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ACP HospitalistWeekly 10-6-10

Highlights

• ACGME approves final duty hour and supervision standards
• Pneumococcal urinary antigen test helps narrow CAP treatment

Health information technology

• "Hard stop" CPOE alert reduces undesired prescribing—at a cost

Infectious disease

• Dexamethasone as adjunct treatment helps pneumococcal meningitis patients

From ACP Internist

• The October issue is online

From the College

• New iPhone app available for Annals of Internal Medicine

Cartoon caption contest

• And the winner is…

Physician editor: A. Scott Keller, FACP

Highlights

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ACGME approves final duty hour and supervision standards

New duty hour rules received final approval, keeping work levels of 80 hours per week but also detailing supervision for first-year residents and capping their work to 16 hours a day.

The Accreditation Council for Graduate Medical Education (ACGME) approved last week the new rules, which take effect July 2011.

Other changes include:

• establishing graduated requirements for minimum time off between scheduled duty periods;
• expanding program and institutional requirements regarding handovers of patient care; and
• setting more specific requirements for alertness management and fatigue mitigation strategies designed to ensure both continuity of patient care and resident safety.

"These new standards are a cohesive whole," said Thomas Nasca, MACP, chief executive officer of ACGME and vice chair of the standards task force, in ACGME's press release. "Implementing them will require small changes in some programs and large changes in others, all with the goals of ensuring patient safety, that the next generations of physicians are well-trained to serve the public and that residents receive their training in a humanistic learning environment."

The standards are based on recommendations made by the Institute of Medicine in 2008, which were based on a scientific review of sleep issues, patient safety and resident training, as well as testimony from more than 100 experts on those topics and statements from 100 medical organizations.

A cost impact analysis will be posted on the ACGME website next week. A compliance review is under development. Under this program, ACGME will review every residency program for its ability to integrate residency education, supervision and fatigue management into its existing patient safety and quality improvement initiatives.

In related news, the Association of American Medical Colleges advocated that ACGME keep the sole oversight role of resident duty hours. In a letter to the Occupational Safety and Health Administration, the organization urged OSHA to reject a petition by public watchdog groups to the contrary.

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Pneumococcal urinary antigen test helps narrow CAP treatment

The pneumococcal urinary antigen test is an effective tool to guide the treatment of hospitalized adult patients with community-acquired pneumonia (CAP), a new study found.

The prospective study included 464 Spanish patients hospitalized with 474 cases of CAP from February 2007 through January 2008. Blood cultures were used in most cases to isolate the organism responsible for the infection. For some patients, pleural fluid was analyzed and for some, paired serum samples were tested for atypical microorganisms.

Pneumococcal urinary antigen assay was performed in 383 cases and the findings were positive in 136 (35.5%). In total, Streptococcus pneumoniae was found to be the causative pathogen in 171 of the 474 total cases. The pathogen was detected exclusively by the urinary antigen test in 75 cases (43.8%). Researchers calculated the specificity of the test to be 96%, while the positive predictive value ranged from 88.8% to 96.5% and the positive likelihood ratio ranged from 14.6 to 19.9.

Physicians were able to use the urinary antigen test result to reduce the spectrum of antibiotics for 41 patients, all of whom were cured of the pneumonia. The study authors theorized that this optimization of therapy could have been possible in all 75 patients whose pathogen was definitively identified. The authors also noted that this study, unlike many others, included patients with immunosuppressive conditions (making up about 20% of the study population), so the findings are applicable to those high-risk patients as well.

A positive result on a pneumococcal urinary antigen test allows clinicians to optimize antimicrobial therapy, the authors concluded. Therefore, they suggested that the test be incorporated into clinical guidelines as a supplement, although not a replacement, for classic microbiological studies. The study was published online by Archives of Internal Medicine on Sept. 27.

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Health information technology

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"Hard stop" CPOE alert reduces undesired prescribing—at a cost

An alert on computerized physician order entry (CPOE) systems that warned against ordering conflicting medications helped lower undesired prescribing, but had unintended negative consequences for several patients, a study found.

Researchers randomly assigned 1,981 clinicians to an intervention group that used a CPOE with an alert to reduce concomitant orders for warfarin and trimethoprim-sulfamethoxazole, or a "usual practice" control group. The "hard-stop" alert appeared as a pop-up window notifying a clinician the order couldn't be processed because of a significant potential drug-drug interaction. It was triggered whenever a clinician placed an order for trimethoprim-sulfamethoxazole with an already active warfarin order, when warfarin was ordered for a patient already taking trimethoprim-sulfamethoxazole, or when both were ordered at the same time. There were two ways to override the alert: Call a pharmacist, or enter an indication of Pneumocystis carinii pneumonia prophylaxis. The control group continued with the usual practice of a pharmacist calling prescribers to notify them of an interaction and recommend cessation of concurrent orders. The study, which comprised 1,872 resident doctors and 99 nurse practitioners, occurred at two academic medical centers in Philadelphia between August 2006 and February 2007. Results were published online Sept. 27 in Archives of Internal Medicine.

There were 194 unique alerts in the intervention group and 148 in the control group. Of the alerts in the intervention group, clinicians had the desired response (not reordering the drug) 57.2% of the time, compared to 13.5% of the time in the control group (adjusted odds ratio, 0.12; 95% CI, 0.045 to 0.33). In both cases, the undesired response most often involved ordering warfarin. The greatest proportion of desired responses was observed in the first three months of the intervention. The study was stopped a month early by the institutional review board because of four instances of unintended consequences in the intervention group—either a delay of treatment with trimethoprim-sulfamethoxazole or a delay in initiating warfarin when these drugs were in fact warranted. Electronic records review showed that no infections or thrombotic complications could have been related to these delays in therapy, however, the authors said.

