Delayed diagnosis of, or treatment for, a spinal epidural abscess (SEA): that will be the case over which you are sued.

Over the last 15 years, I’ve served as an expert witness for six or seven malpractice cases. Most were related to spinal cord injuries, and in all but one of those, the etiology was epidural abscess. I’ve been asked to review about 40 or 50 additional cases, and while I’ve turned them down (I just don’t have time to do reviews), I nearly always ask about the clinical picture in every case. A significant number have been SEA-related. This experience has convinced me that SEA poses a particular liability risk for hospitalists.

Of course, it is patients who bear the real risk and unfortunate consequences of SEA. Being a defendant physician in a lawsuit is stressful, but it’s nothing compared to the distress of permanent loss of neurologic function. To prevent permanent sequelae, we need to maintain a very high index of suspicion to try to make a prompt diagnosis, and ensure immediate intervention once the diagnosis is made.

Data from Malpractice Insurers

I had the pleasure of getting to know a number of leaders at The Doctor’s Company, a large malpractice insurer that provides malpractice policies for all specialties, including a lot of hospitalists. From 2007 to 2011, they closed 28 SEA-related claims, for which they spent an average of $212,000 defending each one. Eleven of the 28 resulted in indemnity payments averaging $754,000 each (median was $455,000). These dollar amounts are roughly double what might be seen for all other claims and reflect only the payments made on behalf of the company’s insured doctors. The total award to each patient was likely much higher, because in most cases, several defendants (other doctors and a hospital) probably paid money to the patient.

The Physician Insurers Association of America (PIAA) “is the insurance industry trade association representing domestic and international medical professional liability insurance companies.” Their member malpractice insurance companies have the opportunity to report claims data that PIAA aggregates and makes available. Data from 2002 to 2011 showed 312 closed claims related to any diagnosis (not just SEA) for hospitalists, with an average indemnity payment of $272,553 (the highest hospitalist-related payment was $1.4 million). The most common allegations related to paid claims were 1) “errors in diagnosis,” 2) “failure/delay in referral or consultation,” and 3) “failure to supervise/monitor case.” Although only three of the 312 claims were related to “diseases of the spinal cord,” that was exceeded in frequency only by “diabetes.”

I think these numbers from the malpractice insurance industry support my concern that SEA is a high-risk area, but it doesn’t really support my anecdotal experience that SEA is clearly hospitalists’ highest-risk area. Maybe SEA is only one of several high-risk areas. Nevertheless, I’m going to stick to my sensationalist guns to get your attention.

Why Is Epidural Abscess a High Risk?

There likely are several reasons SEA is a treacherous liability problem. It can lead to devastating permanent disabling neurologic deficits in people who were previously healthy, and if the medical care was substandard, then significant financial compensation seems appropriate.

Delays in diagnosis of SEA are common. It can be a very sneaky illness that in the early stages is very easy to confuse with less-serious causes of back pain or fever. Even though I think about this particular diagnosis all the time, just last year I had a patient who reported an increase in his usual back pain. I felt reassured that he had no neurologic deficit or fever, and took the time to explain why there was no reason to repeat the spine MRI that had been done about two weeks prior to admission. But he was insistent that he have another MRI, and after a day or two I finally agreed to order it, assuring him it would not explain the cause of his pain. But it did. He had a significant SEA and went to emergency surgery. I was stunned, and profoundly relieved that he had no neurologic sequelae.

One of the remarkable things I’ve seen in the cases I’ve reviewed is that even when there is clear cause for concern, there is too often no action taken. In a number of cases, the nurses’ note indicates increasing back pain, loss of ability to stand, urinary retention, and other alarming signs. Yet the doctors either never learn of these issues, or they choose to attribute them to other causes.

Even when the diagnosis of SEA is clearly established, it is all too common for doctors caring for the patient not to act on this information. In several cases I reviewed, a radiologist had documented reporting the diagnosis to the hospitalist (and in one case the neurosurgeon as well), yet nothing was done for 12 hours or more. It is hard to imagine that establishing this diagnosis doesn’t reliably lead to an emergent response, but it doesn’t. (In some cases, nonsurgical management may be an option, but in these malpractices cases, there was just a failure to act on the diagnosis with any sort of plan.)

Practice Management Perspective

I usually discuss hospitalist practice operations in this space—things like work schedules and compensation. But attending to risk management is one component of effective practice operations, so I thought I’d raise the topic here. Obviously, there is a lot more to hospitalist risk management than one diagnosis, but a column on the whole universe of risk management would probably serve no purpose other than as a sleep aid. I hope that by focusing solely on SEA, there is some chance that you’ll remember it, and you’ll make sure that you disprove my first two sentences.

