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ACP HospitalistWeekly 5-12-10

Highlights

• Early follow-up reduces heart failure readmissions
• Bar codes may improve medication administration safety

Perioperative care

• Noncardiac surgery within six weeks of stent implantation raises complications risk

Critical care

• Non-conventional approach succeeds in extubating unweanable patients

Cardiology

• New drug-eluting stents outperform old ones except in diabetics

FDA update

• Infusion pumps to be recalled and destroyed

From ACP Hospitalist

• Suggest a colleague as a Top Hospitalist
• Follow KevinMD on the ACP Hospitalist blog

Cartoon caption contest

• Put words in our mouth

Physician editor: A. Scott Keller, FACP

Highlights

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Early follow-up reduces heart failure readmissions

Having a follow-up appointment with a physician within a week of being discharged from a hospital with a diagnosis of heart failure appears to reduce a patient’s risk of readmission, according to a comparison of hospitals.

The observational analysis used data from the OPTIMIZE-HF and Get with the Guidelines programs to compare how many of the hospitals’ heart failure patients saw a physician within a week of leaving the hospital.

The study population included more than 30,000 patients treated at 225 hospitals between 2003 and 2006. The hospitals were divided into quartiles based on follow-up rates; those results were then compared with rates of readmission within 30 days. To control for individual patient factors that might confound the association between follow-up and outcomes, the authors examined the association between hospital patterns of early follow up and patient-level outcomes. The results were published in the May 5 Journal of the American Medical Association.

Overall, more than 20% of the patients were readmitted within the month. Most patients also didn’t have a follow-up appointment within a week; the median percentage across the hospitals was only 38.3%. In the quartile of hospitals with the worst follow-up rates, the readmission rate was 23.3% in 30 days, compared to just under 21% in the other three quartiles.

The study also found that most patients had their follow-up appointment with a general internist; less than 10% saw a cardiologist within a week. The vast majority of patients (94%) did have an outpatient appointment scheduled while they were in the hospital, although information on the date for the follow up visit was not available.

The findings highlight the need for improved coordination of care between inpatient and outpatient settings, the study authors concluded. They noted that the narrowing of the scope of medical practice makes this coordination more difficult, but they suggested the models of care using nurse practitioners or physician assistants could improve access to timely follow-up care. The authors also said that early follow-up after discharge could be used in the future as a marker of quality in heart failure performance measure sets, but prospective studies should be performed to evaluate its effect on the risk of readmission.

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Bar codes may improve medication administration safety

Using an electronic medication administration system that incorporates bar code technology appears to help reduce medication errors, according to a new study.

Researchers at Brigham and Women's Hospital in Boston performed a before-after study at an academic medical center that was in the process of implementing a bar code-equipped medication administration system. Outcome measures were error rates for order transcription and medication administration on hospital units before and after the system was implemented. The authors classified errors involving early or late administration of medications as errors of timing; all other errors were classified as nontiming errors. Each error was reviewed by two clinicians, who determined whether the errors could have harmed patients. Those that could have were considered potential adverse drug events. Clinician disagreements were resolved by consensus. The study results are in the May 6 New England Journal of Medicine.

The study involved data from 14,041 administrations of medication and 3,082 order transcriptions. Most medication administrations were observed on a weekday from 7 a.m. to 3 p.m. Seven hundred seventy-six nontiming errors occurred on units that did not use the bar code-equipped system, while 495 occurred on units that did (error rates, 11.5% vs. 6.8%). This translated to a 41.4% relative reduction in medication errors with bar code technology (P<0.001). The rate of potential adverse drug events not associated with timing errors was 3.1% before the system was implemented and 1.6% afterward, a relative reduction of 50.8% (P<0.001). The rate of timing errors decreased by 27.3% (P<0.001), while the rate of potential adverse drug events associated with these errors did not see a significant change. Units that didn't use the bar code system had a transcription error rate of 6.1%, while those that did had a transcription error rate of 0%.

The authors acknowledged that their study involved only one hospital and looked only at potential, not actual, adverse drug events, among other limitations. However, they concluded that bar code technology within a medication administration system reduces errors and improves patient safety. Although they called for further studies to examine optimal implementation of such systems, their findings "provid[e] support for the inclusion of this technology as a 2013 criterion for achieving meaningful use under the American Recovery and Reinvestment Act," they wrote.

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Perioperative care

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Noncardiac surgery within six weeks of stent implantation raises complications risk

Patients who have noncardiac surgery within six weeks of receiving a coronary stent are more likely to die or have heart complications, a new study found.

In a country-wide, retrospective cohort study, researchers linked hospital admission data to the Scottish Coronary Revascularisation Register to examine cardiac outcomes in 1,953 patients who received stents between April 2003 and March 2007, and had subsequent non-cardiac surgery. Twenty-nine percent of the patients were treated with at least one drug-eluting stent, and 71% with bare metal stents only. Results were published online May 4 in Circulation: Cardiovascular Interventions.

For at least two years after implantation, there was no difference by stent type in occurrence of death, ischemic cardiac events or acute myocardial infarction (MI); there was also no temporal difference in outcomes between these groups. Perioperative death and ischemic cardiac events occurred more frequently when noncardiac surgery was performed within 42 days of stent implantation versus after 42 days (42.4% vs. 12.8%, P<0.001), particularly in patients revascularized after acute coronary syndrome compared with those who underwent stent implantation for stable coronary artery disease (65% vs. 32%, P=0.037).

