Ella Choe, MD

 

Clinical question: Which hospitalized older patients are inappropriately prescribed benzodiazepines or sedative hypnotics post discharge, and who is prescribing these medications?

Background: During hospitalization, older patients commonly suffer from agitation and insomnia. Unfortunately, benzodiazepines and sedative hypnotics are commonly used as first-line treatments for these conditions despite significant risk which includes cognitive impairment, postural instability, increased risk of falls and hip fracture as well as lack of effectiveness. The purpose of this study is to determine the magnitude of the issue, discover root causes, and determine the type or types of corrective action needed.

Study Design: Single-center retrospective observational study.

Setting: Urban academic medical center in Toronto.

Synopsis: Patient- and prescriber-level variables were identified and associated with potentially inappropriate newly prescribed benzodiazepine or sedative-hypnotics to medical-surgical inpatients aged 65 or older (regular users were excluded), which amounted to 208 patients of the 1,308 patients studied. The majority of the indications were for insomnia or agitation/anxiety prescribed overnight with 222 out of 1,308 patients (15.9%).

There was significant increase in these prescriptions if the patient was admitted to a surgical or specialty service compared to the general internal medicine service (odds ratio, 6.61; 95% confidence interval, 2.70-16.17). First-year trainees prescribed these medications more than did attending or fellows (OR, 0.28; 95% CI, 0.08-0.93).

Study limitations include being from a single institution, not being blinded, and inadequate statistical power. Therefore, it may lack generalizability, may be subjected to observer bias, and may not detect significant effects of covariates.

Bottom line: Sleep disruption and poor quality of sleep were the primary reason for the majority of potentially inappropriate newly prescribed benzodiazepines and sedative hypnotics, with first-year trainees being more likely to prescribe these medications compared to attendings and fellows.

Citation: Pek EA, Ramfry A, Pendrith C, et al. High prevalence of inappropriate benzodiazepine and sedative hypnotic prescriptions among hospitalized older adults. J Hosp Med. 2017 May;12(5):310-6.

Dr. Choe is a hospitalist at Ochsner Health System, New Orleans.

 

Clinical question: Which hospitalized older patients are inappropriately prescribed benzodiazepines or sedative hypnotics post discharge, and who is prescribing these medications?

Background: During hospitalization, older patients commonly suffer from agitation and insomnia. Unfortunately, benzodiazepines and sedative hypnotics are commonly used as first-line treatments for these conditions despite significant risk which includes cognitive impairment, postural instability, increased risk of falls and hip fracture as well as lack of effectiveness. The purpose of this study is to determine the magnitude of the issue, discover root causes, and determine the type or types of corrective action needed.

Study Design: Single-center retrospective observational study.

Setting: Urban academic medical center in Toronto.

Synopsis: Patient- and prescriber-level variables were identified and associated with potentially inappropriate newly prescribed benzodiazepine or sedative-hypnotics to medical-surgical inpatients aged 65 or older (regular users were excluded), which amounted to 208 patients of the 1,308 patients studied. The majority of the indications were for insomnia or agitation/anxiety prescribed overnight with 222 out of 1,308 patients (15.9%).

There was significant increase in these prescriptions if the patient was admitted to a surgical or specialty service compared to the general internal medicine service (odds ratio, 6.61; 95% confidence interval, 2.70-16.17). First-year trainees prescribed these medications more than did attending or fellows (OR, 0.28; 95% CI, 0.08-0.93).

Study limitations include being from a single institution, not being blinded, and inadequate statistical power. Therefore, it may lack generalizability, may be subjected to observer bias, and may not detect significant effects of covariates.

Bottom line: Sleep disruption and poor quality of sleep were the primary reason for the majority of potentially inappropriate newly prescribed benzodiazepines and sedative hypnotics, with first-year trainees being more likely to prescribe these medications compared to attendings and fellows.

