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ACP HospitalistWeekly 9-23-09

Highlights

• AHA urges changes to CDC's guidance on preventing H1N1 transmission
• More patients leaving hospital against medical advice

Infectious disease

• Guideline-compliant therapy produces better outcomes for hospitalized CAP patients, study concludes

Perioperative care

• Study identifies potential markers of adverse outcomes following liver transplant

Patient safety

• Tip location may affect thromboembolic risk in peripherally inserted central catheters

FDA update

• Approvals for H1N1 vaccines, ovarian cancer test

From ACP Hospitalist

• The next issue of ACP Hospitalist is online and in your mailbox

Cartoon caption contest

• Put words in our mouth

Physician editor: A. Scott Keller, FACP

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Highlights

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AHA urges changes to CDC's guidance on preventing H1N1 transmission

The American Hospital Association last week urged the CDC to update its guidance on infection control for H1N1 influenza in health care facilities.

The CDC's current guidance statement, which dates from May 13, calls for clinicians to use N-95 respirators or higher when providing routine care for patients with confirmed, suspected or probable H1N1 flu. To update this statement, the CDC has gathered input from its own Healthcare Infection Control Practices Committee, labor union stakeholders, and the Institute of Medicine. On July 23, the Healthcare Infection Control Practices Committee issued recommendations supporting standard and droplet precautions (such as use of masks, hand hygiene and face shields) for routine care of patients with suspected or confirmed H1N1 infection and recommended reserving N-95 respirators for "aerosol-generating" procedures. However, on Sept. 3, a committee from the Institute of Medicine concurred with the CDC's initial guidance, recommending fit-tested N-95 respirators for all health care workers in close contact with individuals with H1N1 flu or flu-like illnesses in all settings.

In a Sept. 15 letter to the CDC's National Institute for Occupational Safety and Health, the AHA expressed concern about the conflicting recommendations and noted that the IHI committee's charge "did not permit them to take into account logistical or economic considerations." The association warned that if the IHI's recommendations are finalized, hospitals will not have enough N-95 respirators to go around and "will be forced to limit the number of staff who are available to care for patients at a time when the volume of patients is expected to rise precipitously." Further, the AHA noted, the IHI committee recommended N-95 respirators in all health care settings, not just hospitals, making it less likely that primary care physicians will care for flu patients in their offices.

"We strongly recommend that [the Department of Health and Human Services] adopt a set of recommendations that takes into consideration the supply of N-95 respirators and the most recent epidemiologic data on how H1N1 infections transmit," the letter stated. "We support the use of hierarchy of controls, that surgical or procedure masks should be used for most patient contact and that N-95 respirators be recommended primarily for aerosol-generating procedures."

The CDC plans to issue a revised guidance document by Oct. 1.

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More patients leaving hospital against medical advice

The percentage of patients who left the hospital against medical advice increased significantly between 1997 and 2007, according to a new brief from the Agency for Healthcare Research and Quality.

In 2007, hospitalizations that ended in patients leaving against medical advice (AMA) accounted for 368,000 hospital stays (1.2% of the total) compared to only 264,000 discharges in 1997, a 39% increase. Certain characteristics also distinguished the AMA stays. Patients were more likely to be young (average age 46) and male. Overall women are slightly more likely to be hospitalized, but men left AMA 60% more often than women. Three of the five most common diagnoses for patients who left AMA were related to mental health and substance abuse. Nonspecific chest pain and diabetes with complications were the other two top diagnoses.

Patients were also more likely to leave if they had either Medicaid coverage or no insurance at all. On average, AMA stays were about half as long and half as expensive as other hospitalizations. There were also differences by geographic area. The Northeast had double the rate of AMA departures, while the West had the lowest rate. Patients living in large urban areas were nearly twice as likely to leave AMA compared with patients living in all other areas.

The statistical brief was based on data from the Healthcare Cost and Utilization Project 2007 Nationwide Inpatient Sample. Patients who leave the hospital AMA have higher readmission rates and may be at increased risk for adverse health outcomes, noted the AHRQ report. Greater understanding of the characteristics of these AMA stays may therefore assist in the design of strategies to prevent patients from leaving the hospital prematurely.

