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ACP HospitalistWeekly 11-4-09
Highlights
- Updated guidelines offer new guidance on perioperative beta-blockers
- New funding for projects on nosocomial infections
Critical care
- Rapid transfer to ICU improves outcomes for severe CAP
Cardiology
- ‘Get With the Guidelines’ participation improved age, sex disparities in CAD treatment
FDA update
Free toolkits
- AHRQ offers free tools for assessing health literacy
From ACP Internist
- The November/December issue is online
Cartoon caption contest
- And the winner is …
Physician editor: A. Scott Keller, FACP
Highlights
.Updated guidelines offer new guidance on perioperative beta-blockers
Updated guidelines on the use of perioperative beta-blockers recommend against routinely starting high-dose beta-blockers without dose titration in patients undergoing noncardiac surgery.
The update, issued by an American College of Cardiology Foundation/American Heart Association task force, notes new evidence from the PeriOperative Ischemic Evaluation (POISE) trial, which found that the cardioprotective effect of perioperative beta-blocker therapy was offset by an increased risk of stroke and total mortality. The update gives a class IIa recommendation for titrating beta-blockers to heart rate and blood pressure in patients undergoing vascular surgery who are at high cardiac risk due to coronary artery disease or cardiac ischemia found on preoperative testing.
Initiation of beta-blocker therapy in lower-risk patients calls for careful assessment of the risks and benefits, the authors state. They suggest initiating therapy well before a planned surgical procedure and implementing careful titration to achieve heart rate control while avoiding frank bradycardia or hypotension. Based on the POISE results, physicians should not routinely administer perioperative beta-blockers in high, fixed doses beginning on the day of surgery, they said.
The task force concluded that current evidence supports ongoing examination of indications for and contraindications to beta-blocker therapy throughout the postoperative period. The complete recommendations are published in the Nov. 24 Journal of the American College of Cardiology and the Nov. 24 Circulation.
.New funding for projects on nosocomial infections
A national project to reduce health care-associated infections (HAIs) will receive $17 million in additional funding, the Department of Health and Human Services announced last week.
The Keystone Project, an effort to reduce central-line bloodstream infections, will receive $8 million of the funds. The program involves a checklist of evidence-based safety practices; staff training and other tools for preventing infections that can be implemented in hospital units; standard and consistent measurement of infection rates; and tools to improve teamwork among doctors, nurses and hospital leaders. The project, which was started by Johns Hopkins University in Baltimore and the Michigan Health & Hospital Association, expanded to 10 states last year and now operates in all 50 states.
The new funding will expand the effort to more hospitals, extend it to other settings in addition to ICUs, and broaden the focus to address other types of infections, including catheter-associated urinary tract infections and bloodstream infections in hemodialysis patients.
The remaining $9 million will be applied to projects focusing on a number of HAI-related goals, including:
- reducing Clostridium difficile infections through a regional hospital collaborative,
- reducing the overuse of antibiotics by primary care clinicians treating patients in ambulatory and long-term care settings,
- evaluating two ways to eliminate MRSA in ICUs,
- improving the measurement of the risk of infections after surgery,
- identifying national-, regional- and state-level rates of HAIs that are acquired in the acute care setting,
- reducing infections caused by Klebsiella pneumoniae carbapenemase-producing organisms by applying recently developed recommendations from CDC’s Healthcare Infection Control Practices Advisory Committee.
- standardizing antibiotic use in long-term care settings (two projects), and
- implementing teamwork principles for front-line health care clinicians.
A complete list of institutions funded by the $17 million in resources is online.
Critical care
.Rapid transfer to ICU improves outcomes for severe CAP
Same-day admission to the intensive care unit was associated with better outcomes for patients with severe community-acquired pneumonia, even when patients did not have obvious indications for ICU transfer, a new study reported.
Researchers analyzed four studies including a total of 453 adult patients with community-acquired pneumonia (CAP) who were transferred to ICUs within three days of arriving at the emergency department. Delayed ICU transfer was associated with a higher risk of 28-day mortality and longer length of stay than direct transfer. The results were the same even after researchers excluded 150 patients with an obvious indication for immediate ICU admission. The study appears in the November 2009 Critical Care Medicine.
Guidelines from the Infectious Diseases Society of America/American Thoracic Society recommend direct transfer to the ICU from the ED for patients with at least one major criterion for severe CAP. However, the authors noted, the current findings suggest that the criteria should be expanded because a significant number of patients without major criteria are at risk for organ failure and adverse outcomes.
Better prediction models for severe sepsis are needed in order to identify CAP patients at highest risk for adverse outcomes, the authors said. The study results may help rationalize the decision to admit patients to the ICU, they continued, whereas currently the decision is an individual clinical judgment.
They noted that early ICU admission was associated with shorter length of stay for survivors, which may help alleviate the shortage of ICU beds. Early identification of ICU patients would also allow physicians more time to discuss treatment options with patients and families.