Citation: Pek EA, Ramfry A, Pendrith C, et al. High prevalence of inappropriate benzodiazepine and sedative hypnotic prescriptions among hospitalized older adults. J Hosp Med. 2017 May;12(5):310-6.

Dr. Choe is a hospitalist at Ochsner Health System, New Orleans.

 

Clinical question: Which hospitalized older patients are inappropriately prescribed benzodiazepines or sedative hypnotics post discharge, and who is prescribing these medications?

Background: During hospitalization, older patients commonly suffer from agitation and insomnia. Unfortunately, benzodiazepines and sedative hypnotics are commonly used as first-line treatments for these conditions despite significant risk which includes cognitive impairment, postural instability, increased risk of falls and hip fracture as well as lack of effectiveness. The purpose of this study is to determine the magnitude of the issue, discover root causes, and determine the type or types of corrective action needed.

Study Design: Single-center retrospective observational study.

Setting: Urban academic medical center in Toronto.

Synopsis: Patient- and prescriber-level variables were identified and associated with potentially inappropriate newly prescribed benzodiazepine or sedative-hypnotics to medical-surgical inpatients aged 65 or older (regular users were excluded), which amounted to 208 patients of the 1,308 patients studied. The majority of the indications were for insomnia or agitation/anxiety prescribed overnight with 222 out of 1,308 patients (15.9%).

There was significant increase in these prescriptions if the patient was admitted to a surgical or specialty service compared to the general internal medicine service (odds ratio, 6.61; 95% confidence interval, 2.70-16.17). First-year trainees prescribed these medications more than did attending or fellows (OR, 0.28; 95% CI, 0.08-0.93).

Study limitations include being from a single institution, not being blinded, and inadequate statistical power. Therefore, it may lack generalizability, may be subjected to observer bias, and may not detect significant effects of covariates.

Bottom line: Sleep disruption and poor quality of sleep were the primary reason for the majority of potentially inappropriate newly prescribed benzodiazepines and sedative hypnotics, with first-year trainees being more likely to prescribe these medications compared to attendings and fellows.

Citation: Pek EA, Ramfry A, Pendrith C, et al. High prevalence of inappropriate benzodiazepine and sedative hypnotic prescriptions among hospitalized older adults. J Hosp Med. 2017 May;12(5):310-6.

Dr. Choe is a hospitalist at Ochsner Health System, New Orleans.

Clinical question: Does early identification and treatment of sepsis using protocols improve outcomes?

Background: International clinical guidelines recommend early detection and treatment of sepsis with broad spectrum antibiotics and intravenous fluids which are supported by preclinical and observation studies that show a reduction in avoidable deaths. However, controversy remains in the timing of these treatments on how it relates to patient outcomes such as risk-adjusted mortality.

Study design: Retrospective cohort study using data reported to the New York State Department of Health from April 1, 2014, to June 30, 2016.

Setting: New York hospitals.

Synopsis: For patients with sepsis and septic shock, a sepsis protocol was initiated within 6 hours after arrival in the emergency department and had all items in a 3-hour bundle of care (that is, blood cultures, broad-spectrum antibiotic, and lactate measurement) completed within 12 hours. Among 49,331 patients at 149 hospitals, higher risk-adjusted in-hospital mortality was associated with longer time to the completion of the bundle (P less than .001), administration of antibiotics (P less than .001), but not completion of a bolus of intravenous fluids (P = .21).

Study limitations include being nonrandomized, hospitals all from one state possibly introducing epidemiologic distinct features of sepsis inherent to the region, and accuracy of the data collection (that is, start time).

No association was found between time to completion of the initial bolus of fluids and improved outcomes in risk-adjusted mortality; however, the analysis of time of the initial fluid bolus was most vulnerable to confounding; a causal relationship will need further study.

Bottom line: A lower risk-adjusted in-hospital mortality was associated with rapid administration of antibiotics and a faster completion of a 3-hour bundle of sepsis care, but there was no discernable association with the rapid administration of initial bolus of intravenous fluids.

