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ACP HospitalistWeekly 9-30-09
Highlights
- Warfarin still underused at discharge for heart failure and atrial fibrillation
- 8.3 million adults seriously considered suicide last year
Team care
- Localization of physicians improves communication with nurses
Disaster planning
- Hospital's census reduction strategy offers disaster planning insight
FDA update
- Tamiflu dosing warning issued for mix-ups between milligrams and milliliters
From ACP Internist
- The next issue is online and coming to your mailbox
Cartoon caption contest
- Vote for your favorite entry
Physician editor: A. Scott Keller, FACP
Highlights
.Warfarin still underused at discharge for heart failure and atrial fibrillation
Warfarin continues to be widely underused at discharge for patients with heart failure and atrial fibrillation, and compliance with guidelines varies significantly among hospitals and geographic areas, a recent study concluded.
Researchers analyzed 72,534 heart failure (HF) admissions over three years at 255 hospitals participating in the American Heart Association’s Get with the Guidelines HF program. Among eligible HF patients with atrial fibrillation (AF) without contraindications, the median prevalence of warfarin therapy at discharge was 64.9%. Increasing age, nonwhite race, anemia and treatment in the South were associated with not receiving warfarin, as was CHADS-2 risk (congestive heart failure, hypertension, age >75 years, diabetes, and prior stroke or transient ischemic attack). The study appears in the Sept. 29 Journal of the American College of Cardiology.
Guidelines have recommended using warfarin to treat HF patients with AF since 2005, the authors noted. However, rates of warfarin use did not improve over the course of the study. Another concerning finding, they added, was the variation in warfarin use among hospitals, with warfarin less likely to be used at smaller hospitals and hospitals in the South.
Underuse of warfarin has significant clinical implications, the authors continued. They estimated the risk of stroke or transient ischemic attack in the study’s hospitalized cohort at 5.9% per year, based on a mean CHADS-2 score of 3. Failure to prescribe warfarin in the 5,475 HF admissions could have led to between 110 and 216 preventable thromboembolic events, they said. Generalized to the U.S. population of HF and AF, that would mean 7,000 preventable events per year.
An accompanying editorial noted that while registries are valuable tools for managing evidence-based care, they often do not consider “real life” issues, such as physical, social and mental vulnerabilities, that might influence a physician’s decision about warfarin use. For example, while the population of the registry was elderly, common geriatric problems such as cognitive impairment and fall risk were not recorded.
The current study’s findings, while not a substitute for evidence from a randomized trial, should lead to more research into the root causes of warfarin underuse in HF patients with AF, and to quality improvement interventions to address the problem, the editorial concluded.
.8.3 million adults seriously considered suicide last year
Nearly 8.3 million U.S. adults (3.7%) had serious thoughts of committing suicide in the past year, reported the Substance Abuse and Mental Health Services Administration, a division of the Department of Health and Human Services.
The report is based on 2008 data drawn from the National Survey on Drug Use and Health, which obtained responses from 46,190 persons aged 18 years or older. The study also shows that:
- 2.3 million adults made a suicide plan,
- 1.1 million adults attempted suicide, and
- adult women had marginally higher levels of suicidal thoughts and behaviors than males.
The chart breaks down suicidal ideation by age:
People experiencing substance abuse disorders within the past year were more than three times as likely to have seriously considered suicide (11% vs. 3% of non-substance abusers). Substance abusers were also four times more likely to have planned a suicide than those without substance abuse disorders (3.4% vs. 0.8%), and nearly seven times more likely to have attempted suicide (2% vs. 0.3%).
Of those adults who attempted suicide in the past year, 62.3% received medical attention for their attempts, and 46% stayed in a hospital overnight or longer for treatment.
Team care
.Localization of physicians improves communication with nurses
Assigning physicians to a specific unit within the hospital improved communication and understanding with nurses, but did not improve agreement on all aspects of the plan of care, according to a new study.
The study was conducted in an academic medical center that switched from having patients assigned to a physician service and then randomly admitted to a unit to a system in which physician teams were geographically localized to specific units in the hospital. Three units were designated for the teaching service, and four units were covered by hospitalists. Researchers interviewed about 300 nurses and 300 physicians before and after the change. The results were published by the Journal of General Internal Medicine on Sept. 19.
After the localization was put in place, physicians were significantly more likely to be able to identify the nurse who was treating a particular patient (58% vs. 36%, P<0.001). The same was true for nurses’ ability to correctly identify physicians (93% vs. 71%, P<0.001). Higher percentages of both groups also reported having communicated with each other, and more of these communications occurred face to face instead of over the phone.
The study also looked at agreement between nurses and physicians on patients' plans of care, and found improved cohesion on anticipated length of stay (48% in complete agreement after vs. 33% before) and planned tests (69% vs. 59%) but no significant improvement in other areas.