Lowering your risk of a malpractice lawsuit is valuable and worth spending time on. But far more important is that by keeping the diagnosis in mind, and ensuring that you act emergently when there is cause for concern, you might save someone from the devastating consequences of this disease.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Delayed diagnosis of, or treatment for, a spinal epidural abscess (SEA): that will be the case over which you are sued.

Over the last 15 years, I’ve served as an expert witness for six or seven malpractice cases. Most were related to spinal cord injuries, and in all but one of those, the etiology was epidural abscess. I’ve been asked to review about 40 or 50 additional cases, and while I’ve turned them down (I just don’t have time to do reviews), I nearly always ask about the clinical picture in every case. A significant number have been SEA-related. This experience has convinced me that SEA poses a particular liability risk for hospitalists.

Of course, it is patients who bear the real risk and unfortunate consequences of SEA. Being a defendant physician in a lawsuit is stressful, but it’s nothing compared to the distress of permanent loss of neurologic function. To prevent permanent sequelae, we need to maintain a very high index of suspicion to try to make a prompt diagnosis, and ensure immediate intervention once the diagnosis is made.

Data from Malpractice Insurers

I had the pleasure of getting to know a number of leaders at The Doctor’s Company, a large malpractice insurer that provides malpractice policies for all specialties, including a lot of hospitalists. From 2007 to 2011, they closed 28 SEA-related claims, for which they spent an average of $212,000 defending each one. Eleven of the 28 resulted in indemnity payments averaging $754,000 each (median was $455,000). These dollar amounts are roughly double what might be seen for all other claims and reflect only the payments made on behalf of the company’s insured doctors. The total award to each patient was likely much higher, because in most cases, several defendants (other doctors and a hospital) probably paid money to the patient.

The Physician Insurers Association of America (PIAA) “is the insurance industry trade association representing domestic and international medical professional liability insurance companies.” Their member malpractice insurance companies have the opportunity to report claims data that PIAA aggregates and makes available. Data from 2002 to 2011 showed 312 closed claims related to any diagnosis (not just SEA) for hospitalists, with an average indemnity payment of $272,553 (the highest hospitalist-related payment was $1.4 million). The most common allegations related to paid claims were 1) “errors in diagnosis,” 2) “failure/delay in referral or consultation,” and 3) “failure to supervise/monitor case.” Although only three of the 312 claims were related to “diseases of the spinal cord,” that was exceeded in frequency only by “diabetes.”

I think these numbers from the malpractice insurance industry support my concern that SEA is a high-risk area, but it doesn’t really support my anecdotal experience that SEA is clearly hospitalists’ highest-risk area. Maybe SEA is only one of several high-risk areas. Nevertheless, I’m going to stick to my sensationalist guns to get your attention.

Why Is Epidural Abscess a High Risk?

There likely are several reasons SEA is a treacherous liability problem. It can lead to devastating permanent disabling neurologic deficits in people who were previously healthy, and if the medical care was substandard, then significant financial compensation seems appropriate.

Delays in diagnosis of SEA are common. It can be a very sneaky illness that in the early stages is very easy to confuse with less-serious causes of back pain or fever. Even though I think about this particular diagnosis all the time, just last year I had a patient who reported an increase in his usual back pain. I felt reassured that he had no neurologic deficit or fever, and took the time to explain why there was no reason to repeat the spine MRI that had been done about two weeks prior to admission. But he was insistent that he have another MRI, and after a day or two I finally agreed to order it, assuring him it would not explain the cause of his pain. But it did. He had a significant SEA and went to emergency surgery. I was stunned, and profoundly relieved that he had no neurologic sequelae.

One of the remarkable things I’ve seen in the cases I’ve reviewed is that even when there is clear cause for concern, there is too often no action taken. In a number of cases, the nurses’ note indicates increasing back pain, loss of ability to stand, urinary retention, and other alarming signs. Yet the doctors either never learn of these issues, or they choose to attribute them to other causes.

Even when the diagnosis of SEA is clearly established, it is all too common for doctors caring for the patient not to act on this information. In several cases I reviewed, a radiologist had documented reporting the diagnosis to the hospitalist (and in one case the neurosurgeon as well), yet nothing was done for 12 hours or more. It is hard to imagine that establishing this diagnosis doesn’t reliably lead to an emergent response, but it doesn’t. (In some cases, nonsurgical management may be an option, but in these malpractices cases, there was just a failure to act on the diagnosis with any sort of plan.)

