In the News


Delays in ICU transfer increase mortality and LOS, but early warning score may help

Delays in transfer of critically ill ward patients to the ICU were associated with increases in hospital mortality and length of stay in a recent study, which employed an early warning ICU score that may be useful for quantifying critical illness.

The observational cohort study looked at 269,999 admissions between November 2008 and January 2013 to the medical-surgical wards at 5 hospitals. To estimate the effect of delayed ICU transfer on patient outcomes, researchers retrospectively applied the previously published electronic Cardiac Arrest Risk Triage (eCART) score, which utilizes demographics, vital signs, and laboratory data as an objective measure of critical illness. Results were published online on June 28 by the Journal of Hospital Medicine.

To define a ward patient as critically ill, researchers used an eCART score of 60, which is at the 95% specificity cutoff for ICU transfer. Of 11,995 patients who were either transferred to the ICU or who had a cardiac arrest on the wards, 3,789 patients reached this score within 24 hours of transfer. The median time from the first critical eCART value to transfer was 5.4 hours (mean, 8 hours).

Delayed transfer (>6 hours) occurred in about 46% of patients (n=1,734) and was associated with increased in-hospital mortality (33.2% vs. 24.5%, P<0.001). With each 1-hour increase in transfer delay, the odds of in-hospital death increased by 3% (P<0.001), and this linear association between delay and mortality remained unchanged after researchers controlled for several variables.

Patients with delayed transfer were slightly older than those without delayed transfer (median age, 73 years vs. 71 years; P=0.002), but all other characteristics were similar. In terms of vital signs and laboratory values, patients with delayed transfer had lower median respiratory rate, blood pressure, heart rate, and hemoglobin levels but higher median white blood cell count and creatinine levels.

In addition, patients with delayed transfer who survived to discharge stayed in the hospital for a median 2 days longer than those with nondelayed transfer who survived to discharge (median length of stay, 13 days vs. 11 days; P=0.01). Patients with timely transfer had a more rapid rise in eCART score prior to transfer than those with delayed transfer.

The study authors noted limitations to their work, such as using just 1 potential measure of critical illness and a cutoff that included only one-third of patients transferred to the ICU. They also noted that the cause of physiologic deterioration, code status, comorbidities, and reason for ICU admission were not available in the dataset.

“This work highlights the importance of timely transfer to the ICU for critically ill ward patients, which can be affected by several factors such as ICU bed availability and caregiver recognition and triage decisions,” they concluded. “Our findings have significant implications for patient safety on the wards and provide further evidence for implementing early warning scores into practice to aid with clinical decision making.”

ACC, AHA release updated performance, quality measures for atrial fibrillation

The American College of Cardiology (ACC) and the American Heart Association (AHA) released updated clinical performance and quality measures recently for treatment of atrial fibrillation or atrial flutter in adults in both outpatient and inpatient settings.

The AHA/ACC writing committee reviewed evidence-based guidelines and clinical guidance documents to develop 24 total measures, including 6 performance measures (3 inpatient and 3 outpatient) and 18 quality measures (10 inpatient and 8 outpatient). All of the measures were designed to assess care quality for inpatients and outpatients with atrial fibrillation or atrial flutter, excluding patients younger than age 18 and those receiving comfort care only.

The performance measures, classified under the domain of effective clinical care, were as follows:

  • CHA2DS2-VASc risk score documented before discharge (inpatient)
  • Anticoagulation prescribed before discharge (inpatient)
  • Planned follow-up documented before discharge for warfarin treatment (inpatient)
  • CHA2DS2-VASc risk score documented (outpatient)
  • Anticoagulation prescribed (outpatient)
  • Monthly international normalized ratio for warfarin treatment (outpatient)

The quality measures were classified under the domains of effective clinical care, patient safety, or communication and care coordination. Measures that addressed both inpatient and outpatient care were as follows, with inpatient measures applying prior to discharge:

  • Beta-blocker prescription when the left ventricular ejection fraction is less than or equal to 40%
  • Inappropriate prescription of antiarrhythmic drugs for rhythm control in patients with permanent atrial fibrillation
  • Inappropriate prescription of dofetilide or sotalol in patients with atrial fibrillation and end-stage kidney disease or on dialysis
  • Inappropriate prescription of a direct thrombin or factor Xa inhibitor in patients with atrial fibrillation with a mechanical heart valve
  • Inappropriate prescription of a direct thrombin or factor Xa inhibitor in patients with atrial fibrillation and end-stage kidney disease or on dialysis
  • Inappropriate prescription of antiplatelet and oral anticoagulation therapy for patients who do not have coronary artery disease and/or vascular disease
  • Inappropriate prescription of nondihydropyridine calcium-channel antagonist in patients with reduced ejection fraction heart failure
  • Shared decision making between physicians and patients regarding anticoagulation prescription

Inpatient-only quality measures included prescription of an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker when left ventricular ejection fraction is less than or equal to 40% and lack of anticoagulant treatment during or after a procedure in patients who had atrial catheter ablation.

The writing committee did not recommend documentation of a bleeding score or bleeding risk assessment because not enough data were available. “Future research is needed to determine whether bleeding scores can lead to actionable risk stratification of patients,” the committee wrote.

The committee also called for more research on use of an outcome such as stroke rate per capita as a measure of care quality in atrial fibrillation and on anticoagulation in at-risk adults with congenital heart disease. Other areas highlighted for future study included shared decision making about rhythm or rate control strategies, inappropriate use of anticoagulation in very low-risk patients, and pharmacokinetic guides for dose adjustment of new oral anticoagulants.

