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ACP HospitalistWeekly 3-10-10

Highlights

• Current, validated med lists reduce errors on hospital admission
• Use of probiotics helps lower ventilator-associated pneumonia rates

Pulmonology

• Higher PEEP levels associated with improved survival, but only in ARDS

Anemia management

• Effects of large ESA and iron doses vary with hematocrit level

FDA update

• Glucose test strips recalled

Cartoon caption contest

• Put words in our mouth

Physician editor: A. Scott Keller, FACP

Highlights

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Current, validated med lists reduce errors on hospital admission

Presenting a physician-validated medication list upon hospital admission significantly protects against medication errors, a new study found.

Researchers at Northwestern Memorial Hospital in Chicago conducted a study for 14 months in 2006-2007. They retrieved the previous days' admissions and obtained from the electronic medical records the physician-obtained medical history, as well as admission medication orders and patient demographics for 651 adult inpatients with 5,701 prescriptions.

The pharmacists then interviewed the patients, checked their prescription bottles, and consulted with pharmacies to reconcile information and compare it with medication orders to identify unexplained history and order discrepancies. Those resulting in order changes were considered errors, and were classified by drug class, type of error and the potential to cause harm had it not been caught. Findings were published online Feb. 24 by the Journal of General Internal Medicine.

Among the group, 35.9% experienced 309 order errors and 85% had errors originate in medication histories, almost half of which were omissions. Cardiovascular agents were commonly in error (29.1%). If undetected, 52.4% of order errors could have potentially required increased monitoring or intervention to preclude harm and 11.7% were rated as potentially harmful. Factors significantly associated with errors that could require monitoring or cause harm included age 65 and older (odds ratio [OR], 2.17; 95% CI, 1.09 to 4.30) and number of prescription medications (OR, 1.21; 95% CI, 1.14-1.29). Presenting a medication list (OR, 0.35; 95% CI, 0.19-0.63) or prescription bottles (OR, 0.55; 95% CI, 0.27-1.10) at admission helped.

Researchers wrote that attempts to improve the accuracy of medication histories should focus on older patients with a large number of medications, and that primary care physicians should help patients and caregivers maintain complete, accurate and understandable medication lists.

Unexplained discrepancies occurred even though the researchers and the prescribing physician used the same medication lists or bottles. Researchers attributed this to physicians copying lists or prescription labels verbatim without systematically reviewing each medication. This step is important, they said, because labels on prescription bottles may not accurately reflect current regimens, newly prescribed medications or recent changes. A medication reconciliation toolkit is online.

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Use of probiotics helps lower ventilator-associated pneumonia rates

Administering probiotics to critically ill patients appears to help lower the incidence of ventilator-associated pneumonia (VAP), a meta-analysis found.

Researchers analyzed five randomized controlled trials that compared administration of probiotics with control (placebo or otherwise) in 689 adult patients undergoing mechanical ventilation, and that reported on VAP incidence. Probiotics were administered alone or with prebiotics. All five studies were published after 2005; the mean sample size of the studies was 159 subjects. The proportion undergoing mechanical ventilation who were trauma patients was 100% in two studies, 20% to 25% in two studies, and less than 10% in one study. The review was published in the March Critical Care Medicine.

Compared with control patients, probiotics patients had lower incidence of VAP (fixed effects model: odds ratio [OR], 0.61; 95% CI, 0.41 to 0.91; random effects model: OR, 0.55; 95% CI, 0.31 to 0.98) and shorter length of ICU stay (fixed effects model: weighted mean difference, −0.99 day; 95% CI, −1.37 to −0.61). Probiotics were also associated with lower colonization of the respiratory tract with Pseudomonas aeruginosa (OR, 0.35; 95% CI, 0.13 to 0.93). Probiotic administration had no effect on ICU mortality, in-hospital mortality, duration of mechanical ventilation and diarrhea. The benefit of probiotics in lowering VAP was retained in subgroup analyses.

The benefit of probiotics on VAP incidence seems to contradict the conclusions of previous reviews, which found no benefit on nosocomial infections, the authors noted. However, the current analysis incorporates studies published since those prior analyses, and focuses on the preventive effects of a different disease, they added. The fact that probiotics patients were less likely to be colonized with Pseudomonas aeruginosa, and that incidence of VAP attributable to this bacterium was found to be lower, may reflect a species-specific effect of probiotics against Pseudomonas, the authors said. However, another cause, such as concurrent antipseudomonal antibiotic therapy, could also explain this effect. Future research is warranted on the issue, they noted.