Practice Management Perspective

I usually discuss hospitalist practice operations in this space—things like work schedules and compensation. But attending to risk management is one component of effective practice operations, so I thought I’d raise the topic here. Obviously, there is a lot more to hospitalist risk management than one diagnosis, but a column on the whole universe of risk management would probably serve no purpose other than as a sleep aid. I hope that by focusing solely on SEA, there is some chance that you’ll remember it, and you’ll make sure that you disprove my first two sentences.

Lowering your risk of a malpractice lawsuit is valuable and worth spending time on. But far more important is that by keeping the diagnosis in mind, and ensuring that you act emergently when there is cause for concern, you might save someone from the devastating consequences of this disease.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Delayed diagnosis of, or treatment for, a spinal epidural abscess (SEA): that will be the case over which you are sued.

Over the last 15 years, I’ve served as an expert witness for six or seven malpractice cases. Most were related to spinal cord injuries, and in all but one of those, the etiology was epidural abscess. I’ve been asked to review about 40 or 50 additional cases, and while I’ve turned them down (I just don’t have time to do reviews), I nearly always ask about the clinical picture in every case. A significant number have been SEA-related. This experience has convinced me that SEA poses a particular liability risk for hospitalists.

Of course, it is patients who bear the real risk and unfortunate consequences of SEA. Being a defendant physician in a lawsuit is stressful, but it’s nothing compared to the distress of permanent loss of neurologic function. To prevent permanent sequelae, we need to maintain a very high index of suspicion to try to make a prompt diagnosis, and ensure immediate intervention once the diagnosis is made.

Data from Malpractice Insurers

I had the pleasure of getting to know a number of leaders at The Doctor’s Company, a large malpractice insurer that provides malpractice policies for all specialties, including a lot of hospitalists. From 2007 to 2011, they closed 28 SEA-related claims, for which they spent an average of $212,000 defending each one. Eleven of the 28 resulted in indemnity payments averaging $754,000 each (median was $455,000). These dollar amounts are roughly double what might be seen for all other claims and reflect only the payments made on behalf of the company’s insured doctors. The total award to each patient was likely much higher, because in most cases, several defendants (other doctors and a hospital) probably paid money to the patient.

The Physician Insurers Association of America (PIAA) “is the insurance industry trade association representing domestic and international medical professional liability insurance companies.” Their member malpractice insurance companies have the opportunity to report claims data that PIAA aggregates and makes available. Data from 2002 to 2011 showed 312 closed claims related to any diagnosis (not just SEA) for hospitalists, with an average indemnity payment of $272,553 (the highest hospitalist-related payment was $1.4 million). The most common allegations related to paid claims were 1) “errors in diagnosis,” 2) “failure/delay in referral or consultation,” and 3) “failure to supervise/monitor case.” Although only three of the 312 claims were related to “diseases of the spinal cord,” that was exceeded in frequency only by “diabetes.”

I think these numbers from the malpractice insurance industry support my concern that SEA is a high-risk area, but it doesn’t really support my anecdotal experience that SEA is clearly hospitalists’ highest-risk area. Maybe SEA is only one of several high-risk areas. Nevertheless, I’m going to stick to my sensationalist guns to get your attention.

Why Is Epidural Abscess a High Risk?

There likely are several reasons SEA is a treacherous liability problem. It can lead to devastating permanent disabling neurologic deficits in people who were previously healthy, and if the medical care was substandard, then significant financial compensation seems appropriate.

Delays in diagnosis of SEA are common. It can be a very sneaky illness that in the early stages is very easy to confuse with less-serious causes of back pain or fever. Even though I think about this particular diagnosis all the time, just last year I had a patient who reported an increase in his usual back pain. I felt reassured that he had no neurologic deficit or fever, and took the time to explain why there was no reason to repeat the spine MRI that had been done about two weeks prior to admission. But he was insistent that he have another MRI, and after a day or two I finally agreed to order it, assuring him it would not explain the cause of his pain. But it did. He had a significant SEA and went to emergency surgery. I was stunned, and profoundly relieved that he had no neurologic sequelae.

One of the remarkable things I’ve seen in the cases I’ve reviewed is that even when there is clear cause for concern, there is too often no action taken. In a number of cases, the nurses’ note indicates increasing back pain, loss of ability to stand, urinary retention, and other alarming signs. Yet the doctors either never learn of these issues, or they choose to attribute them to other causes.

