A Quantitative Approach to Defining “High-Touch” Surfaces in Hospitals.

Infect Control Hosp Epidemiol. 2010 Jun 22;

Authors: Huslage K, Rutala WA, Sickbert-Bennett E, Weber DJ

Fifty interactions between healthcare workers and patients were observed to obtain a quantifiable definition of “high-touch” (ie, frequently touched) surfaces based on frequency of contact. Five surfaces were defined as high-touch surfaces: the bed rails, the bed surface, the supply cart, the over-bed table, and the intravenous pump.

PMID: 20569115 [PubMed - as supplied by publisher]

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Echocardiography: a help in the weaning process.

Crit Care. 2010 Jun 22;14(3):R120

Authors: Caille V, Amiel JB, Charron C, Belliard G, Vieillard-Baron A, Vignon P

ABSTRACT: INTRODUCTION: To evaluate the ability of transthoracic echocardiography (TTE) to detect the effects of spontaneous breathing trial (SBT) on central hemodynamics and to identify indices predictive of cardiac-related weaning failure. METHODS: TTE was performed just before and at the end of a 30-min SBT in 117 patients fulfilling weaning criteria. Maximal velocities of mitral E and A waves, deceleration time of E wave (DTE), maximal velocity of E' wave (tissue Doppler at the lateral mitral annulus), and left ventricular (LV) stroke volume were measured. Values of TTE parameters were compared between baseline (pressure support ventilation) and SBT in all patients and according to LV ejection fraction (EF): >50% (n=58), 35% to 50% (n=30), and <35% (n=29). Baseline TTE indices were also compared between patients who were weaned (n=94) and those who failed (n=23). RESULTS: Weaning failure was of cardiac origin in 20/23 patients (87%). SBT resulted in a significant increase in cardiac output and E/A, and a shortened DTE. At baseline, DTE was significantly shorter in patients with LVEF <35% when compared to other subgroups (median [25th-75th percentiles]: 119 ms [90-153] vs. 187 ms [144-224] vs. 174 ms [152-193]; P<0.01) and E/E' was greater (7.9 [5.4-9.1] vs. 6.0 [5.3-9.0] vs. 5.2 [4.7-6.0]; P<0.01). When compared to patients who were successfully weaned, those patients who failed exhibited at baseline a significantly lower LVEF (36% [27-55] vs. 51% [43-55]: P=0.04) and higher E/E' (7.0 [5.0-9.2] vs. 5.6 [5.2-6.3]: P=0.04). CONCLUSIONS: TTE detects SBT-induced changes in central hemodynamics. When performed by an experienced operator prior to SBT, TTE helps in identifying patients at high risk of cardiac-related weaning failure when documenting a depressed LVEF, shortened DTE and increased E/E'. Further studies are needed to evaluate the impact of this screening strategy on the weaning process and patient outcome.

PMID: 20569504 [PubMed - as supplied by publisher]

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Handoffs in teaching hospitals: situation, background, assessment, and recommendation.

Am J Med. 2010 Jun;123(6):563-7

Authors: Logio LS, Djuricich AM

PMID: 20569767 [PubMed - in process]

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Non-adherence to Recommendations for Further Testing after Outpatient CT and MRI.

Am J Med. 2010 Jun;123(6):557.e1-557.e8

Authors: You JJ, Laupacis A, Newman A, Bell CM

BACKGROUND: Nearly 1 in every 5 outpatient visits ends with a request for a diagnostic imaging test, and imaging reports often contain recommendations for further testing. Little is known about adherence to recommendations for further testing after outpatient computed tomography (CT) and magnetic resonance imaging (MRI). METHODS: We performed a retrospective cohort study linking provincial administrative data to a cross-sectional audit of 23,691 outpatient CT and MRI scans performed in 2005 in Ontario, Canada. After excluding patients who died (n=1031), were hospitalized (n=3030), or visited an emergency department (n=3660) within 180 days of the index CT/MRI scan, 15,970 CT/MRI scans were included. The primary outcome was adherence to recommendations for further testing within 180 days of an index CT/MRI scan. RESULTS: Further testing was recommended in 2027 of 15,970 (12.7%) index CT/MRI scan reports and was recommended most frequently after CT chest scans (593 of 2276 [26.1%]). From the 2027 scans in which further testing was recommended, we identified 2102 individual recommendations for a specific type of follow-up test and found that just over one third (37.6%) of these recommendations were followed at 180 days. Adherence was lower (32.3%) when patients had a visit to the referring physician within 180 days of the index CT/MRI scan, compared with when they had no such visit (50.5%; P <.001). CONCLUSIONS: Radiologists commonly recommend further testing after outpatient CT and MRI scanning. However, nearly two thirds of these recommendations are not followed. This suggests that substantial opportunities exist to improve the exchange of information between clinicians and radiologists and to advance the quality of outpatient care.