Researchers concluded that localization can improve several aspects of nurse-physician communication. However, they noted, proximity is not sufficient to create a shared understanding among team members on the plan of care, although proximity did allow the researchers to implement interventions such as interdisciplinary rounds. The researchers suggested that additional techniques, such as team training, be investigated as means to further improve communication among physicians and nurses.
The advantages and disadvantages of localization, or geographic rounding, were addressed in a February 2009 ACP Hospitalist article.
Disaster planning
.Hospital's census reduction strategy offers disaster planning insight
Cancelling elective surgeries and admissions and expediting discharges before a planned relocation helped one hospital decrease its census by 36% in one week, and its experience may be applicable to disaster planning, according to a new study.
During a planned move of operations at UCLA Medical Center to a new facility, researchers performed a prospective analysis of the hospital's activities to help identify ways to improve surge capacity in the event of a disaster. The researchers analyzed census data on the hospital's operations two weeks before the planned move, or baseline, and one week before the planned move, or the transition period. The study results appear in the September Archives of Surgery.
The medical center's census management strategy used the following three components:
- restricting the elective surgery schedule starting one week before the planned move,
- limiting incoming transfers, and
- delegating discharges to a multidisciplinary team to increase efficiency.
At baseline, the average daily census was 537 patients. The census was reduced by a rate of 18 patients per day during the transition period to 345 patients on the day of the move, a reduction of 36%. All services saw decreases, but reductions were larger for surgical than for nonsurgical services (46% vs. 30%; P=0.02). The ICU and medical/surgical wards both saw significant reductions in their censuses, although the latter reduction was greater (17% vs. 40%; P<0.001). Surgery volume decreased by 45% between the baseline and transition periods, entirely due to reductions in elective surgeries; rates of emergency surgeries did not change. Admissions decreased by 42%, while an 8% increase was seen in adjusted discharges per occupied bed. No effect on inpatient mortality was noted.
The authors concluded that the strategy used to decrease UCLA Medical Center's census before its planned move could also be used in planning for disasters with longer lead times, such as hurricanes or pandemics. They noted that it took three or four days to achieve a significant decrease in the census and a resulting availability of acute care beds. "This strategy might serve as a model both for large-scale disaster inpatient surge capacity planning as a component of hospital disaster preparedness and for day-to-day census management in individual hospitals," they wrote.
FDA update
.Tamiflu dosing warning issued for mix-ups between milligrams and milliliters
The FDA alerted prescribers and pharmacists about potential dosing errors with oseltamivir (Tamiflu) for oral suspension. U.S. health care providers usually write prescriptions for liquid medicines in milliliters or teaspoons, while Tamiflu is dosed in milligrams. The dosing dispenser packaged with Tamiflu has markings only in 30, 45 and 60 mg. The agency has received reports of errors where dosing instructions for the patient do not match the dosing dispenser.
Health care providers should write doses in milligrams if the dosing dispenser with the drug is in milligrams. Pharmacists should ensure that the units of measure on the prescription instructions match the dosing device provided with the drug. If prescription instructions specify administration using milliliters, the dosing device accompanying the product should be replaced with a measuring device (such as a syringe) calibrated in milliliters.
Additional information, including Tamiflu dosing for children over one year of age, is available online.
From ACP Internist
.The next issue is online and coming to your mailbox
The October issue of ACP Internist highlights the following stories:
Hospitals again look to integrate doctors. A new incarnation of hospital integration has sprung up, leaving some internists leery about signing on and others eager to set aside the increasingly onerous responsibilities of practice ownership.
Coordination key to post-stroke follow-up. Patients being treated by specialists for post-stroke care should keep primary care physicians at the center of their follow-up regimen.
Sorting out the worst offenders among herbal supplements. Internists need to monitor the ever-expanding range of herbs and supplements their patients might be taking, for their patients’ and their own benefit.
Readers respond: Town hall meetings on health care seen as failure. Readers responding to ACP Internist's survey on the summer's town hall meetings said they saw them as a failure in the effort to reform health care.
Cartoon caption contest
.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.
"Apparently, HIPAA now requires we keep personal health information from the patient as well."
"We always cover the ears of the patient whenever we need to ask the nurse how to do something."
"As you may have surmised, palpation of the ears of a patient who presented with topical epoxy exposure is ill-advised."
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 Oct. 5, with the winner announced in the Oct. 7 issue.
About ACP HospitalistWeekly
ACP HospitalistWeekly is a weekly newsletter produced by the staff of ACP Hospitalist. Please forward any comments or suggestions to acphospitalist@acponline.org.
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Copyright 2009 by the American College of Physicians.
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