Even when the diagnosis of SEA is clearly established, it is all too common for doctors caring for the patient not to act on this information. In several cases I reviewed, a radiologist had documented reporting the diagnosis to the hospitalist (and in one case the neurosurgeon as well), yet nothing was done for 12 hours or more. It is hard to imagine that establishing this diagnosis doesn’t reliably lead to an emergent response, but it doesn’t. (In some cases, nonsurgical management may be an option, but in these malpractices cases, there was just a failure to act on the diagnosis with any sort of plan.)

Practice Management Perspective

I usually discuss hospitalist practice operations in this space—things like work schedules and compensation. But attending to risk management is one component of effective practice operations, so I thought I’d raise the topic here. Obviously, there is a lot more to hospitalist risk management than one diagnosis, but a column on the whole universe of risk management would probably serve no purpose other than as a sleep aid. I hope that by focusing solely on SEA, there is some chance that you’ll remember it, and you’ll make sure that you disprove my first two sentences.

Lowering your risk of a malpractice lawsuit is valuable and worth spending time on. But far more important is that by keeping the diagnosis in mind, and ensuring that you act emergently when there is cause for concern, you might save someone from the devastating consequences of this disease.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Dr. Hospitalist

I see more and more people taking one of the newer anticoagulants. I’ve also seen a few disasters with these drugs. What’s the story?

Stacy M. Harper, Green Bay, Wis.

Dr. Hospitalist responds:

Although warfarin (Coumadin) has been a mainstay anticoagulant for decades, it can often be a frustrating medicine to manage due to its myriad drug interactions and the constant need for therapeutic testing. Recently, we have seen new medications hit the market (with one more likely to be approved soon), each with its pros and cons. Here’s an overview:

• Dabigatran (Pradaxa): It’s a direct thrombin inhibitor, taken twice daily. It has been approved for use in stroke prevention for atrial fibrillation (afib) (RELY trial) at 150 mg bid. It’s also been extensively studied for VTE prevention after orthopedic surgery, but it has not yet been approved in the U.S. for this indication.

As with all of these drugs, there is no reversal agent and there are no levels to measure. A recent report noted an increased risk of bleeding in patients who are older, have a low BMI, or have renal dysfunction. The manufacturer recommends a dose of 75 mg bid for patients with renal dysfunction, defined as a GFR of 15 to 30 mL/min; however, that dosing regimen was never explicitly studied.

Overall, it’s become quite a popular drug with the cardiologists in my neck of the woods. GERD can be a bothersome side effect. I avoid using it in patients older than 80, or in a patient with any renal dysfunction. Also, remember that it is not approved for VTE prevention or treatment.

• Rivaroxaban (Xarelto): An oral factor Xa inhibitor. Usually taken once daily at 10 mg for VTE prevention (RECORD trials). It is dosed at 20 mg/day for stroke prevention in afib (ROCKET-AF trial). Just recently, it was approved by the FDA for use in the acute treatment of DVT and PE (EINSTEIN trial), dosed at 15 mg BID for the first 21 days, and then continued at 20 mg daily after the initial period (see “Game-Changer,” p. 41). It is more hepatically metabolized than dabigatran, but it still has a significant renal clearance component. When compared to lovenox in orthopedic patients, it’s as effective but with a slightly higher risk of bleeding. I would avoid using it in any patients with significant renal or hepatic dysfunction.
• Apixaban (Eliquis): Another oral factor Xa inhibitor. Studied at 2.5 mg BID for VTE prevention in orthopedic patients (ADVANCE trials). Studied at 5 mg BID for stroke prevention in afib (ARISTOTLE trial). It is not yet approved in the U.S for any indication, but a final decision is expected from the FDA by March. Overall, the data are fairly compelling, and it looks like a strong candidate. The data show a drug that is potentially more effective than lovenox, with less risk of bleeding for orthopedic patients. It is mainly hepatically metabolized.

So, with no drug company relationships to disclose, here are my general observations: For starters, I think dabigatran is being overused in older patients with renal dysfunction. I seem to stop it more than I recommend it, and it is far from my favorite drug. With rivaroxaban, it looks appropriate for VTE prevention, and now having the option of being able to transition patients who develop a clot onto a treatment dose of the drug is appealing. Apixaban’s data look the best out of all three agents in terms of both efficacy and bleeding, and although it is yet to be approved here, I imagine that will change in the near future. For all of these drugs, remember that we have no long-term safety data, and no reversal agents. It will be interesting to see how this plays out and which of these drugs have staying power. For all of warfarin’s faults, at least we know how to measure it and how to stop it.

