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In the News

for the Week of 1-26-11

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Highlights

Intervention helps community hospital ICUs adopt evidence-based practices

A multi-pronged quality improvement program helped community hospitals adopt six evidence-based practices in the ICU, a new study reports. More...

Program sustains reduction in MRSA infections after surgery

An intervention to reduce methicillin-resistant Staphylococcus aureus wound infections after cardiothoracic surgery dramatically reduced the infections and sustained the result for at least 30 months, a study found. More...

Infectious disease

Pneumonia guideline adherence increased mortality

A performance-improvement initiative found that compliance with guidelines may actually have increased mortality from pneumonia among intensive care patients. More...

Pulmonary disease

Nonrespiratory causes of death becoming more common in oxygen-dependent COPD

Mortality rates are decreasing for respiratory disease and increasing for nonrespiratory causes in patients receiving long-term oxygen therapy for chronic obstructive pulmonary disease, according to a recent study. More...

FDA update

Prescription acetaminophen gets new limit, warnings

Prescription drugs that contain combinations of acetaminophen and other medications will be required to contain no more than 325 mg of acetaminophen per tablet or capsule, the FDA recently announced. More...

From ACP Hospitalist

The latest issue is online

The January issue of ACP Hospitalist is online. Included in this issue are stories on getting along with PCPs, early diagnosis of sepsis, and retooling the M&M conference. More...

Cartoon Caption Contest

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. More...

Physician editor: A. Scott Keller, FACP

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Highlights

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Intervention helps community hospital ICUs adopt evidence-based practices

A multi-pronged quality improvement program helped community hospitals adopt six evidence-based practices in the ICU, a new study reports.

The targeted care practices (with process-of-care indicators) were prevention of ventilator-associated pneumonia (indicators: semirecumbent positioning, orotracheal intubation); prophylaxis for deep vein thrombosis (indicators: anticoagulant administration, antiembolic stockings if anticoagulants were contraindicated); daily spontaneous breathing trials (indicators: spontaneous breathing trial or extubation within the last 24 hours); preventing catheter-related bloodstream infections (indicators: completing 7-point checklist for sterile insertion, fulfilling all 7 checklist criteria, anatomical site of catheter insertion); early enteral feeding (indicator: initiation of enteral feeding within 48 hours of ICU admission); and decubitus ulcer prevention (indicator: completion of the Braden index at least twice a day).

In the cluster-randomized trial of 15 community hospital intensive care units (ICUs) in Ontario, Canada, researchers examined 9,269 admissions over 12 months, and 7,141 admissions over a separate decay-monitoring period of nine months. To improve the six care practices, they used a videoconference-based forum with auditing and feedback, expert-led educational sessions, and disbursement of algorithms. ICUs were randomized into two groups. Each group received the intervention, which targeted a new practice every four months, and also acted as a control for another group in which a different practice was targeted in the same time period. The six practices were paired to minimize the potential for quality improvement efforts that targeted one practice to influence process measures related to the other practice.

Adoption of targeted practices was greater in intervention ICUs than in controls (summary ratio of odds ratios [ORs], 2.79; 95% CI, 1.00 to 7.74). In intervention ICUs, care delivery improved the most for semirecumbent positioning to prevent ventilator-associated pneumonia (90.0% of patient-days in last month vs. 50.0% in first month; OR, 6.35; 95% CI, 1.85 to 21.79) and precautions to prevent catheter-related bloodstream infection (70% of patients receiving central lines vs. 10.6%; OR, 30.06; 95% CI, 11.00 to 82.17). Adoption of other practices didn't change much, but several already had high baseline adherence. Results were published online Jan. 19 in the Journal of the American Medical Association.

The success of the intervention is noteworthy in that it occurred in community (not academic) ICUs, which admit the majority of critically ill patients, the authors noted. Further, the videoconferencing aspect of the intervention can help health care workers in geographically dispersed hospitals access resources that are usually restricted to academic facilities, they noted. Post hoc analyses indicate the intervention had the largest effect in ICUs with low baseline adherence to certain practices, suggesting similar initiatives should target these types of ICUs and practices, the authors wrote. Generally, large-scale quality improvement initiatives "should choose practices based on measured rather than reported care gaps, consider site-specific (vs. aggregated) needs assessments to determine target care practices, and conduct baseline audits to focus on poorly performing ICUs," the authors concluded.

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Program sustains reduction in MRSA infections after surgery

An intervention to reduce methicillin-resistant Staphylococcus aureus (MRSA)wound infections after cardiothoracic surgery dramatically reduced the infections and sustained the result for at least 30 months, a study found.