The performance and quality measures were published jointly online June 27 by the Journal of the American College of Cardiology and Circulation: Cardiovascular Quality and Outcomes.

Women less likely than men to survive cardiac arrest, receive therapeutic intervention

Women who undergo cardiac arrest appear to be more likely than men to die in the hospital and less likely to undergo certain interventions, according to a recent study.

Researchers used data from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, a 20% stratified sample of all nonfederal U.S. hospitals, to study these sex-based differences in outcomes and interventions. Results were published online on June 22 by the Journal of the American Heart Association.

Hospitalizations with a primary or secondary diagnosis of cardiac arrest (n=1,436,052, 45.4% female) between 2003 and 2012 were included in the analysis, which examined in-hospital all-cause mortality and likelihood of undergoing coronary angiography, percutaneous coronary intervention (PCI), or targeted temperature management (TTM). Researchers also examined 2 subgroups: patients with shockable rhythms (ventricular tachycardia [VT] and ventricular fibrillation [VF]) and patients with pulseless electrical activity (PEA) or asystole.

During the study period, the annual incidence of cardiac arrests increased by 14.0% (by 25.9% for VT/VF arrests and by 10.6% for PEA/asystole arrests), and in-hospital all-cause mortality decreased from 68.1% to 59.6%. However, in-hospital mortality was higher in women compared to men in the overall cardiac arrest cohort (64.0% vs. 61.4%; adjusted odds ratio [OR], 1.02; P<0.001), particularly in the VT/VF arrest cohort (49.4% vs. 45.6%; adjusted OR, 1.11; P<0.001).

Utilization of the 3 therapeutic interventions increased during the study period, and these changes were greater in men than women overall (16.5% to 19.9% vs. 12.1% to 13.4% for coronary angiography; 7.2% to 10.1% vs. 4.8% to 5.8% for PCI; and 0% to 3.2% vs. 0% to 2.3% for TTM). For VT/VF arrests, men also experienced more of an increase in interventions (34.6% to 42.3% vs. 28.4% to 31.7% for coronary angiography; 17.3% to 24.1% vs. 12.5% to 14.7% for PCI; and 0.1% to 6.1% vs. 0% to 4.2% for TTM). Changes were less pronounced between men and women for PEA/asystole arrests.

Compared to men, women presenting with cardiac arrest were older, had more comorbid conditions, and were less likely to present with preexisting coronary artery disease, ST-segment elevation myocardial infarction, and a shockable rhythm. “Lower rates of angiography and PCI may...be due to higher frequency of alternative etiologies, such as pulmonary embolism,” the study authors wrote. “Furthermore, revascularization in women is associated with [about a] 2-fold higher bleeding risk, which can lead to more reserved use of angiography and PCI, particularly when the etiology of cardiac arrest is not clearly identified.”

They noted limitations to their study, such as its retrospective nature and the fact that data were derived from a representative 20% sample of U.S. hospitals. “These data present an opportunity to improve national cardiac arrest processes and outcomes, and to focus on reducing sex-based disparities in caring for postarrest patients,” they concluded.

Avoiding beta-lactam therapy in hospitalized patients with self-reported allergies may lead to more adverse events

Avoidance of preferred beta-lactam therapy in hospitalized patients who report allergy is associated with an increased risk of adverse events, a study found.

Researchers prospectively evaluated the impact of reported allergies to beta-lactam antibiotics on clinical outcomes via a trainee-led prospective cohort study to determine the burden and clinical impact on patients seen by the infectious diseases consultation service at 3 academic hospitals in Toronto.

The primary outcome was a composite measure of readmission for the same infection, acute kidney injury, Clostridium difficile infection, or drug-related adverse reactions requiring discontinuation. The predictors of interest were history of beta-lactam allergy and receipt of preferred beta-lactam therapy. Results were published in the Oct. 1 Clinical Infectious Diseases.

Among 507 patients, 95 (23%) reported beta-lactam allergy. Beta-lactam was preferred therapy in 72 of these 95 patients (76%). When beta-lactam therapy was preferred, 25 patients (35%) did not receive preferred therapy due to their report of allergy even though 13 (52%) had had nonsevere prior reactions.

After adjustment for confounders, patients who did not receive preferred beta-lactam therapy were at greater risk of adverse events (adjusted odds ratio, 3.18; 95% CI, 1.28 to 7.89) compared with those without reported allergy. Patients who reported an allergy but received preferred beta-lactam therapy had a similar risk of adverse events compared to patients who did not report an allergy (adjusted odds ratio, 1.33; 95% CI, 0.62 to 2.87).

Developing inpatient programs aimed at accurately identifying beta-lactam allergies to safely promote beta-lactam administration among these patients is warranted, the authors wrote.

“In our study, the avoidance of beta-lactam therapy in patients for whom beta-lactam therapy was preferred, occurred more frequently among patients with more ‘serious' allergy histories, in keeping with an increased degree of physician caution,” the authors noted. “Despite this, over one-third of patients who had a clinical indication for beta-lactam therapy did not receive preferred treatment due to reports of simple rashes, suggesting marked room for improvement in the prescribing of preferred beta-lactam therapy in these patients.”

An editorial noted that up to 95% of patients who report an allergy to beta-lactam are not truly allergic. In this study, all patients had an allergy history taken, but 35% of beta-lactam “allergic” patients were still not given a beta-lactam when indicated. “This suggests that it is important to go beyond the allergy history to an assessment and plan informed by well-validated allergy practice and procedures, such as implementation of the penicillin skin test and/or graded challenges (also known as test doses) under medical observation,” the editorial stated.