PMID: 20569765 [PubMed - as supplied by publisher]

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Admission Hypoglycemia and Increased Mortality in Patients Hospitalized with Pneumonia.

Am J Med. 2010 Jun;123(6):556.e11-556.e16

Authors: Gamble JM, Eurich DT, Marrie TJ, Majumdar SR

BACKGROUND: The relationship between spontaneous admission hypoglycemia and mortality in patients hospitalized with community-acquired pneumonia is unclear. METHODS: From 2000 to 2002, clinical data were prospectively collected on all patients with community-acquired pneumonia who were admitted to all 6 hospitals in Edmonton, Alberta, Canada. Patients with admission glucose greater than 6.1 mmol/L (n=1996) were excluded; the remaining patients were categorized as having admission hypoglycemia (<4.0 mmol/L [n=54]) or normoglycemia (4.0 to</=6.1 mmol/L [n=902]). Multivariable Cox proportional hazards models were used to examine the relationship between hypoglycemia and all-cause mortality in-hospital, at 30 days, and at 1 year. RESULTS: The mean age was 65 (standard deviation=20) years, 48% were female, 8% had diabetes, and 56% had severe pneumonia. Overall, admission hypoglycemia was present in 2% (54/2990) of the entire cohort and 6% of those with glucose of 6.1 mmol/L or less. Total deaths were 89 (9%) in-hospital, 96 (10%) at 30 days, and 247 (26%) at 1 year. In-hospital mortality was higher among patients with admission hypoglycemia (11 [20%] deaths) compared with those with normoglycemia (78 [9%]; adjusted hazards ratio [aHR] 2.96; 95% confidence interval [CI], 1.39-6.31; P=.005). An increased risk of mortality was observed at 30 days (11 [20%] vs 85 [10%]; aHR 2.89; 95% CI, 1.32-6.29) and remained elevated at 1 year (19 [35%] vs 228 [25%]; aHR1.80; 95% CI, 1.02-3.17). These results were not influenced by treatment for diabetes (P>.4 for interaction). CONCLUSION: In a population-based sample of patients with community-acquired pneumonia, spontaneous admission hypoglycemia was independently associated with increased mortality during hospitalization that persisted to 1 year. Patients with hypoglycemia are an easily identified group that may warrant more intensive inpatient and postdischarge follow-up.

PMID: 20569764 [PubMed - as supplied by publisher]

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Adherence to Pharmacological Thromboprophylaxis Orders in Hospitalized Patients.

Am J Med. 2010 Jun;123(6):536-541

Authors: Fanikos J, Stevens LA, Labreche M, Piazza G, Catapane E, Novack L, Goldhaber SZ

OBJECTIVE: We compared adherence to unfractionated heparin (UFH) 2 or 3 times daily prophylaxis orders versus low-molecular-weight heparin (LMWH) once daily orders. Our goals were to determine which strategy demonstrated the best adherence in terms of timing and frequency of dose administration, and to determine reasons for ordered heparin not being administered. METHODS: We queried our electronic medication administration record where nurses document reasons for delayed administration or omitted doses. We identified 250 consecutive patients who were prescribed prophylaxis with UFH 2 or 3 times daily or LMWH once daily. We followed patients for their hospitalization to determine adherence to physicians' prophylaxis orders. RESULTS: Adherence, defined as the ratio of prophylaxis doses given to doses ordered, was greater with LMWH (94.9%) than UFH 3 times daily (87.8%) or UFH twice daily (86.8%) regimens (P <.001). Patients receiving LMWH more often received all of their scheduled prophylaxis doses (77%) versus UFH 3 times daily (54%) or UFH twice daily (45%) (P <.001). There were no differences between regimens regarding reasons for omitted doses. The most common reason for late or omitted doses was patient refusal, which explained 44% of the UFH and 39% of the LMWH orders that were not administered. CONCLUSIONS: LMWH once a day had better adherence than UFH 2 or 3 times daily. For both LMWH and UFH, patient refusal was the most common reason for not administering prophylaxis as prescribed. These findings require consideration when evaluating pharmacological prophylaxis strategies. Educational programs, explaining the rationale, may motivate patients to improve adherence during hospitalization.

