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ACP HospitalistWeekly



In the News for the Week of November 21, 2012




Highlights

Full clinical situation should be considered when ordering, interpreting troponin test

Guidance on when to order and how to interpret a troponin level, in order to initiate appropriate treatment and to optimize outcomes, was offered last week by a new consensus document issued by six medical societies. More...

Acetaminophen doses too high in some hospitalized patients

Some hospitalized patients may be receiving too much acetaminophen, according to a recent study. More...


Cardiology

Registry appears to improve survival, neurologic outcomes after in-hospital cardiac arrest

Survival and neurologic outcomes after in-hospital cardiac arrest have improved at hospitals participating in the Get with the Guidelines—Resuscitation registry, according to a recent study. More...


Critical care

Central line bundle reduced infections across hospital systems

A multi-faceted intervention to reduce central line-associated bloodstream infections (CLABSIs) proved to be sustainable and replicable in a recent trial. More...


From ACP Hospitalist

The next issue of ACP Hospitalist is online

The November issue of ACP Hospitalist is now online, featuring its annual Top Docs article. 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...

Editorial note: ACP HospitalistWeekly will not be published next week due to the Thanksgiving Day holiday.


Physician editor: A. Scott Keller, MD, FACP



Highlights


.
Full clinical situation should be considered when ordering, interpreting troponin test

Guidance on when to order and how to interpret a troponin level, in order to initiate appropriate treatment and to optimize outcomes, was offered last week by a new consensus document issued by six medical societies.

Elevated troponin levels by themselves do not indicate myocardial infarction (MI, defined as myonecrosis due to ischemia), the document states. Troponin levels are nonspecific relative to the etiology of cardiac myonecrosis and occur in many nonischemic clinical conditions. As assays become more sensitive, more conditions that elevate troponin by even small amounts will be identified, the document continues.

The full report appeared online at the American College of Cardiology website and will be published in the Dec. 12 Journal of the American College of Cardiology.

The document also explains when a troponin level should be obtained.

  • Because it is not specific for MI, troponin evaluation should be performed only if clinically indicated for suspected MI.
  • An elevated troponin level must always be interpreted in the context of the clinical presentation and pre-test likelihood that it represents MI.
  • Troponin is recommended for diagnosis of MI in chronic kidney disease (CKD) patients with symptoms of MI (regardless of severity of renal impairment). Dynamic changes in troponin values of ≥20% over six to nine hours should be used to define acute MI in end-stage renal disease patients, who may have chronically elevated troponin levels.
  • In the absence of specific interventions based on the results, routine troponin testing is not recommended for nonischemic clinical conditions. Two exceptions include Food and Drug Administration-approved troponin testing for prognosis in CKD patients and treating chemotherapy patients who have a drug-induced cardiac injury.

The consensus document also defines the prognostic significance of an elevated troponin level and provides at-a-glance resources for physicians, including a schematic of potential reasons for elevated troponin levels and flow diagrams to help clinicians determine when to use troponin in therapeutic decision making.

The consensus document was developed in collaboration with the American College of Cardiology, American Association for Clinical Chemistry, American College of Chest Physicians, American College of Emergency Physicians, American Heart Association, and Society for Cardiovascular Angiography and Interventions.


.
Acetaminophen doses too high in some hospitalized patients

Some hospitalized patients may be receiving too much acetaminophen, according to a recent study.

Researchers performed a retrospective review of patients' electronic health records at two tertiary care hospitals to determine acetaminophen use during hospitalization and potential risk factors for supratherapeutic dosing. Data on acetaminophen administration (including drug name, dose, administration time and hospital units), demographics, diagnoses, and liver function tests results were analyzed. The study's main outcome measures were rate of acetaminophen exposure and supratherapeutic dosing, hazard ratios for risk factors for supratherapeutic dosing, and liver function before and after supratherapeutic dosing. The study results were published online Nov. 12 by Archives of Internal Medicine.

Records from 23,750 adult patients hospitalized between June and August 2010 were studied. Of these patients, 14,411 (61%) had received acetaminophen during their hospital stay. Nine hundred fifty-five patients (6.6%) received more than 4 g, the maximum recommended daily dose. In patients 65 years of age and older and in patients with chronic liver disease, the recommended daily limit is 3 g, but 22.3% and 17.6% of these subgroups, respectively, received more than this amount. Supratherapeutic dosing was significantly more likely in patients who were white (HR, 1.5 [95% CI, 1.3 to 1.7]); had diagnosed osteoarthritis (HR, 1.4 [95% CI, 1.3 to 1.6]); and received scheduled drug administration (HR, 16.6 [95% CI, 13.5 to 20.6]), more than one product (HR, 2.4 [95% CI, 2.0 to 2.9]), or 500-mg doses (HR, 1.9 [95% CI, 1.5 to 2.3]). Patients at one of the hospitals were more likely to receive supratherapeutic dosing than patients at the other hospital. Lower risk was associated with as-needed drug administration and care in nonsurgical and nonintensive care units.

The authors noted that some potential confounding factors were not measured and that there may have been time gaps between when a dose was recorded and when the patient actually took the medication, among other limitations. However, they concluded that several factors may predispose patients to receive supratherapeutic doses of acetaminophen while hospitalized, and that targeted interventions, including electronic clinical decision support tools, could help minimize this risk.

