ACC/AHA Task Force updates STEMI and PCI guidelines
The American College of Cardiology/American Heart Association Task Force on Practice Guidelines has updated its guidelines on treatment for ST-segment elevation myocardial infarction (STEMI) and for percutaneous coronary intervention (PCI). The updates, which were published online by the Journal of the American College of Cardiology on Dec. 10 and Dec. 13, 2007, respectively, are focused updates of the Task Force's 2004 recommendations on STEMI and its 2005 recommendations on PCI.
The updated STEMI recommendations include the following:
- Patients with STEMI should receive PCI within 90 minutes if they present at a hospital with PCI capability or can be transferred to a hospital with PCI capability and treated within that time window. Patients who present to a hospital without PCI capability and cannot be transferred and treated within 90 minutes should instead receive fibrinolytic therapy within 30 minutes unless contraindicated.
- Intravenous beta-blockers should be avoided in STEMI patients with signs of heart failure or low output state, increased cardiogenic shock risk, or other contraindications.
- Clopidogrel should be added to aspirin and continued for at least 14 days in STEMI patients regardless of whether they receive reperfusion with fibrinolytic therapy or do not receive reperfusion.
- Routine use of nonsteroidal anti-inflammatory drugs (NSAIDs), except aspirin, should be discontinued at presentation with STEMI, and NSAIDs other than aspirin should be avoided during hospitalization for STEMI.
The guidelines also include new recommendations for transitioning patients to the catheterization laboratory after they have received fibrinolytic treatment and for using anticoagulants in patients receiving reperfusion with fibrinolytics.
The updated PCI recommendations include the following:
- Physicians should consider drug-eluting stents rather than bare-metal stents in patients with favorable safety and effectiveness profiles as defined by clinical trials.
- The guidelines stressed the importance of dual-antiplatelet therapy with aspirin and clopidogrel after implantation of a drug-eluting stent. Patients undergoing PCI with drug-eluting stents should receive clopidogrel for at least one year after the procedure. Physicians should discuss the need for dual-antiplatelet therapy with patients before the procedure to ensure that they will be able to adhere to it over the long term.
- Drug-eluting stents should be avoided in patients who are likely to need additional surgery in the future. Bare-metal stents or balloon angioplasty with provisional stents should be used instead.
- PCI should not be performed for one- or two-vessel disease with a totally occluded coronary artery in hemodynamically and electrically stable patients without “ongoing or easily provoked chest pain 24 hours to 28 days after a heart attack.”
The guidelines also stressed the importance of several factors, including smoking cessation, blood pressure control, and lipid management, to reducing risk in patients with coronary disease or other vascular disease after PCI.
FDA approves first rapid blood test to detect MRSA
The FDA approved for marketing a test that can identify in two hours whether blood is infected with MRSA (methicillin-resistant Staphylococcus aureus) or a different staph bacterium.
The BD GeneOhm StaphSR Assay identified 100% of MRSA-positive specimens and more than 98% of more common staph infections in a clinical trial at five locations. Other tests take more than two days to yield results, the FDA said.
The new test shouldn't be used to monitor treatment for staph infections because it can't quantify a patient's response to treatment, the FDA said. The test also may reflect the bacteria's presence in patients who have been successfully treated for staph infections, so it shouldn't be used as the sole basis for diagnosis. It also can't rule out other complicating conditions or infections, the FDA said.
System errors make up 30% of settled malpractice claims in one analysis
System errors contributed to nearly 30% of settled claims between 2004 and 2006, according to a closed claims analysis by one malpractice insurer.
In an effort to determine what impact health system errors have on medical malpractice claims, The Doctors Company analyzed 363 of its closed claims that were settled for between $100,000 and $500,000 from 2004 to 2006.
Of these 363 claims, 63% (228 claims) showed provider error only, largely due to the nature of settled claims that generally occur when there is some caregiver responsibility for the adverse event that caused the patient injury. Another 28.7% (104 claims) involved both provider and system error while just 1% of total claims (four claims) involved only system error.
The most common type of system errors included: medication-related errors (32%), communication errors (27%), health care-associated infections (18%), medical record errors (13%), and wrong-site surgery (5%). These five types of system errors accounted for 95% of all system errors in The Doctors Company's analysis.
Internal medicine, family practice and psychiatry are involved in nearly half of all medication-related errors in the analysis. Medication monitoring (43%) and dosage errors (26%) accounted for 69% of medication-related errors. Of the medication monitoring errors, one-third involved failing to properly monitor warfarin.
Other key findings include:
- More than one-third of errors involving medical records resulted from the absence of a written informed consent. Another 35% were associated with medication-related errors.
- Internal medicine accounted for 11.4% of the 35 communications errors studied and 12.5% of the 24 health care associated infections that occurred.
AHRQ offers toolkits to prevent medical errors
New toolkits are available from the Agency for Healthcare Research and Quality (AHRQ) to help physicians and other health care providers reduce medical errors.
A group of patient-safety experts developed the 17 toolkits, which range from checklists to help reconcile medications at hospital discharge to processes that enhance effective communication with caregivers and patients. The tools were developed through the AHRQ's Partnerships in Implementing Patient Safety program, and are based on best practices from a wide range of health care settings and diverse patient populations. The toolkits also correlate with the Joint Commission's National Patient Safety Goals.
The free, publicly available toolkits include:
- The Re-Engineered Hospital Discharge “Project RED” toolkit, which standardizes the hospital discharge process with manuals and software to improve communication.
- The Medications at Transitions and Clinical Handoffs “MATCH” toolkit, which focuses on identifying patient risk factors for inaccurate medication reconciliation, including limited English proficiency and low health literacy, complex medication histories, or impaired mental status.
- The Preventing Venous Thromboembolisms in the Hospital toolkit and the Interactive Venous Thromboembolism Safety Toolkit for Providers and Patients.
- The ED Pharmacist as a Safety Measure in Emergency Medicine toolkit, which focuses on improving medication safety and reconciliation by placing pharmacists in hospital emergency departments.