PMID: 20569760 [PubMed - as supplied by publisher]

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Review: treatment of gastroesophageal reflux disease in the elderly.

Am J Med. 2010 Jun;123(6):496-501

Authors: Poh CH, Navarro-Rodriguez T, Fass R

The prevalence of gastroesophageal reflux disease (GERD) increases with age; older patients are more likely to develop severe disease. Common symptoms of GERD in the elderly include dysphagia, vomiting, and respiratory problems. Older patients are more likely to require aggressive therapy, and usually their management is compounded by the presence of comorbidities and consumption of various medications. Proton pump inhibitors are the mainstay of GERD treatment in the elderly because of their profound and consistent acid suppressive effect. Overall, proton pump inhibitors seem to be safe for both short- and long-term therapy in elderly patients with GERD. Antireflux surgery may be safe and effective in a subset of elderly patients with GERD.

PMID: 20569750 [PubMed - in process]

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Improving Stroke Risk Stratification in Atrial Fibrillation.

Am J Med. 2010 Jun;123(6):484-488

Authors: Lip GY, Halperin JL

Risk factors for stroke and thromboembolism in patients with atrial fibrillation used in current risk stratification schema are derived largely from analyses of clinical trial cohorts, and the available data depend on the comprehensiveness of trial reports and whether specific risk factors were sought. The most commonly used schema is the Cardiac failure, Hypertension, Age, Diabetes, Stroke [Doubled] (CHADS(2)) score. Although simple and well validated, some limitations of CHADS(2) this schema are apparent. A more recent approach to risk stratification of patients with nonvalvular atrial fibrillation defines "major (definitive)" risk factors (eg, previous stroke/transient ischemic attack and age>/=75 years) and "clinically relevant non-major" risk factors (eg, heart failure, hypertension, diabetes, female gender, age 65-75 years, and atherosclerotic vascular disease). This scheme can be expressed as an acronym, CHA(2)DS(2)-VASc, denoting Cardiac failure or dysfunction, Hypertension, Age>/=75 [Doubled], Diabetes, Stroke [Doubled]-Vascular disease, Age 65-74, and Sex category [Female]), whereby 2 points are assigned for a history of stroke or age 75 years or more and 1 point each is assigned for age 65 to 74 years, a history of hypertension, diabetes, cardiac failure, and vascular disease. Patients with 1 definitive risk factor or a patient with a CHA(2)DS(2)-VASc score of 1 or more could be considered for oral anticoagulation, but a patient with a CHA(2)DS(2)-VASc score of 0 is truly low risk and could be managed with no antithrombotic therapy. This would simplify our approach to thromboprophylaxis in patients with atrial fibrillation.

PMID: 20569748 [PubMed - as supplied by publisher]

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Related Articles

Vascular access management III: central venous catheters.

J Ren Care. 2010 Mar;36(1):25-33

Authors: McCann M, Einarsdottir H, Van Waeleghem JP, Murphy F, Sedgewick J

This third article, the final part of a Continuing Education (CE) series on Vascular Access Management for patients with end stage renal disease (ESRD), focuses on central venous catheters. CVCs are considered the last choice in vascular access due to the numerous complications associated with their use. This CE article explores the incidence and prevalence of central venous catheters within the context of international guidelines, type and design of central venous catheters, insertion procedure, strategies for preventing infection and complications associated with their use.

PMID: 20214706 [PubMed - indexed for MEDLINE]

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Internal jugular vein cannulation: an ultrasound-guided technique versus a landmark-guided technique.