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Pulmonology

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Higher PEEP levels associated with improved survival, but only in ARDS

Higher levels of positive end-expiratory pressure are associated with improved survival in acute lung injury, but only in patients with acute respiratory distress syndrome, according to a new study.

Researchers performed a meta-analysis of three trials to determine whether higher or lower positive end-expiratory pressure (PEEP) affected outcomes in patients with acute lung injury or acute respiratory distress syndrome (ARDS) receiving low tidal volume ventilation. Patients with a PaO₂:FIO₂ of 200 mm Hg or less at baseline were considered to have ARDS. The study results appeared in the March 3 Journal of the American Medical Association.

Data from 2,299 patients were examined. Of these, 1,136 received higher PEEP and 1,163 received lower PEEP. Overall, 374 patients (32.9%) in the higher PEEP group and 409 (35.2%) in the lower PEEP group died (adjusted relative risk [RR], 0.94; 95% CI, 0.86 to 1.04; P=0.25). Among 1,892 patients with ARDS, 324 (34.1%) died in the higher PEEP group while 368 (39.1%) died in the lower PEEP group (adjusted RR, 0.90; 95% CI, 0.81 to 1.00; P=0.049). Among 404 patients without ARDS, 50 (27.2%) died in the higher PEEP group and 44 (19.4%) died in the lower PEEP group (adjusted RR, 1.37; 95% CI, 0.98 to 1.92; P=0.07). Patients receiving higher versus lower PEEP had similar rates of pneumothorax, vasopressor use, and days of breathing unassisted during the study’s first 28 days.

The authors acknowledged that their findings in patients with ARDS could have been caused by chance and that their study had low statistical power, among other limitations. However, their conclusion suggests that higher PEEP may be associated with improved outcomes in patients with ARDS. They stressed that clinicians should remember the possible harms of PEEP when treating patients without ARDS, and called for additional meta-analyses of individual-patient data to help determine more definitive guidelines for use.

An accompanying editorial said that the study would be helpful to researchers but less so to clinicians because it did not offer specific treatment recommendations, and that additional meta-analyses may not clarify the remaining clinical questions. “Patients may be better off with a single sufficiently powered and well-designed clinical trial that rigorously tests a specific approach,” the editorialist wrote.

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Anemia management

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Effects of large ESA and iron doses vary with hematocrit level

More aggressive treatment with erythropoiesis-stimulating agents (ESAs) and iron benefitted dialysis patients with lower hematocrit levels but increased mortality risks in the patients with high hematocrit, a new study found.

Researchers used data from the Medicare end-stage renal disease program to analyze the anemia management practices of U.S. dialysis centers. The main outcome was one-year all-cause mortality, and the study found the highest mortality rates in patients with hematocrit below 30% (2.1% monthly mortality) and the lowest (0.7%) in those with hematocrit of 36% or above. The study was published in the March 3 Journal of the American Medical Association.

Among the patients in the under 30% hematocrit group, the lowest mortality rates were seen in dialysis centers that used larger doses of ESAs. Similarly, more use of iron was associated with lower mortality in patients with hematocrit below 33%. However, for patients with hematocrit of 36% or higher, the centers that used ESAs and iron more intensively had higher mortality rates. For ESAs, the association between bigger doses and higher mortality extended to patients with hematocrit between 33% and 35.9%.

The cause of these findings is uncertain, the study authors said. It’s unlikely that greater mortality relates directly to higher doses of ESA and iron, since the largest doses were given to the patients with the lowest hematocrit levels. Previous trials have found higher mortality risk associated with targeting of higher hematocrit levels, the authors noted. They concluded that, whatever the cause, greater use of ESAs and iron in patients with higher hematocrit levels is problematic and further research should be conducted to identify optimal treatment algorithms.

The FDA recently required the development of a risk management program for ESAs, as reported in a recent issue of ACP HospitalistWeekly.

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FDA update

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Glucose test strips recalled

Eight lots of OneTouch SureStep Test Strips, used for home glucose monitoring, are being recalled by manufacturer LifeScan, the FDA announced last week.

The test strips are being recalled because they may provide falsely low glucose results when the glucose level is higher than 400 mg/dL. A list of affected lots is online. Lot numbers are located on the outer carton and test strip vial.

Approximately 14,000 packages (50- and 100-count) of OneTouch SureStep Test Strips were distributed nationwide between Aug. 1, 2009 and Jan. 28, 2010, the FDA reported. Patients with access to other testing materials should discontinue using the strips. If other options are not available, patients should contact a health care professional if a reading above 400 mg/dL appears, the FDA said.

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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 to acphospitalist@acponline.org. ACP staff will choose three finalists and post them online for an online vote by readers. The winner will appear in an upcoming 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