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Infectious disease

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Guideline-compliant therapy produces better outcomes for hospitalized CAP patients, study concludes

Two studies in the latest issue of Archives of Internal Medicine support treating hospitalized community-acquired pneumonia patients according to recommendations in current clinical practice guidelines.

In one study, researchers evaluated the association between in-hospital survival and guideline-concordant therapy in more than 54,000 non-intensive care unit inpatients with community-acquired pneumonia (CAP) at 113 community hospitals and tertiary care centers. After controlling for severity of illness and other patient characteristics, they found a significant decrease in in-hospital mortality (odds ratio, 0.70; 95% CI, 0.63 to 0.77) and a 0.6-day decrease in length of stay (LOS) in patients treated according to guidelines. Guideline-compliant treatment also was associated with fewer complications, such as sepsis and renal failure, and earlier switch to oral therapy.

Improved outcomes were linked to the use of fluoroquinolones or macrolides, which provide coverage for atypical organisms, the authors noted, and were associated with a Pneumonia Severity Index-adjusted reduction in mortality of 20% to 40% compared with treatment regimens that excluded these antibiotic classes. Until further data are available, the study supports the use of the Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) guidelines as the default treatment plan for non-ICU hospitalized adults with CAP, the authors concluded.

In a second study, researchers analyzed a database of 1,649 patients age 65 or older who were hospitalized with CAP at 43 centers in 12 countries. Of the patients treated according to guidelines, 71% reached clinical stability within seven days, compared with 57% in the nonadherent group. Adherence to guidelines also was associated with shorter LOS and decreased in-hospital mortality. The absolute risk reduction in mortality was 9.9% with a number needed to treat of 10.The authors theorized that the benefit of using fluoroquinolones or adding macrolides to beta-lactum CAP regimens may be related to targeted therapy for atypical pathogens, especially Legionella species.

An accompanying editorial noted that future studies of CAP should focus on rapid bedside testing to identify patients most likely to benefit from guideline-concordant therapy.

These two articles add to a growing body of evidence supporting guideline-compliant therapy for hospitalized patients with CAP, the editorial said. While further research is needed to confirm the results, the editorialist added, the evidence is compelling enough to support guideline-concordant antibiotic regimens as the default treatment for typical and atypical organisms. The editorialist added that hospitals should standardize treatment for all CAP patients based on current guidelines.

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Perioperative care

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Study identifies potential markers of adverse outcomes following liver transplant

History of stroke, coronary artery disease, postoperative sepsis and increased interventricular septal thickness were markers of adverse cardiac outcomes after liver transplantation in a retrospective study of older patients at intermediate cardiac risk.

Researchers retrospectively studied 403 patients (mean age 52+9 years, 67% male) who had liver transplants between 2001 and 2005 and analyzed outcomes of nonfatal myocardial infarction (MI), death and either outcome within the first 30 days after surgery. During this perioperative period, 7% of patients suffered MIs and 9% died. Using a multivariate model, researchers determined that history of coronary artery disease (CAD), prior stroke and postoperative sepsis predicted greater risk while the use of perioperative beta-blockers was protective for combined cardiac outcomes. The study was published online Sept. 14 in Circulation.

Although the study analyzed many cardiac risk factors, including diabetes, hypertension and age, only history of CAD and stroke significantly increased perioperative cardiac outcomes in the 30-day period, the authors said. Increased intraventricular septal thickness—likely a surrogate marker for left ventricular hypertrophy—also increased risk of death, they added.

The study also found that a normal stress test had a very high negative predictive value (>90%) in all transplant patients, the authors noted. However, an abnormal stress echocardiography was not associated with adverse cardiac outcomes, suggesting that only patients at low risk for negative cardiac outcomes would benefit from noninvasive stress testing.

Current guidelines recommend perioperative beta-blockers during noncardiac surgery in high-risk patients but not lower-risk patients, the authors noted. The protective effect of beta-blockers found in this study likely reflects its high-risk population, they noted, adding that the finding needs to be further evaluated in randomized trials.

The authors emphasized that the results provide insight into this specific population, and future prospective randomized trials are needed that analyze the role of stress testing, use of beta-blockers, and identification of variables associated with adverse cardiac outcomes before firm conclusions or recommendations can be made.