Clinics (Sao Paulo). 2009;64(10):989-92

Authors: Turker G, Kaya FN, Gurbet A, Aksu H, Erdogan C, Atlas A

OBJECTIVES: To compare the landmark-guided technique versus the ultrasound-guided technique for internal jugular vein cannulation in spontaneously breathing patients. METHODS: A total of 380 patients who required internal jugular vein cannulation were randomly assigned to receive internal jugular vein cannulation using either the landmark- or ultrasound-guided technique in Bursa, Uludag University Faculty of Medicine, between April and November, 2008. Failed catheter placement, risk of complications from placement, risk of failure on first attempt at placement, number of attempts until successful catheterization, time to successful catheterization and the demographics of each patient were recorded. RESULTS: The overall complication rate was higher in the landmark group than in the ultrasound-guided group (p < 0.01). Carotid puncture rate and hematoma were more frequent in the landmark group than in the ultrasound-guided group (p < 0.05). The number of attempts for successful placement was significantly higher in the landmark group than in the ultrasound-guided group, which was accompanied by a significantly increased access time observed in the landmark group (p < 0.05 and p < 0.01, respectively). Although there were a higher number of attempts, longer access time, and a more frequent complication rate in the landmark group, the success rate was found to be comparable between the two groups. CONCLUSION: The findings of this study indicate that internal jugular vein catheterization guided by real-time ultrasound results in a lower access time and a lower rate of immediate complications.

PMID: 19841706 [PubMed - indexed for MEDLINE]

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Hospital resource utilization and costs of inappropriate treatment of candidemia.

Pharmacotherapy. 2010 Apr;30(4):361-8

Authors: Arnold HM, Micek ST, Shorr AF, Zilberberg MD, Labelle AJ, Kothari S, Kollef MH

STUDY OBJECTIVES: To evaluate the impact of inappropriate therapy–defined as delayed antifungal therapy beyond 24 hours from culture collection, inadequate antifungal dosage, or administration of an antifungal to which an isolate was considered resistant–on postculture hospital length of stay and costs, and to evaluate the relationship between modifiable risk factors, including failure to remove a central venous catheter, antifungal delay, and inadequate dosage, for an additive effect on hospital length of stay and costs. DESIGN: Single-center retrospective cohort study. SETTING: 1250-bed academic medical center. PATIENTS: One hundred sixty-seven consecutive adult patients admitted between January 2004 and May 2006 with culture-confirmed Candida bloodstream infections that occurred within 14 days of hospital admission and who received at least one dose of antifungal treatment. MEASUREMENTS AND MAIN RESULTS: Patients were stratified according to appropriateness of antifungal therapy. Appropriate therapy was defined as initiation of an antifungal to which the isolated pathogen was sensitive in vitro within 24 hours of positive culture collection, in addition to receipt of an adequate dose as recommended by the Infectious Diseases Society of America and the antifungal package insert. Postculture length of stay was the primary outcome and hospital costs the secondary outcome. An evaluation of modifiable risk factors was performed separately. Data were analyzed for 167 patients (22 in the appropriate therapy group and 145 in the inappropriate therapy group). Postculture length of stay was shorter in the appropriate therapy group (mean 7 vs 10.4 days, p=0.037). This correlated with total hospital costs that were lower in the appropriate therapy group (mean $15,832 vs $33,021, p<0.001.) A graded increase in costs was noted with increasing number of modifiable risk factors (p=0.001). CONCLUSION: Inappropriate therapy for Candida bloodstream infection occurring within 14 days of hospitalization was associated with prolonged postculture length of stay and increased costs. A rise in costs, but not length of stay, was noted with increasing modifiable risk factors.

PMID: 20334456 [PubMed - indexed for MEDLINE]

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Deposits on the intraluminal surface and bacterial growth in central venous catheters.

J Hosp Infect. 2010 May;75(1):19-22

Authors: Nishikawa K, Takasu A, Morita K, Tsumori H, Sakamoto T

Central venous catheter (CVC) tip and blood cultures are generally used to diagnose a catheter-related infection. Such methodology does not confirm the presence of bacterial colonisation on parts of CVCs other than the CVC tip. In order to assess the extent of bacterial colonisation, 10 catheters were examined in detail from patients admitted to intensive care unit. Swabs from the lumen at several sites (hub, indwelling and non-indwelling) were cultured and the intraluminal surface of the device subjected to scanning electron microscopy (SEM). Bacteria were detected on five out of 10 catheters (50%), and bacterial contamination of CVCs was common in the hub area of the device. Deposits (crystallisation) that differed from bacterial colonisation or biofilm were observed on the intraluminal surface of used CVCs. SEM showed bacteria firmly anchored to the deposits. Experimental flow studies demonstrated that deposits were more likely to appear after exposure to solutions such as total parenteral nutrition rather than distilled water. These deposits facilitated bacterial colonisation 30 times more than CVCs free from deposits.