Researchers at a community-based medical-surgical hospital examined data from all patients who underwent cardiac surgery and required a median sternotomy incision from Jan. 1, 2004 through Jan. 31, 2010. They compared postoperative wound infection rates for the three years before the intervention and the three years after. The intervention included preoperative screening for MRSA colonization, administration of intravenous vancomycin for MRSA carriers, administration of intranasal mupirocin calcium ointment to all patients for five days starting the day before surgery, application of mupirocin to the chest tube sites of all patients at the time of removal, and—at the program outset—screening of cardiothoracic staff for nasal carriage of MRSA with decolonization if necessary.

Following the intervention, postoperative MRSA infections fell by 93% (32 infections per 2,767 cases during baseline vs. 2 infections per 2,496 cases during intervention; relative risk, 0.069; P<0.001). There was no change in the number of MRSA infections after noncardiac surgery during the intervention period. Overall wound infection rates fell from 2.1% to 0.8% (59 infections per 2,769 cases vs. 20 infections per 2,496 cases; P<0.001). The number needed to treat to prevent one postoperative MRSA wound infection was 93. Results were published in the Jan. 10 Archives of Internal Medicine.

Study limitations include the use of data from a historical control group rather than from a randomized, double-blind, placebo-controlled trial, and the fact that effects from vancomycin vs. mupirocin can't be distinguished since both were introduced at the same time. While it is possible that factors unrelated to the intervention may have affected the observed MRSA rates, hospital-wide rates of nosocomial MRSA surgical site infections didn't change during the intervention period, suggesting other effects weren't operative, the authors said. The intervention program "resulted in a near-complete and sustained elimination of MRSA wound infections after cardiac surgery," the authors concluded.

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Infectious disease

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Pneumonia guideline adherence increased mortality

A performance-improvement initiative found that compliance with guidelines may actually have increased mortality from pneumonia among intensive care patients.

Four academic medical centers in the U.S. instituted a program to improve clinicians' compliance with guidelines for management of hospital-acquired, ventilator-associated and health care-associated pneumonias that were issued in 2005 by the American Thoracic Society and the Infectious Diseases Society of America. The study included 303 ICU patients who had risk factors for multidrug-resistant (MDR) pneumonia, most of whom also required mechanical ventilation.

Researchers assessed mortality rates among these patients and compared them with compliance with the ATS/IDSA guidelines, which call for treating patients at risk for MDR with an antipseudomonal cephalosporin, carbapenem, or beta-lactam and beta-lactamase inhibitor; an aminoglycoside or antipseudomonal fluoroquinolone; and linezolid or vancomycin. The study found that 129 patients had received treatment in compliance with these criteria, but 174 had not. The most common deviation from the guidelines was failure to use a secondary anti-Gram-negative drug (154 patients), followed by failure to use a primary anti-Gram-negative drug (24 patients) and failure to use an anti-MRSA drug (24 patients).

Patients who received guideline-compliant therapy had a 28-day mortality rate of 34% compared to 20% in the non-compliant group. The difference persisted after adjustment for severity of illness, leading study authors to conclude that compliance with the guidelines was associated with increased mortality. They therefore recommended that the guidelines be reassessed, and that a comparison be conducted of single versus dual Gram-negative coverage. One potential explanation for the findings is antibiotic-specific toxic effects, the authors said.

A comment, published with the article in The Lancet Infectious Diseases on Jan. 20, agreed that toxicity was a possible cause, but the author also pointed out several concerns regarding the study. The study authors failed to comment on significant mortality differences among patients depending on which pathogen they had or to measure the timeliness of treatment. The commenter also critiqued the study authors' disregard of treatment de-escalation in classification of compliance. "De-escalation is what matters," the commenter wrote, although he also acknowledged that the current guidelines may be insensitive to local variations in pathogen prevalence and the need for variations for elderly and severely disabled patients.

ACP Hospitalist covered guidelines and treatment for health care-associated pneumonia in March 2010.

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Pulmonary disease

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Nonrespiratory causes of death becoming more common in oxygen-dependent COPD

Mortality rates are decreasing for respiratory disease and increasing for nonrespiratory causes in patients receiving long-term oxygen therapy for chronic obstructive pulmonary disease (COPD), according to a recent study.