The author of an accompanying editorial said that the study, with its use of electronic medical records and other online data sources, shows that health information technology (HIT) can be used to help improve care, noting that this work could not have been performed by manual record review. However, the editorialist said, the study also points to obstacles that must first be overcome when using HIT to improve performance. Innovation and rapid change are key, he said.

"We have a unique opportunity to use health information technology to substantially improve our nation's health care system," the editorialist wrote. "However, we must go beyond the implementation of EHR and create a system that expands the use of business intelligence and analytics and produces technology-enabled solutions that improve quality, safety, and efficiency."

ACP supports Know Your Dose, a nationwide campaign to increase patients' awareness of their acetaminophen intake. More information about the campaign is available online.



Cardiology


.
Registry appears to improve survival, neurologic outcomes after in-hospital cardiac arrest

Survival and neurologic outcomes after in-hospital cardiac arrest have improved at hospitals participating in the Get with the Guidelines—Resuscitation registry, according to a recent study.

Researchers looked at data from adults who had a cardiac arrest at any of 374 hospitals participating in the Get with the Guidelines—Resuscitation registry between 2000 and 2009. Temporal trends in risk-adjusted rates of survival to discharge were analyzed, and causes and relation to neurologic disability were examined. The study results appeared in the Nov. 15 New England Journal of Medicine.

A total of 84,625 patients had a cardiac arrest in the hospital, and 14,357 (17%) survived until discharge. Overall, 79.3% initially had asystole or pulseless electrical activity and 20.7% had ventricular fibrillation or pulseless ventricular tachycardia. Over time, the proportion of cardiac arrests related to asystole or pulseless electrical activity increased (68.7% in 2000 vs. 82.4% in 2009; P<0.001 for trend), as did risk-adjusted rates of survival to discharge (13.7% in 2000 vs. 22.3% in 2009; adjusted rate ratio per year, 1.04; P<0.001 for trend). Acute and postresuscitation survival improved in both rhythm groups, leading to similar overall improvements in survival. Clinically significant neurologic disability decreased over time (risk-adjusted rate, 32.9% in 2000 vs. 28.1% in 2009; adjusted rate ratio per year, 0.98; P=0.02 for trend).

The authors noted that residual confounding could have affected their results and that data on specific processes and treatments were not available, among other limitations. However, they concluded that both survival to hospital discharge and rates of clinically significant neurologic disability after in-hospital cardiac arrest have improved in hospitals participating in Get with the Guidelines—Resuscitation. The authors estimated that based on their findings, an additional 17,200 patients survived to discharge in 2009 compared with 2000 and that over 13,000 cases of neurological disability were similarly avoided. They called for future studies to determine which specific factors led to the improvements so that they can be applied in all hospitals.



Critical care


.
Central line bundle reduced infections across hospital systems

A multi-faceted intervention to reduce central line-associated bloodstream infections (CLABSIs) proved to be sustainable and replicable in a recent trial.

Researchers conducted a randomized trial in 45 intensive care units in 35 hospitals from two health systems. The tested intervention included the CLABSI-prevention bundle developed by the Johns Hopkins Quality and Safety Research Group: hand washing before line placement; using full barrier precautions; avoiding line placement at the femoral site; using chlorhexidine to cleanse the site; and removing unnecessary lines. They added to this a culture-change intervention, the Comprehensive Unit-based Safety Program, which included training about systems and safety, collaboration with hospital executives, and efforts to improve teamwork and communication.

One of the hospital systems implemented the intervention beginning in March 2007. The other served as a control group until October 2007, when it began the intervention. At baseline, CLABSI rates were 4.48 per 1,000 central line days in the intervention group and 2.71 per 1,000 in the control group. By October-December 2007, the intervention group's infection rate had declined to 1.33, compared to 2.16 in the control group (P=0.003). The intervention group's rate decreased further and was sustained below 1 per 1,000 even 19 months after the intervention. The control group, once it began the intervention, also reduced rates below 1 per 1,000 and had sustained them at 12 months. Results appeared in the November Critical Care Medicine.

The study is the first randomized, controlled trial of such a combined bundle/culture change effort to reduce CLABSI, the authors said. The participating hospitals successfully replicated (and actually improved on) the results of the project, providing further proof that most CLABSI infections are preventable. It's also significant that the project was nurse-led, confirming nurses' role as logical leaders of such interdisciplinary safety programs. However, in interviews about the intervention process, nurses reported that more physician engagement would have been beneficial.



From ACP Hospitalist


.
The next issue of ACP Hospitalist is online

The November issue of ACP Hospitalist is now online. Featured stories include the following:

acph-20121121-hospcover.jpg

Top Docs. Meet our 2012 Top Hospitalists! Our fifth annual Top Docs issue recognizes 10 dedicated physicians in the field of hospital medicine.

Hold on to your tail. What questions should you ask about malpractice insurance? Limitations in coverage can cause problems if a physician is sued or changes jobs.

Caring for inpatients with chronic diseases from childhood. Hospitalists may need to help smooth the transition from pediatric to adult care.



Cartoon caption contest


.
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.

acph-20121121-cartoon.jpg

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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