PMID: 20227135 [PubMed - indexed for MEDLINE]

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Niacin’s role in the statin era.

Expert Opin Pharmacother. 2010 Jun 22;

Authors: Brooks EL, Kuvin JT, Karas RH

Importance of the field: The combination use of niacin and HMG Co-A reductases (statins) is increasing. While statin therapy reduces the risk of adverse cardiovascular events, additional therapies are needed to decrease event rates further. High-density lipoprotein cholesterol (HDL-C) is of interest as a potential therapeutic target as epidemiologic evidence demonstrates that low HDL-C is a strong predictor of incident coronary events. Niacin is the most effective agent available at present to increase HDL-C. Areas covered in this review: This review focuses on the efficacy and safety of niacin in combination with statins, along with the combination’s effects on cardiovascular end points and clinical outcomes. We systematically reviewed studies, dating from 2001 to the present, identified through MEDLINE and searches of reference lists, which contained a combination statin and niacin group. What the reader will gain: The reader will gain an understanding of the rationale and results of using niacin and statin therapy concurrently. Take home message: The addition of niacin to statin therapy results in multiple favorable effects on lipid levels, and the combination seems to be as safe as the individual drugs separately. Current evidence indicates that adding niacin to statin therapy has the potential to result in substantial reductions in risk for adverse cardiovascular events. However, large-scale clinical outcome trials are needed to confirm the benefits of this combination.

PMID: 20569085 [PubMed - as supplied by publisher]

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Pharmacotherapy of cluster headache.

Expert Opin Pharmacother. 2010 Jun 22;

Authors: Evers S

Importance of the field: Cluster headache belongs to the trigemino-autonomic cephalgias and is one of the most devastating idiopathic pain syndromes. Despite its extreme severity and its prevalence of about 0.1%, little attention has been paid to this painful syndrome by either basic or clinical research. Areas covered in this review: All clinical trials on the acute and prophylactic drug treatment of cluster headache are reviewed, including review articles and book chapters. What the reader will gain: The treatment of cluster headache is based on acute and prophylactic drug treatment. Oxygen inhalation, subcutaneous or intranasal sumatriptan, and intranasal zolmitriptan are recommended to stop an attach. For prophylaxis, verapamil is drug of first choice. Other drugs efficacious in cluster headache are steroids, lithium, some anticonvulsants and methysergide. Recently, interventional procedures have been studied for the treatment of refractory cluster headache. In the future, new anticonvulsants and unconventional ways of immunotherapy should be evaluated. Take home message: In most cases, cluster headache can be treated sufficiently (i.e., with sufficient quality of life) by an individual concept of acute and prophylactic drug treatment.

PMID: 20569084 [PubMed - as supplied by publisher]

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Weekend hospital admission, acute kidney injury, and mortality.

J Am Soc Nephrol. 2010 May;21(5):845-51

Authors: James MT, Wald R, Bell CM, Tonelli M, Hemmelgarn BR, Waikar SS, Chertow GM

Admission to the hospital on weekends is associated with increased mortality for several acute illnesses. We investigated whether patients admitted on a weekend with acute kidney injury (AKI) were more likely to die than those admitted on a weekday. Using the Nationwide Inpatient Sample, a large database of admissions to acute care, nonfederal hospitals in the United States, we identified 963,730 admissions with a diagnosis of AKI between 2003 and 2006. Of these, 214,962 admissions (22%) designated AKI as the primary reason for admission (45,203 on a weekend and 169,759 on a weekday). We used logistic regression models to examine the adjusted odds of in-hospital mortality associated with weekend versus weekday admission. Compared with admission on a weekday, patients admitted with a primary diagnosis of AKI on a weekend had a higher odds of death [adjusted odds ratio (OR) 1.07, 95% confidence interval (CI) 1.02 to 1.12]. The risk for death with admission on a weekend for AKI was more pronounced in smaller hospitals (adjusted OR 1.17, 95% CI 1.03 to 1.33) compared with larger hospitals (adjusted OR 1.07, 95% CI 1.01 to 1.13). Increased mortality was also associated with weekend admission among patients with AKI as a secondary diagnosis across a spectrum of co-existing medical diagnoses. In conclusion, among patients hospitalized with AKI, weekend admission is associated with a higher risk for death compared with admission on a weekday.

PMID: 20395373 [PubMed - indexed for MEDLINE]

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