Cardiology
.‘Get With the Guidelines’ participation improved age, sex disparities in CAD treatment
Hospitals that participated in a national quality improvement program for heart disease have almost eliminated gender and age disparities in evidence-based treatment, although small differences remain, a new analysis found.
Researchers studied trends in treatment among 237,225 patients hospitalized with coronary artery disease (CAD) at hospitals participating in the American Heart Association/American College of Cardiology’s Get With the Guidelines-CAD program from 2002 to 2007. Adherence to six quality measures (aspirin on admission and discharge, beta-blockers at discharge, angiotensin-converting enzyme [ACE] inhibitor or angiotensin-receptor antagonist [ARB] use, lipid-lowering medication use, and tobacco cessation counseling) improved from 86.5% to 97.4% in men and from 84.8% to 96.2% in women over the study period. Adherence in elderly patients also increased, although the improvement was not as high in those at least 75 years old compared with patients younger than 75. The study was published online Oct. 27 in Circulation: Cardiovascular Quality and Outcomes.
While the study showed improvement overall, younger men still were more likely than younger women (less than age 75) to receive recommended lipid-lowering medications at discharge, the authors said. In addition, men were more likely than women to receive all of the evidence-based therapies.
Future research should examine the reasons for the remaining treatment differences and develop strategies to close the gaps, the authors said. In particular, hospitals should look at why age- and sex-based treatment gaps persist in lipid treatment and between younger and older patients getting ACE inhibitors or ARBs for left ventricular dysfunction and those receiving smoking cessation counseling.
FDA update
.Insulin syringe recall expanded
A nationwide recall has been issued for all Accusure insulin syringes, according to an FDA alert.
Certain lots of the syringes were recalled in August, but the recall has expanded to all syringes distributed between January 2002 and October 2009, regardless of lot number. The syringes may have needles that detach from the syringe. If the needle becomes detached during use, it can become stuck in the insulin vial, push back into the syringe, or remain in the skin after injection.
.IV antiviral authorized under H1N1 emergency
The FDA has issued emergency use authorization (EUA) for the investigational antiviral drug peramivir intravenous in certain adult and pediatric patients hospitalized with confirmed or suspected 2009 H1N1 influenza.
Patients should be given the drug only if they meet one or more of the following criteria: 1) They do not respond to either oral or inhaled antiviral therapy, 2) drug delivery by a route other than an IV route is not expected to be dependable or feasible, or 3) for adults only, the clinician judges IV therapy is appropriate due to other circumstances, according to an FDA release.
There are no FDA-approved intravenously administered antivirals for the treatment of influenza. EUA authority allows the FDA, based on the evaluation of available data, to authorize the use of unapproved or uncleared medical products in an emergency. Peramivir is the only intravenously administered influenza treatment currently authorized for use under EUA for 2009 H1N1 infections. As part of the conditions of the EUA, clinicians must report adverse events and all medication errors associated with peramivir to FDA's MedWatch program within seven days.
Free toolkits
.AHRQ offers free tools for assessing health literacy
The Agency for Healthcare Research and Quality has released a new free toolkit to help physicians assess their patients' health literacy.
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Item Set for Addressing Health Literacy measures how well health information is communicated by health care professionals. The item set, which is available in English and Spanish, allows physicians to:
- identify specific topic areas for quality improvement (communication about test results, medications, and forms);
- measure their health literacy practices;
- recognize behaviors that inhibit effective communication (e.g., talking too fast); and
- design an environment where patients feel comfortable discussing their health concerns.
The item set and other materials are available on the AHRQ Web site.
From ACP Internist
.The November/December issue is online
The next issue of ACP Internist is online. Check out the latest stories:
Experts debate pros, cons of vitamin D. A once-obscure nutrient is now being hailed as a link to prevention of diseases as disparate as diabetes, schizophrenia, cancer, strokes and heart attacks. Experts square off on how vitamin D relates to these illnesses, the proper amount that people should get, and how they can get it.
Work up the whole patient when treating IBS. With so many confounding factors to consider with irritable bowel syndrome, physicians can benefit their patients most with an important diagnostic tool—listening. Learn how to work up these patients from first steps to cognitive therapy options.
Uncertain diagnosis for pain leads doctor to dig further. A 66-year-old woman presents with abdominal pain radiating to her back, and CT scans show multiple lesions worrisome for metastatic disease. But when the pain resolves and the lesions don’t change, one internist reconsiders the diagnosis.
Cartoon caption contest
.And the winner is …
ACP HospitalistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.
This issue's winning cartoon caption was submitted by Howard C. Crisp, ACP Associate Member. He will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 168 ballots online to choose the winning entry. Thanks to all who voted!
"Livin' the dream—how about you?"
The winning entry captured 42.3% of the votes.
The runners up were:
"What forms do I need to fill out to get preauthorization on a second inbox?" (36.9%)
"That’s why I’m called an in-ternist." (20.8%)
About ACP HospitalistWeekly
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Copyright 2009 by the American College of Physicians.
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