotic prescribing for non-otitis media ARTI decreased by 41% among young children and by 24% among those older than five. While prescriptions decreased for penicillin, cephalosporin and sulfonamide/tetracycline, ARTI-related prescriptions of azithromycin increased during the study period (ninefold among those five and under and sixfold among those older than five), and prescriptions for quinolones increased fivefold in those older than five. The results appear in the Aug. 19 Journal of the American Medical Association.

The findings point to improvements in antibiotic prescribing practices since the mid-1990s, when the CDC and other health organizations launched initiatives promoting appropriate use of antibiotics, the authors said. Declines in ARTI visit rates could be due to physicians applying stricter diagnostic criteria for ARTI, they speculated, and parents becoming more educated about how to identify and treat mild ear infections at home.

However, the substantial rise in prescriptions for selected macrolides and quinolones is concerning, the authors said. Increased use of these antibiotics has the potential to fuel emergent antibiotic-resistant microorganisms, especially Streptococcus pneumoniae, they said, suggesting that further efforts are needed to encourage appropriate antibiotic use.

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Palliative care

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Palliative care program improves mood but not symptoms

A palliative care intervention improved mood and quality of life for patients with advanced cancer, although it did not affect their symptoms or use of medical services in a recent trial.

Participating patients had been diagnosed with life-limiting cancer 8 to 12 weeks before they entered the study and given a prognosis of approximately one year. The 322 patients were randomized to either usual care or an intervention conducted by advanced practice nurses with palliative care training. The intervention included four initial educational and problem-solving sessions followed by telephone follow-up at least monthly. Patients were also invited to shared medical appointments led by a palliative care physician. The study was conducted in rural New Hampshire and Vermont.

All study participants completed questionnaires about their quality of life, symptom intensity and mood every three months until death or study completion. Overall, patients in the intervention group had higher quality of life scores (P=0.02) and less depressed mood (P=0.02) but an insignificant improvement in symptom intensity (P=0.06). Patients who died during the study had similar results to the overall group. There was no difference in the number of hospital days, ICU days or emergency department visits between groups.

Study authors noted that they could not meet their original target significance level of 0.01 since they did not achieve the planned enrollment of 400 patients. They also could not determine why mood and quality of life improved without any change in symptom intensity. Overall, patients in the study reported relatively low symptom intensity so it may have been difficult for the intervention to have much more effect on symptoms, the authors suggested. The intervention might also have had greater effect if it had been conducted in person rather than by phone, but that was not feasible in the rural study location.

Despite the study's limitations, the researchers did conclude that an early palliative care intervention for patients with advanced cancer can improve quality of life and mood, two high-priority patient-centered goals. The research was published in the Aug. 19 Journal of the American Medical Association.

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Critical care

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Early exercise training in the ICU could aid functional recovery

Early use of a bedside cycle ergometer may enhance recovery of functional exercise capacity in ICU patients, a new study reports.

Belgian researchers performed a randomized, controlled trial in 90 patients at a single center’s medical and surgical ICU to determine whether daily exercise on a bedside cycle ergometer would improve patients' functional recovery. Forty-five patients were assigned to the control group, which received respiratory physiotherapy and a daily session of standardized passive or active motion for upper and lower limbs, and 45 were assigned to the exercise group, which received the control therapy plus one 20-minute active or passive exercise training session daily on a bedside ergometer. Patients were included in the study as soon as their cardiorespiratory condition allowed them to participate in a cycling session. The researchers measured quadriceps force and functional status at both ICU and hospital discharge and six-minute walking distance at hospital discharge only. The study results appear in the September Critical Care Medicine.

Sixteen percent of patients in the control group and 24% of patients in the exercise group died while in the hospital (P=0.29). Only data from survivors were analyzed. At discharge from the ICU, the control and exercise groups did not differ in quadriceps force or functional status. However, at hospital discharge, the patients in the treatment group were found to have significantly better six-minute walking distance, isometric quadriceps force and functional well-being as measured by the physical functioning item of the Short-Form 36 Health Survey (P<0.05). No patients in the exercise group reported adverse outcomes associated with the ergometer sessions.

The study authors called their findings "promising" but acknowledged their study's limitations, including the fact that the exercise group received approximately 20 more minutes of exercise per day than did the control group. However, they concluded that their results indicate the feasibility of initiating "an individually tailored exercise protocol" in critically ill ICU patients and that such a protocol, when begun early in a prolonged stay, may improve functional outcome at hospital discharge.

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FDA update

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Hospira devices recalled

A number of devices used in hospitals are being recalled for defective AC power cords, according to a press release issued last week by manufacturer Hospira, Inc.

The prongs of the power cord on these devices may crack and fail at or inside the plug and reports have been received of sparking, charring and fires on the plug. The potential risks from power cord failure include electrical shock, delay in setup and therapy, interruption of therapy, device failure and fires.

Users with affected power cords that have bent or cracked prongs, burnt plastic or excessive wear and tear should discontinue use immediately and contact their Hospira sales representative or Hospira Technical Support Operations at 1-800-241-4002 for instructions on receiving replacement parts or devices. Users with affected power cords that are not exhibiting any of these characteristics should monitor the power cords regularly and be mindful of excessive wear and tear, misuse or abuse until all affected cords can be replaced.

A list of the recalled devices is online.

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Cartoon caption contest

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Vote for your favorite entry

ACP HospitalistWeekly's cartoon caption contest continues. ACP staff has selected three finalists for the latest contest and is now asking readers to vote for their favorite caption to determine the winner.

"Sir, I said follow my finger, not swallow my finger."
"This is a new treatment for excessive verbiage about health care reform."
"You'll still need to undress. I told you I wouldn't be able to feel your prostate from this end."

Go online to view the cartoon and pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through Aug. 31, with the winner announced in the Sept. 2 issue.

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