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Patient safety

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Tip location may affect thromboembolic risk in peripherally inserted central catheters

The location of the catheter tip during placement of a peripherally inserted central catheter may affect thromboembolic risk, according to a new study.

Researchers performed a retrospective chart review at a single hospital in Memphis, Tenn., to determine rates of venous thromboembolism (VTE) after placement of a peripherally inserted central catheter (PICC). The primary outcome measures were upper-extremity deep venous thrombosis, defined as a symptomatic event in the ipsilateral extremity subsequently confirmed by duplex ultrasonography, and pulmonary embolism, defined as a symptomatic event leading to ventilation-perfusion lung scan or spiral CT. The study results appear in the September Journal of Hospital Medicine.

Nine hundred fifty-four PICCs were inserted in 777 patients from Aug. 1 to Nov. 1, 2005. Thirty-eight patients (4.89%) developed one or more VTEs while in the hospital (total PICC-days, 7,444; 5.10 VTEs/1,000 PICC-days). Twenty-seven patients (3.47%) developed upper-extremity deep venous thrombosis, four (0.51%) developed superficial upper-extremity thrombosis and eight (1.03%) developed pulmonary embolism. The PICC was inserted in the superior vena cava (SVC) in 85.3% of patients; VTE risk was higher in those whose PICC was inserted at a different location from the SVC or SVC/right atrial junction (odds ratio, 2.61 [95% CI, 1.28 to 5.35]). Patients with a history of VTE were more likely to develop PICC-related VTE (odds ratio, 10.83 [95% CI, 4.89 to 23.95]), as were patients who had a longer length of stay (odds ratio, 1.21 [95% CI, 1.07 to 1.37]). Duration of PICC use also seemed to be associated with VTE risk, but the relationship was not statistically significant.

The authors acknowledged the limitations of their study, including an inability to determine independent risk factors and a possible underestimation of PICC-associated VTE rates. However, they concluded that approximately 5% of patients who receive PICCs while hospitalized will develop VTEs, especially those with a history of the condition, and that current use of large (5 French) double-lumen catheters may be more likely to cause thrombosis. They suggested that the location of the catheter tip at insertion "may be an important modifiable risk factor."

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FDA update

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Approvals for H1N1 vaccines, ovarian cancer test

The FDA recently approved four vaccines for 2009 H1N1 influenza and a test for ovarian cancer.

The vaccines are made by CSL Limited, MedImmune LLC, Novartis and sanofi pasteur Inc. They are expected to become available nationally within the next four weeks, according to an FDA release. In preliminary trials, the vaccines produced a robust immune response in healthy adults and potential side effects are expected to be similar to those from the seasonal flu vaccine.

The new test, called OVA1, was approved to help detect ovarian cancer in a pelvic mass that is already known to require surgery, an FDA release said. OVA1 uses a blood sample to test for levels of five proteins that change due to ovarian cancer. It combines the five separate results into a single numerical score between 0 and 10 to indicate the likelihood that the pelvic mass is benign or malignant.

The test should be used by primary care physicians or gynecologists as an adjunctive test to complement, not replace, other diagnostic and clinical procedures. It can identify women who will benefit from referral to a gynecological oncologist for their surgery, despite negative results from other clinical and radiographic tests for ovarian cancer, the FDA said.

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From ACP Hospitalist

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The next issue of ACP Hospitalist is online and in your mailbox

The next issue of ACP Hospitalist is online, featuring the following stories and more.

Increasing adherence to spontaneous awakening trials in the ICU. Although research shows spontaneous awakening trials are effective, many hospitals still don't do them.

Lost in transition. Medication discrepancies between hospitals and skilled nursing facilities are common. Learn why and what you can do about it.

Success story: Hospitalist Web site streamlines signouts, helps communication. At St. John’s Mercy Medical Center in St. Louis, Mo., a hospitalist-developed Web site makes it easy to identify and contact each patient’s attending physician.

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Cartoon caption contest

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Put words in our mouth

ACP HospitalistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

E-mail all entries by Sept. 24. ACP staff will choose three finalists and post them in the Sept. 30 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the Oct. 7 edition.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated