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In the News

for the Week of 2-9-11

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Highlights

Interval between aspirin use and CABG affects transfusions, not mortality

Stopping aspirin less than six days before coronary artery bypass grafting (CABG) did not change patients' mortality risk, but it did increase the need for transfusions, according to a new retrospective study. More...

Keystone ICU project associated with lower hospital mortality in Michigan vs. region

The Michigan Keystone ICU project, a statewide quality improvement initiative, was associated with lower hospital mortality compared to surrounding Midwestern states, a study found. More...

Sepsis

Response team and feedback reduce sepsis deaths in ICU

Activating a sepsis response team and using weekly feedback reduced mortality for ICU patients with severe sepsis or septic shock, a study found. More...

Stroke

Prognostic scores don't reliably predict early recurrence after minor stroke

Leading prognostic scores don't reliably predict risk for early recurrence after a minor stroke, a new study has indicated. More...

Cartoon Caption Contest

Put words in our mouth

ACP HospitalistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...

Physician editor: A. Scott Keller, FACP

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Highlights

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Interval between aspirin use and CABG affects transfusions, not mortality

Stopping aspirin less than six days before coronary artery bypass grafting (CABG) did not change patients' mortality risk, but it did increase the need for transfusions, according to a new retrospective study.

For the study, researchers at the Cleveland Clinic categorized more than 4,000 patients who were on aspirin and underwent CABG by how close to surgery they took aspirin. About 2,300 patients discontinued aspirin use six or more days before surgery (early discontinuation) and 1,845 were taking aspirin within five days of surgery (late use). Due to substantial differences between the two groups, the study authors used propensity matching to obtain 1,579 matched pairs of patients. The results showed no difference in in-hospital mortality, myocardial infarction and stroke between the early discontinuation and late use groups (1.7% vs. 1.8%, P=0.80). The study was published online by Circulation on Jan. 31.

The late use group did have more intraoperative transfusions (23% vs. 20%, P=0.03) and postoperative transfusions (30% vs. 26%, P=0.009) than the early discontinuation patients. Patients in the late group also had a trend toward more reoperations, but the difference was not statistically significant (3.4% vs. 2.4%, P=0.10). Some experts would consider the difference in transfusions to be an argument for early discontinuation, the study authors noted, but they concluded that physicians should weigh the risks and benefits for individual patients.

In high-risk patients, the study authors recommended late use of aspirin to reduce the risk of preoperative cardiovascular events. They pointed out that patients who did not undergo planned surgery due to a preoperative illness were not included in the analysis, so any preoperative MIs or strokes resulting from early discontinuation would not have been measured in the analysis.

Current practice and guidelines on aspirin use before CABG vary widely, according to the authors of the study and an accompanying editorial. The American College of Cardiology and American Heart Association call for discontinuation 7 to 10 days before, the Society of Thoracic Surgeons recommends stopping 5 days before elective CABG, and the American Society of Chest Physicians suggests continuing aspirin up to and beyond CABG. The variation is indicative of the lack of definitive evidence on this issue, and the need for a randomized controlled trial to provide such data, the researchers concluded. The authors and the editorialist note that the ongoing Aspirin and Tranxemic Acid for Coronary Artery Surgery (ATACAS) study should yield data on the use of antiplatelet and antifibrinolytic therapy given immediately before surgery.

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Keystone ICU project associated with lower hospital mortality in Michigan vs. region

The Michigan Keystone ICU project, a statewide quality improvement initiative, was associated with lower hospital mortality compared to surrounding Midwestern states, a study found.

Previous research has shown that the Michigan Keystone ICU project reduced catheter-related bloodstream infection rates and ventilator-associated pneumonia in the ICU through its promotion of evidence-based practices, improved communication and a culture of safety. This retrospective study used Medicare claims data to evaluate whether the initiative was associated with fewer deaths and lower length of stay for older adults in ICUs in Michigan compared to other Midwestern states. The study period spanned October 2001 to December 2006, representing a start date two years before the project was initiated to 22 months after its implementation. It included hospital admissions for patients age 65 years and older in 95 Michigan hospitals (238,937 total admissions) compared with 364 hospitals in the surrounding Midwest region (1,091,547 admissions).

The trajectory of mortality differed significantly between the study and comparison groups once the initiative was implemented (Wald test X2=8.73, P =0.033). Mortality reductions were greater for the study group than the comparison group at 1 to 12 months after project implementation (odds ratio [OR], 0.83, 95% CI, 0.79 to 0.87 vs. OR, 0.88, 95% CI, 0.85 to 0.90; P =0.041) and 13 to 22 months after implementation (OR, 0.76, 95% CI, 0.72 to 0.81 vs. OR, 0.84, 95% CI, 0.81 to 0.86; P =0.007). Length of stay did not differ significantly between the groups during or after implementation. Results were published online Jan. 31 by BMJ.

The study results may be conservative, since all Michigan hospitals were included in the study group although only 77% actually participated and contributed data to the Keystone ICU project, the authors noted. Improvement in mortality increased over the two post-implementation periods, suggesting the full benefit of the program took time to be realized, and/or that other quality initiatives at Michigan hospitals during this time may have boosted the effect, they wrote. Overall, the findings suggest that large-scale, robust and successful quality improvement initiatives can reduce adverse events, improve quality of care, and save lives, they concluded.

ACP Hospitalist ran an article in May 2010 about how the Michigan Keystone ICU project helped reduce catheter-associated urinary tract infections.

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Sepsis

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Response team and feedback reduce sepsis deaths in ICU

Activating a sepsis response team and using weekly feedback reduced mortality for ICU patients with severe sepsis or septic shock, a study found.

In a 33-month prospective, interventional cohort study at a medical ICU, researchers performed daily screening of patients for severe sepsis or septic shock. Study periods were divided into baseline (screening only), daily auditing with weekly feedback, and sepsis response team activation, with comparisons made among the three periods. The baseline period, from Jan. 1, 2007 to Dec. 28, 2007, involved an educational program for nurses and housestaff on recognizing sepsis, and training on a protocol and order set, among other things. From Dec. 29, 2007 to Sept. 26, 2008, clinicians initiated daily auditing of all septic shock/severe sepsis patients in the ICU, in addition to baseline activities. ED and medical ICU clinicians received weekly feedback on compliance with the sepsis resuscitation bundle, and were encouraged to discuss issues with a quality improvement team that met monthly.

From Sept. 27, 2008 to Sept. 30, 2009, a multidisciplinary sepsis response team (SRT) was active. The SRT call was activated 24/7 through an electronic paging system that notified the team when a patient met sepsis criteria. The team included doctors, nurses, respiratory therapists and several other medical staff. Auditing and feedback continued during the SRT period. Outcome measures included compliance with the overall sepsis resuscitation bundle and its individual elements, and hospital mortality. Results were published in February's Critical Care Medicine.

There were 984 episodes of severe sepsis (5.3%, n=52) and septic shock (94.7%, n=932) used during the study periods. Compliance with the overall sepsis bundle increased from 12.7% at baseline to 37.7% during the weekly feedback period and 53.7% during the SRT activation period (P<0.001). Mortality was 30.3%, 28.3% and 22% during baseline, feedback and SRT periods, respectively (P=0.029). On multiple logistic regression analysis, the SRT was associated with reduced risk of mortality (odds ratio, 0.657; 95% CI, 0.456 to 0.945; P=0.023). The following conditions were associated with increased risk of death: hepatic cirrhosis, hepatic failure, leukemia, multiple myeloma, transfer from the same hospital ward, do-not-resuscitate status at recognition of severe sepsis/septic shock, and lactate level.

While some have suggested that the sepsis resuscitation bundle and early goal-directed therapy may not benefit patients in facilities with low baseline mortality, the current study suggests otherwise, the authors noted. The results demonstrate that weekly feedback and SRT activation are complimentary in improving process of care and outcomes for severe sepsis/septic shock patients, they wrote. Study limitations include generalizability, as it was conducted in a single ICU. Also, researchers may have excluded some patients with severe sepsis due to their inclusion of only patients with hypotension despite fluid resuscitation or elevated lactate levels. Use of before-after comparisons also may have ignored undocumented differences among the study groups and in the patient mix, they noted.

ACP Hospitalist ran an article about early diagnosis of sepsis in its January 2011 issue.

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Stroke

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Prognostic scores don't reliably predict early recurrence after minor stroke

Leading prognostic scores don't reliably predict risk for early recurrence after a minor stroke, a new study has indicated.

Researchers used data from the Oxford Vascular Study, a prospective, population-based study of all incident and recurrent strokes in Oxfordshire, United Kingdom, to examine the prognostic value of three stroke scores for early recurrence after minor stroke: the ABCD² score, the Essen Stroke Risk Score (ESRS) and the Stroke Prognosis Instrument II (SPI-II). Strokes were considered minor if they scored 5 or lower on the National Institutes of Health Stroke Scale. The study was published online Jan. 27 by Stroke.

A total of 1,247 first events occurred from April 1, 2002 to March 31, 2007. Of these, 488 were transient ischemic attacks, 520 were minor strokes and 239 were major strokes. Patients were a mean age of 73 years (range, 24 to 98 years) when the first event occurred. One hundred forty-two recurrent strokes occurred within 90 days of the first event, 81 within 7 days and 111 within 30 days. Only the ABCD² score was predictive of recurrence 7 and 90 days after minor stroke, but its predictive value was modest (area under the receiver operator curve, 0.64, 95% CI, 0.53 to 0.74, P=0.03 and 0.62, 95% CI, 0.54 to 0.70, P=0.004, respectively). The Essen Stroke Risk Score and the Stroke Prognosis Instrument II did not predict 7-day or 90-day risk. The authors examined the risk factors included in the ABCD² score and found that only two, blood pressure above 140/90 mm Hg and large artery disease, predicted 90-day recurrence risk (hazard ratio, 2.75, 95% CI, 1.18 to 6.38, P=0.02 and 2.21, 95% CI, 1.00 to 4.88, P=0.05, respectively).

The authors noted that their estimates of stroke risk may have been imprecise because some patients with minor stroke don't seek medical care, and that relatively few outcomes were used to validate the scores for recurrence. They concluded that while the ABCD² score is highly predictive of recurrent stroke after a TIA in the acute phase, it is less predictive after minor stroke, and neither the ESRS nor the SPI-II predict 90-day recurrence. "More reliable early risk prediction after minor stroke is required," they wrote.

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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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