The decreased effectiveness of the intervention over time may be due to the fact that the clinicians usually worked in teams, and may have worked alongside someone in a different study group (though researchers tried to prevent this), thus spreading awareness of the interaction alert, the authors said. Researchers didn't review the medical records or outcomes of all patients who went on to receive concurrent medications despite alerts, so they were unable to conclude whether the benefit of reducing the drug interaction may have outweighed the harm that led to the trial's early termination, they said.

Given that the U.S. will soon invest $50 billion in health information technology and CPOE is a key part of that, it's important to nail down the best use of CPOE, the authors and a commentator noted. For one, there needs to be more discrimination with alerts so that physicians don't get alert fatigue. "Clinicians tend to override alerts because they are perceived to be nonspecific and lack the clinicians' additional knowledge of the clinical situation for the specific patient context," the authors wrote. The strength of a CPOE alert should be related to the severity and importance of a drug-drug interaction, the commentator said, with hard stops used only when there are no exceptions.

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Infectious disease

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Dexamethasone as adjunct treatment helps pneumococcal meningitis patients

Dexamethasone as an adjunctive treatment for pneumococcal meningitis substantially improves the illness prognosis, a large Dutch study found.

Researchers studied 357 episodes of pneumococcal meningitis in 354 patients between 2006 and 2009. Of those, 84% were given 10 mg of dexamethasone intravenously every six hours for four days with or before their first dose of parenteral antibiotics. Results were compared to an earlier study of 352 people who were treated for bacterial meningitis in 1998-2002, before Dutch guidelines recommended using dexamethasone. In that study, only 3% of patients were given dexamethasone. In both studies, participants were assessed with the Glasgow Outcome Scale at discharge. A score of one was given for death, two for coma, three for severe disability, four for moderate disability and five for mild or no disability. Scores from one to four were considered "unfavorable," and a score of five was "favorable."

Characteristics on admission were comparable for both cohorts. Antimicrobial treatment consisted of penicillin or amoxicillin in 33% of episodes, third-generation cephalosporins in 28%, and a combination of penicillin or amoxicillin and third-generation cephalosporins in 34% of episodes. Another regimen was used in 5%. Adherence to antibiotic guidelines was similar between the two cohorts; guidelines haven't changed between 1998 and 2009. At discharge, an unfavorable outcome was present in 39% of patients in 2006-2009 and 50% in 1998-2002 (odds ratio [OR], 0.63; 95% CI, 0.46 to 0.86; P=0.002). Mortality rates (20% vs. 30%; P=0.001) and rates of hearing loss (12% vs. 22%; P=0.001) were lower in 2006-2009. Differences in outcome remained after adjusting for differences in case mix between cohorts via use of a multivariable prognostic model. Results were published online Sept. 29 in Neurology.

These data are valuable because the key analysis is based on comparing two national cohorts on an intent-to-treat basis (one from a period in which hardly any dexamethasone was used and one in which dexamethasone was generally prescribed). A bias due to prescribing dexamethasone to patients who are systematically in poorer or better condition does not apply when comparing two national cohorts as a whole, the authors noted. Also, the researchers applied an extensive adjustment for differences in case mix between the cohorts based on a large amount of data on prognostic factors in bacterial meningitis, they noted. And, there weren't any substantial improvements in other types of treatment for bacterial meningitis during this time period. The decline in case fatality from 30% to 20% between the two cohorts can't be attributed to a change in disease severity as researchers corrected for many prognostic factors, they noted; thus, the main difference was the use of adjunctive dexamethasone therapy, they said.

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From ACP Internist

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The October issue is online

The October issue of ACP Internist highlights continuous glucose monitoring, house calls and managing irritable bowel syndrome.

Monitoring glucose minute by minute. Continuous glucose monitoring presents challenges not only to patients, but to internists learning how best to teach their patients to use monitors.

House calls becoming a viable practice model. Think of it as the patient-centered medical home’s ultimate evolution—care inside the patient’s own home. More doctors are making house calls, either to see patients who don’t travel easily, or to improve the quality of care they can deliver in an office.

Expressive writing could help erase irritable bowel syndrome. Expressive writing, used for other illnesses with a known psychological component, is now being studied to control the symptoms of irritable bowel syndrome.

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From the College

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New iPhone app available for Annals of Internal Medicine

ACP has released a new iPhone application for its flagship journal, Annals of Internal Medicine. Available for free at the iPhone App Store, the Annals of IM application allows iPhone, iPod Touch, and iPad users to:

• view abstracts from the current issue,
• access published clinical guidelines,
• see listings of In the Clinic and ACP Journal Club articles,
• listen to podcasts and view videos and
• access the “Popular” feed to see which recent Annals articles are creating the most media buzz.

The new Annals of IM iPhone application is available online.

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Cartoon caption contest

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And the winner is …

ACP HospitalistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

"Welcome to New Age Podiatry Associates, where we treat the foot as if it were the whole person."

This issue's winning cartoon caption was submitted by Benjamin Galen, ACP Associate Member. Readers cast 104 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry captured 37.5% of the votes.

The runners-up were:
"Sorry, we don't admit de feet."
"Worst case of pedal edema I've ever seen."

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