Citation: Seymour CW, Gesten F, Prescott HC, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med. 2017; 376:2235-44.

Dr. Choe is a hospitalist at Ochsner Health System, New Orleans.

Clinical question: Does early identification and treatment of sepsis using protocols improve outcomes?

Background: International clinical guidelines recommend early detection and treatment of sepsis with broad spectrum antibiotics and intravenous fluids which are supported by preclinical and observation studies that show a reduction in avoidable deaths. However, controversy remains in the timing of these treatments on how it relates to patient outcomes such as risk-adjusted mortality.

Study design: Retrospective cohort study using data reported to the New York State Department of Health from April 1, 2014, to June 30, 2016.

Setting: New York hospitals.

Synopsis: For patients with sepsis and septic shock, a sepsis protocol was initiated within 6 hours after arrival in the emergency department and had all items in a 3-hour bundle of care (that is, blood cultures, broad-spectrum antibiotic, and lactate measurement) completed within 12 hours. Among 49,331 patients at 149 hospitals, higher risk-adjusted in-hospital mortality was associated with longer time to the completion of the bundle (P less than .001), administration of antibiotics (P less than .001), but not completion of a bolus of intravenous fluids (P = .21).

Study limitations include being nonrandomized, hospitals all from one state possibly introducing epidemiologic distinct features of sepsis inherent to the region, and accuracy of the data collection (that is, start time).

No association was found between time to completion of the initial bolus of fluids and improved outcomes in risk-adjusted mortality; however, the analysis of time of the initial fluid bolus was most vulnerable to confounding; a causal relationship will need further study.

Bottom line: A lower risk-adjusted in-hospital mortality was associated with rapid administration of antibiotics and a faster completion of a 3-hour bundle of sepsis care, but there was no discernable association with the rapid administration of initial bolus of intravenous fluids.

Citation: Seymour CW, Gesten F, Prescott HC, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med. 2017; 376:2235-44.

Dr. Choe is a hospitalist at Ochsner Health System, New Orleans.

Clinical question: Does early identification and treatment of sepsis using protocols improve outcomes?

Background: International clinical guidelines recommend early detection and treatment of sepsis with broad spectrum antibiotics and intravenous fluids which are supported by preclinical and observation studies that show a reduction in avoidable deaths. However, controversy remains in the timing of these treatments on how it relates to patient outcomes such as risk-adjusted mortality.

Study design: Retrospective cohort study using data reported to the New York State Department of Health from April 1, 2014, to June 30, 2016.

Setting: New York hospitals.

Synopsis: For patients with sepsis and septic shock, a sepsis protocol was initiated within 6 hours after arrival in the emergency department and had all items in a 3-hour bundle of care (that is, blood cultures, broad-spectrum antibiotic, and lactate measurement) completed within 12 hours. Among 49,331 patients at 149 hospitals, higher risk-adjusted in-hospital mortality was associated with longer time to the completion of the bundle (P less than .001), administration of antibiotics (P less than .001), but not completion of a bolus of intravenous fluids (P = .21).

Study limitations include being nonrandomized, hospitals all from one state possibly introducing epidemiologic distinct features of sepsis inherent to the region, and accuracy of the data collection (that is, start time).

No association was found between time to completion of the initial bolus of fluids and improved outcomes in risk-adjusted mortality; however, the analysis of time of the initial fluid bolus was most vulnerable to confounding; a causal relationship will need further study.

Bottom line: A lower risk-adjusted in-hospital mortality was associated with rapid administration of antibiotics and a faster completion of a 3-hour bundle of sepsis care, but there was no discernable association with the rapid administration of initial bolus of intravenous fluids.

Citation: Seymour CW, Gesten F, Prescott HC, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med. 2017; 376:2235-44.

Dr. Choe is a hospitalist at Ochsner Health System, New Orleans.