Limitations of the study include that fewer patients in the drug-eluting stent group than the bare metal stent group underwent percutaneous coronary intervention after presenting with acute coronary syndrome. Also, national data on the use of perioperative antiplatelets and on bleeding complications weren't available for analysis, the authors noted. Possible reasons for the apparent excess risk with noncardiac surgery after stents include that physiological stressors (e.g., anemia) may lead to myocardial ischemia when fixed coronary obstruction is present; withdrawal of antiplatelet therapy may lead to an increase in atherothrombotic events; and the pro-inflammatory state of noncardiac surgery may contribute to developing vulnerable or inflamed plaques in the coronary vascular bed, the authors said.

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Critical care

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Non-conventional approach succeeds in extubating unweanable patients

Unweanable patients with neuromuscular disease (NMD) can be successfully extubated using a non-conventional approach, a new study found.

Researchers collected data on 157 consecutive patients who were unweanable—i.e., who couldn't pass spontaneous breathing trials or conventional ventilator weaning parameters. Before hospitalization, 61% of patients had no experience with noninvasive mechanical ventilation support (NIV), 26% used it less than 24 hours a day, and 13% were continuously NIV-dependent. As treatment, patients were extubated to full NIV and aggressive mechanically assisted coughing (MAC) once pulse oxyhemoglobin saturation (SpO₂) was maintained at >95% in ambient air. NIV and MAC were used to maintain or return SpO₂ to >95%. Extubation was considered successful if patients didn't require reintubation while hospitalized, and success was considered as a function of diagnosis, patient group, vital capacity, preintubation NIV experience, and assisted cough peak flow (CPF) at extubation.

On the first attempt at the protocol, 95% of patients were successfully extubated. On patients with assisted CPF >160 L/m, all 98 extubation attempts were successful. Dependence on continuous NIV and the duration of dependence before intubation correlated with extubation success (P<0.005). Six of eight patients who initially failed extubation succeeded on later attempts; the remaining two patients, who had no measurable assisted CPF, underwent tracheotomy. Results were published in the May issue of Chest.

Benefits of extubating unweanable patients included no mortality, fewer days intubated, no tracheostomies, and return home, the authors said. Avoiding tracheostomy can improve quality of life and diminish long-term pneumonia rates, they noted. The idea that early tracheotomy after intubation facilitates ventilator weaning should be reassessed for patients with NMD, the authors added. "Patients with measurable assisted cough flows should no longer be advised to refuse intubation for fear of extubation failure and tracheotomy," they wrote.

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Cardiology

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New drug-eluting stents outperform old ones except in diabetics

Second-generation drug-eluting stents that released everolimus lowered rates of stent thrombosis and restenosis compared to paclitaxel-eluting stents, a new trial found.

The trial randomized 3,687 patients to receive one or the other drug-eluting stents without routine follow-up angiography. Over the next year, rates of cardiac death, target-vessel myocardial infarction and ischemia-driven target-lesion revascularization (combined as target-lesion failure) were compared between the two groups. The study was published in the May 6 New England Journal of Medicine.

Everolimus-eluting stents performed significantly better than paclitaxel-eluting ones on the composite endpoint of target-lesion failure (4.2% vs. 6.8% of patients; relative risk, 0.62, 95% CI, 0.46 to 0.82; P=0.001). The newer stents also significantly reduced the risk of ischemia-driven target-lesion revascularization (P=0.001), myocardial infarction (1.9% vs. 3.1%, P=0.02) and stent thrombosis (0.17% vs. 0.85%, P=0.004). Study authors noted that the rate of stent thrombosis was among the lowest ever reported for a drug-eluting stent. The everolimus stents were non-inferior to the paclitaxel stents in the rate of cardiac death and target-vessel myocardial infarction.

There was no significant difference between the two stents in patients with diabetes, however, similar to what the recent COMPARE trial found. That finding suggests that the mechanism of restenosis and/or the response to antiproliferative agents may differ in diabetic patients, said an accompanying editorial. Therefore, the paclitaxel-eluting stent may be more appropriate for these patients, the editorialist concluded.

In patients without diabetes, more data about cost-effectiveness is needed to determine whether the higher cost of the everolimus-eluting stents (about $300 extra) is justified by the reduction in adverse events, the editorialist concluded. He also called for additional research on the stents’ effect on stent thrombosis and MI when prasugrel instead of clopidogrel is used as anti-platelet therapy.

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FDA update

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Infusion pumps to be recalled and destroyed

The FDA last week ordered Baxter Healthcare Corp. to recall and destroy all of its Colleague Volumetric Infusion Pumps.

In the past several years, the pumps have been associated with reports of adverse events and subjected to several class I recalls, according to an FDA press release. Changes to the pumps have not resolved the problems, and the FDA believes there may be as many as 200,000 of the pumps currently in use.

Therefore, the FDA has ordered Baxter to recall and destroy all Colleague infusion pumps, reimburse customers for the value of the recalled devices, and assist in finding a replacement for these customers. Hospitals and other users of the pumps will be receiving further instructions and information from Baxter and the FDA.

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From ACP Hospitalist

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Suggest a colleague as a Top Hospitalist

ACP Hospitalist is seeking candidates for our third annual Top Hospitalists issue. We're looking for hospitalists who made notable contributions to the field in 2010, whether through exceptional clinical skills, improved work flow, patient safety, cost savings, leadership, mentorship or quality improvement.

Do you know a colleague who might qualify? Fill out our form and tell us who and why. All recommendations must be received by July 16, 2010, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2010 issue.

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Follow KevinMD on the ACP Hospitalist blog

ACP Member Kevin Pho, MD, aka KevinMD, now posts on the ACP Hospitalist blog. Voted best medical blog in 2008, and with over 29,000 subscribers and 21,000 Twitter followers, KevinMD.com is the Web's definitive site for influential health commentary.

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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 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