Swedish researchers performed a prospective study of 7,628 patients with COPD (4,027 women, 3,601 men) who started long-term oxygen therapy between Jan. 1, 1987 and Dec. 31, 2004. Patients were followed until the end of the study, until oxygen therapy was stopped, or until death. The goal of the study was to determine whether there have been any time trends in overall and cause-specific mortality, especially as more older people and more women with severe COPD have begun receiving long-term oxygen therapy. The study's primary end point was cause of death according to the Swedish National Causes of Death Register. The study results were published online Jan. 7 by the American Journal of Respiratory and Critical Care Medicine.

Median follow-up was 1.7 years (range, 0 to 18 years). Overall, 5,457 patients (71.5%) died during the study, with a 1.6% (95% CI, 0.9% to 2.2%; P<0.001) annual increase in crude overall mortality rate. Seventy-one percent of deaths were due to respiratory causes, 16% were due to circulatory causes, 7.6% were due to cancer and 1.1% were due to digestive organ disease. The absolute risk for death increased by 2.8% annually (95% CI, 1.3% to 4.3%; P<0.001) for circulatory disease and by 7.8% (95% CI, 1.9% to 14.0%; P=0.009) for digestive organ disease but decreased by 2.7% annually (95% CI, 2.0% to 3.3%; P<0.001) for respiratory disease and by 3.4% (95% CI, 1.1% to 5.7%; P=0.004) for lung cancer.

The authors cautioned that their mortality estimates are based on death certificate data and that estimates of cause-specific mortality could have been affected by changes in such factors as diagnostics and coding. However, they concluded that both overall mortality rates and mortality rates due to nonrespiratory causes have increased over time in patients with oxygen-dependent COPD. "The present study supports the important prognostic role of co-morbidity in oxygen-dependent COPD and shows that mortality has increased for non-respiratory causes, such as cardiovascular disease," the authors wrote.

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FDA update

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Prescription acetaminophen gets new limit, warnings

Prescription drugs that contain combinations of acetaminophen and other medications will be required to contain no more than 325 mg of acetaminophen per tablet or capsule, the FDA recently announced.

The limit will be phased in over the next three years. In addition, a boxed warning on the potential for severe liver injury and a warning on the potential for allergic reactions (e.g., swelling of the face, mouth, and throat; difficulty breathing; itching; or rash) will be added to the labels of these drugs.

Acetaminophen is one of the most commonly used drugs in the United States, and between 1998 and 2003 it was the leading cause of acute liver failure in the country, with 48% of acetaminophen-related cases (131 of 275) associated with accidental overdose, the FDA announcement said. The new regulations are intended to reduce the risk of severe liver injury and allergic reactions associated with acetaminophen, as well as making it less likely that patients will overdose if they mistakenly take too many doses of acetaminophen-containing products.

Clinicians should educate patients about the importance of reading all prescription and over-the-counter (OTC) labels to ensure they are not taking multiple acetaminophen-containing products, the FDA advised. Patients should also be advised not to drink alcohol while taking acetaminophen and not to exceed the maximum total daily dose of 4 g/d. Dosing of combination medications will not need to change in response to the reformulations. For example, if a product that previously contained 500 mg of acetaminophen with an opioid and was prescribed as 1 to 2 tablets every 4 to 6 hours is reformulated to contain 325 mg of acetaminophen, the dosing instructions can remain unchanged, the FDA said.

OTC products containing acetaminophen are not affected by this action, and the FDA is continuing to evaluate ways to reduce the risk of acetaminophen-related liver injury from OTC products, according to the announcement.

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From ACP Hospitalist

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The latest issue is online

The January issue of ACP Hospitalist is online. Don't miss stories on:

Making nice with PCPs. Learn the strategies hospitalist practices use to maintain strong connections to their referring PCPs, and how this benefits both doctors and patients.

Improving sepsis diagnosis. Detect the subtle early symptoms and order tests appropriately.

Retooling the M&M conference. New meetings focus less on finger-pointing and more on uncovering systemic problems.

These features and more, including Test Yourself with the MKSAP Quiz: Sepsis, are now online.

Are you involved in hospital medicine? Then you should be getting ACP Hospitalist and ACP HospitalistWeekly. Click here to subscribe.

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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.

"This is not quite what I meant by androgen blockade."

This issue's winning cartoon caption was submitted by John Allan, ACP Associate Member. Readers cast 113 ballots online to choose the winning entry. Thanks to all who voted! The winning entry captured 59.3% of the votes.

The runners-up were:

"Given how you feel, Erik, maybe watchful waiting is a better way to go."

"I'll be gentler than the TSA agent."

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