Reducing Inappropriate Urinary Catheter Use: A Statewide Effort.

Arch Intern Med. 2012 Jan 9;

Authors: Fakih MG, Watson SR, Greene MT, Kennedy EH, Olmsted RN, Krein SL, Saint S

Abstract
BACKGROUND: Indwelling urinary catheters may lead to both infectious and noninfectious complications and are often used in the hospital setting without an appropriate indication. The objective of this study was to evaluate the results of a statewide quality improvement effort to reduce inappropriate urinary catheter use. METHODS: Retrospective analysis of data collected between 2007 and 2010 as part of a statewide collaborative initiative before, during, and after an educational intervention promoting adherence to appropriate urinary catheter indications. The data were collected from 163 inpatient units in 71 participating Michigan hospitals. The intervention consisted of educating clinicians about the appropriate indications for urinary catheter use and promoting the daily assessment of urinary catheter necessity during daily nursing rounds. The main outcome measures were change in prevalence of urinary catheter use and adherence to appropriate indications. We used flexible generalized estimating equation (GEE) and multilevel methods to estimate rates over time while accounting for the clustering of patients within hospital units. RESULTS: The urinary catheter use rate decreased from 18.1% (95% CI, 16.8%-19.6%) at baseline to 13.8% (95% CI, 12.9%-14.8%) at end of year 2 (P < .001). The proportion of catheterized patients with appropriate indications increased from 44.3% (95% CI, 40.3%-48.4%) to 57.6% (95% CI, 51.7%-63.4%) by the end of year 2 (P = .005). CONCLUSIONS: A statewide effort to reduce inappropriate urinary catheter use was associated with a significant reduction in catheter use and improved compliance with appropriate use. The effect of the intervention was sustained for at least 2 years.

PMID: 22231611 [PubMed - as supplied by publisher]

Overtreatment of enterococcal bacteriuria.

Arch Intern Med. 2012 Jan 9;172(1):33-8

Authors: Lin E, Bhusal Y, Horwitz D, Shelburne SA, Trautner BW

Abstract
BACKGROUND: The purposes of this study were to investigate the clinical outcomes of enterococcal bacteriuria and to determine whether current management is adherent to Infectious Diseases Society of America guidelines.
METHODS: We conducted a retrospective medical record review of patients from 2 academic teaching hospitals for 3 months (September 1 through November 30, 2009). Patients were classified as having urinary tract infection (UTI) or asymptomatic bacteriuria (ABU) by applying the guidelines. Antibiotic use was deemed appropriate in patients with UTI and inappropriate in ABU. Medical records were reviewed for Enterococcus cultured from another sterile site within 30 days.
RESULTS: A total of 375 urine cultures growing Enterococcus were reviewed, with 339 cultures meeting inclusion criteria. Of these 339 episodes, 183 (54.0%) were classified as ABU and 156 (46.0%) as UTI. In 289 episodes accompanied by urinalysis, pyuria was associated with UTI in 98 of 140 episodes (70.0%) compared with 63 of 149 episodes of ABU (42.3%) (odds ratio, 3.19; 95% CI, 1.96-5.18). Providers inappropriately treated 60 of 183 episodes of ABU (32.8%) with antibiotics. In multivariate analysis, only pyuria was associated with the inappropriate use of antibiotics (odds ratio, 3.27; 95% CI, 1.49-7.18). Only 7 subsequent infections with Enterococcus occurred in the 339 episodes of bacteriuria overall (2.1%), with 2 of the 183 cases of ABU (1.1%) having distant infection.
CONCLUSIONS: Providers often overtreat enterococcal ABU with antibiotics, particularly in patients with pyuria. Given the low incidence of infectious complications, efforts should be made to optimize the use of antibiotics in enterococcal bacteriuria.

PMID: 22232145 [PubMed - in process]

The Transitionalist: Optimizing Inpatient-to-Outpatient Transitions of Care.

Arch Intern Med. 2012 Jan 9;172(1):81

Authors: Ota KS

PMID: 22232157 [PubMed - in process]

Dabigatran Association With Higher Risk of Acute Coronary Events: Meta-analysis of Noninferiority Randomized Controlled Trials.

Arch Intern Med. 2012 Jan 9;

Authors: Uchino K, Hernandez AV

Abstract
BACKGROUND: The original RE-LY (Randomized Evaluation of Long-term Anticoagulant Therapy) trial suggested a small increased risk of myocardial infarction (MI) with the use of dabigatran etexilate vs warfarin in patients with atrial fibrillation. We systematically evaluated the risk of MI or acute coronary syndrome (ACS) with the use of dabigatran. METHODS: We searched PubMed, Scopus, and the Web of Science for randomized controlled trials of dabigatran that reported on MI or ACS as secondary outcomes. The fixed-effects Mantel-Haenszel (M-H) test was used to evaluate the effect of dabigatran on MI or ACS. We expressed the associations as odds ratios (ORs) and their 95% CIs. RESULTS: Seven trials were selected (N = 30 514), including 2 studies of stroke prophylaxis in atrial fibrillation, 1 in acute venous thromboembolism, 1 in ACS, and 3 of short-term prophylaxis of deep venous thrombosis. Control arms included warfarin, enoxaparin, or placebo administration. Dabigatran was significantly associated with a higher risk of MI or ACS than that seen with agents used in the control group (dabigatran, 237 of 20 000 [1.19%] vs control, 83 of 10 514 [0.79%]; OR(M-H), 1.33; 95% CI, 1.03-1.71; P = .03). The risk of MI or ACS was similar when using revised RE-LY trial results (OR(M-H), 1.27; 95% CI, 1.00-1.61; P = .05) or after exclusion of short-term trials (OR(M-H), 1.33; 95% CI, 1.03-1.72; P = .03). Risks were not heterogeneous for all analyses (I(2) = 0%; P ? .30) and were consistent using different methods and measures of association. CONCLUSIONS: Dabigatran is associated with an increased risk of MI or ACS in a broad spectrum of patients when tested against different controls. Clinicians should consider the potential of these serious harmful cardiovascular effects with use of dabigatran.

PMID: 22231617 [PubMed - as supplied by publisher]

Efficacy of corticosteroid therapy in patients with an acute exacerbation of chronic obstructive pulmonary disease receiving ventilatory support.

Arch Intern Med. 2011 Nov 28;171(21):1939-46

Authors: Alía I, de la Cal MA, Esteban A, Abella A, Ferrer R, Molina FJ, Torres A, Gordo F, Elizalde JJ, de Pablo R, Huete A, Anzueto A

Abstract
BACKGROUND: Randomized trials assessing the effect of systemic corticosteroids on chronic obstructive pulmonary disease (COPD) exacerbations excluded patients who were mechanically ventilated or admitted to the intensive care unit (ICU). Critically ill patients constitute a population of persons who are prone to develop complications that are potentially associated with the use of corticosteroids (eg, infections, hyperglycemia, ICU-acquired paresis) that could prolong the duration of mechanical ventilation and even increase mortality.
METHODS: A double-blind placebo-controlled trial was conducted to evaluate the efficacy and safety of systemic corticosteroid treatment in patients with an exacerbation of COPD who were receiving ventilatory support (invasive or noninvasive mechanical ventilation). A total of 354 adult patients who were admitted to the ICUs of 8 hospitals in 4 countries from July 2005 through July 2009 were screened, and 83 were randomized to receive intravenous methylprednisolone (0.5 mg/kg every 6 hours for 72 hours, 0.5 mg/kg every 12 hours on days 4 through 6, and 0.5 mg/kg/d on days 7 through 10) or placebo. The main outcome measures were duration of mechanical ventilation, length of ICU stay, and need for intubation in patients treated with noninvasive mechanical ventilation.
RESULTS: There were no significant differences between the groups in demographics, severity of illness, reasons for COPD exacerbation, gas exchange variables, and corticosteroid rescue treatment. Corticosteroid treatment was associated with a significant reduction in the median duration of mechanical ventilation (3 days vs 4 days; P = .04), a trend toward a shorter median length of ICU stay (6 days vs 7 days; P = .09), and significant reduction in the rate of NIV failure (0% vs 37%; P = .04).
CONCLUSION: Systemic corticosteroid therapy in patients with COPD exacerbations requiring mechanical ventilation is associated with a significant increase in the success of noninvasive mechanical ventilation and a reduction in the duration of mechanical ventilation Trial Registration  clinicaltrials.gov Identifier: NCT01281748.

PMID: 22123804 [PubMed - in process]

Diagnostic Blood Loss From Phlebotomy and Hospital-Acquired Anemia During Acute Myocardial Infarction.

Arch Intern Med. 2011 Aug 8;

Authors: Salisbury AC, Reid KJ, Alexander KP, Masoudi FA, Lai SM, Chan PS, Bach RG, Wang TY, Spertus JA, Kosiborod M

BACKGROUND: Hospital-acquired anemia (HAA) during acute myocardial infarction (AMI) is associated with higher mortality and worse health status and often develops in the absence of recognized bleeding. The extent to which diagnostic phlebotomy, a modifiable process of care, contributes to HAA is unknown. METHODS: We studied 17 676 patients with AMI from 57 US hospitals included in a contemporary AMI database from January 1, 2000, through December 31, 2008, who were not anemic at admission but developed moderate to severe HAA (in which the hemoglobin level declined from normal to <11 g/dL), a degree of HAA that has been shown to be prognostically important. Patients' total diagnostic blood loss was calculated by multiplying the number and types of blood tubes drawn by the standard volume for each tube type. Hierarchical modified Poisson regression was used to test the association between phlebotomy and moderate to severe HAA, after adjusting for site and potential confounders. RESULTS: Moderate to severe HAA developed in 3551 patients (20%). The mean (SD) phlebotomy volume was higher in patients with HAA (173.8 [139.3] mL) vs those without HAA (83.5 [52.0 mL]; P < .001). There was significant variation in the mean diagnostic blood loss across hospitals (moderate to severe HAA: range, 119.1-246.0 mL; mild HAA or no HAA: 53.0-110.1 mL). For every 50 mL of blood drawn, the risk of moderate to severe HAA increased by 18% (relative risk [RR], 1.18; 95% confidence interval [CI], 1.13-1.22), which was only modestly attenuated after multivariable adjustment (RR, 1.15; 95% CI, 1.12-1.18). CONCLUSIONS: Blood loss from greater use of phlebotomy is independently associated with the development of HAA. These findings suggest that HAA may be preventable by implementing strategies to limit blood loss from laboratory testing.

PMID: 21824940 [PubMed - as supplied by publisher]

Procalcitonin algorithms for antibiotic therapy decisions: a systematic review of randomized controlled trials and recommendations for clinical algorithms.

Arch Intern Med. 2011 Aug 8;171(15):1322-31

Authors: Schuetz P, Chiappa V, Briel M, Greenwald JL

Previous randomized controlled trials suggest that using clinical algorithms based on procalcitonin levels, a marker of bacterial infections, results in reduced antibiotic use without a deleterious effect on clinical outcomes. However, algorithms differed among trials and were embedded primarily within the European health care setting. Herein, we summarize the design, efficacy, and safety of previous randomized controlled trials and propose adapted algorithms for US settings. We performed a systematic search and included all 14 randomized controlled trials (N = 4467 patients) that investigated procalcitonin algorithms for antibiotic treatment decisions in adult patients with respiratory tract infections and sepsis from primary care, emergency department (ED), and intensive care unit settings. We found no significant difference in mortality between procalcitonin-treated and control patients overall (odds ratio, 0.91; 95% confidence interval, 0.73-1.14) or in primary care (0.13; 0-6.64), ED (0.95; 0.67-1.36), and intensive care unit (0.89; 0.66-1.20) settings individually. A consistent reduction was observed in antibiotic prescription and/or duration of therapy, mainly owing to lower prescribing rates in low-acuity primary care and ED patients, and shorter duration of therapy in moderate- and high-acuity ED and intensive care unit patients. Measurement of procalcitonin levels for antibiotic decisions in patients with respiratory tract infections and sepsis appears to reduce antibiotic exposure without worsening the mortality rate. We propose specific procalcitonin algorithms for low-, moderate-, and high-acuity patients as a basis for future trials aiming at reducing antibiotic overconsumption.

PMID: 21824946 [PubMed - in process]

Utility of clinical examination in the diagnosis of emergency department patients admitted to the department of medicine of an academic hospital.

Arch Intern Med. 2011 Aug 8;171(15):1394-6

Authors: Paley L, Zornitzki T, Cohen J, Friedman J, Kozak N, Schattner A

PMID: 21824956 [PubMed - in process]

Process changes to increase compliance with the universal protocol for bedside procedures.

Arch Intern Med. 2011 May 23;171(10):947-9

Authors: Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV

PMID: 21606103 [PubMed - indexed for MEDLINE]

Potentially Inappropriate Medications Defined by STOPP Criteria and the Risk of Adverse Drug Events in Older Hospitalized Patients.

Arch Intern Med. 2011 Jun 13;171(11):1013-9

Authors: Hamilton H, Gallagher P, Ryan C, Byrne S, O'Mahony D

Previous studies have not demonstrated a consistent association between potentially inappropriate medicines (PIMs) in older patients as defined by Beers criteria and avoidable adverse drug events (ADEs). This study aimed to assess whether PIMs defined by new STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) criteria are significantly associated with ADEs in older people with acute illness.

PMID: 21670370 [PubMed - in process]

Nonmedical use of opioid analgesics obtained directly from physicians: prevalence and correlates.

Arch Intern Med. 2011 Jun 13;171(11):1034-6

Authors: Becker WC, Tobin DG, Fiellin DA

PMID: 21670373 [PubMed - in process]

Effect of computerized physician order entry on radiologic examination order indication quality.

Arch Intern Med. 2011 Jun 13;171(11):1036-8

Authors: Schneider E, Franz W, Spitznagel R, Bascom DA, Obuchowski NA

PMID: 21670374 [PubMed - in process]

The optimal delivery of palliative care: a national comparison of the outcomes of consultation teams vs inpatient units.

Arch Intern Med. 2011 Apr 11;171(7):649-55

Authors: Casarett D, Johnson M, Smith D, Richardson D

Growing attention to end-of-life care has led to intensive efforts to provide better palliative care. However, it is not known whether palliative care is best provided by consultative teams or in dedicated units.

PMID: 21482838 [PubMed - indexed for MEDLINE]

Hypomagnesemia and Proton Pump Inhibitors: Below the Tip of the Iceberg.

Arch Intern Med. 2011 May 9;

Authors: Furlanetto TW, Faulhaber GA

Severe magnesium deficiency associated with proton pump inhibitors (PPIs) has been described recently with clinical presentations varying from life-threatening conditions to muscle cramps and paresthesias. Probably milder cases go undetected. We report an asymptomatic case of hypomagnesemia associated with chronic use of PPIs in a 67-year-old woman. She had had symptoms of gastroesophageal reflux disease for several years, which abated partially with PPIs, and denied any other symptoms or medications. Her initial evaluation showed an unexplained hypomagnesemia with a very low magnesium excretion rate in urine. Serum calcium, phosphorus, potassium, and glucose levels and renal function were normal. After PPI withdrawal, serum and urinary magnesium levels normalized.

PMID: 21555654 [PubMed - as supplied by publisher]

Time trends in pulmonary embolism in the United States: evidence of overdiagnosis.

Arch Intern Med. 2011 May 9;171(9):831-7

Authors: Wiener RS, Schwartz LM, Woloshin S

Computed tomographic pulmonary angiography (CTPA) may improve detection of life-threatening pulmonary embolism (PE), but this sensitive test may have a downside: overdiagnosis and overtreatment (finding clinically unimportant emboli and exposing patients to harms from unnecessary treatment).

PMID: 21555660 [PubMed - in process]