Dr. Hospitalist

I see more and more people taking one of the newer anticoagulants. I’ve also seen a few disasters with these drugs. What’s the story?

Stacy M. Harper, Green Bay, Wis.

Dr. Hospitalist responds:

Although warfarin (Coumadin) has been a mainstay anticoagulant for decades, it can often be a frustrating medicine to manage due to its myriad drug interactions and the constant need for therapeutic testing. Recently, we have seen new medications hit the market (with one more likely to be approved soon), each with its pros and cons. Here’s an overview:

• Dabigatran (Pradaxa): It’s a direct thrombin inhibitor, taken twice daily. It has been approved for use in stroke prevention for atrial fibrillation (afib) (RELY trial) at 150 mg bid. It’s also been extensively studied for VTE prevention after orthopedic surgery, but it has not yet been approved in the U.S. for this indication.

As with all of these drugs, there is no reversal agent and there are no levels to measure. A recent report noted an increased risk of bleeding in patients who are older, have a low BMI, or have renal dysfunction. The manufacturer recommends a dose of 75 mg bid for patients with renal dysfunction, defined as a GFR of 15 to 30 mL/min; however, that dosing regimen was never explicitly studied.

Overall, it’s become quite a popular drug with the cardiologists in my neck of the woods. GERD can be a bothersome side effect. I avoid using it in patients older than 80, or in a patient with any renal dysfunction. Also, remember that it is not approved for VTE prevention or treatment.

• Rivaroxaban (Xarelto): An oral factor Xa inhibitor. Usually taken once daily at 10 mg for VTE prevention (RECORD trials). It is dosed at 20 mg/day for stroke prevention in afib (ROCKET-AF trial). Just recently, it was approved by the FDA for use in the acute treatment of DVT and PE (EINSTEIN trial), dosed at 15 mg BID for the first 21 days, and then continued at 20 mg daily after the initial period (see “Game-Changer,” p. 41). It is more hepatically metabolized than dabigatran, but it still has a significant renal clearance component. When compared to lovenox in orthopedic patients, it’s as effective but with a slightly higher risk of bleeding. I would avoid using it in any patients with significant renal or hepatic dysfunction.
• Apixaban (Eliquis): Another oral factor Xa inhibitor. Studied at 2.5 mg BID for VTE prevention in orthopedic patients (ADVANCE trials). Studied at 5 mg BID for stroke prevention in afib (ARISTOTLE trial). It is not yet approved in the U.S for any indication, but a final decision is expected from the FDA by March. Overall, the data are fairly compelling, and it looks like a strong candidate. The data show a drug that is potentially more effective than lovenox, with less risk of bleeding for orthopedic patients. It is mainly hepatically metabolized.

So, with no drug company relationships to disclose, here are my general observations: For starters, I think dabigatran is being overused in older patients with renal dysfunction. I seem to stop it more than I recommend it, and it is far from my favorite drug. With rivaroxaban, it looks appropriate for VTE prevention, and now having the option of being able to transition patients who develop a clot onto a treatment dose of the drug is appealing. Apixaban’s data look the best out of all three agents in terms of both efficacy and bleeding, and although it is yet to be approved here, I imagine that will change in the near future. For all of these drugs, remember that we have no long-term safety data, and no reversal agents. It will be interesting to see how this plays out and which of these drugs have staying power. For all of warfarin’s faults, at least we know how to measure it and how to stop it.

Dr. Hospitalist

I see more and more people taking one of the newer anticoagulants. I’ve also seen a few disasters with these drugs. What’s the story?

Stacy M. Harper, Green Bay, Wis.

Dr. Hospitalist responds:

Although warfarin (Coumadin) has been a mainstay anticoagulant for decades, it can often be a frustrating medicine to manage due to its myriad drug interactions and the constant need for therapeutic testing. Recently, we have seen new medications hit the market (with one more likely to be approved soon), each with its pros and cons. Here’s an overview:

• Dabigatran (Pradaxa): It’s a direct thrombin inhibitor, taken twice daily. It has been approved for use in stroke prevention for atrial fibrillation (afib) (RELY trial) at 150 mg bid. It’s also been extensively studied for VTE prevention after orthopedic surgery, but it has not yet been approved in the U.S. for this indication.

As with all of these drugs, there is no reversal agent and there are no levels to measure. A recent report noted an increased risk of bleeding in patients who are older, have a low BMI, or have renal dysfunction. The manufacturer recommends a dose of 75 mg bid for patients with renal dysfunction, defined as a GFR of 15 to 30 mL/min; however, that dosing regimen was never explicitly studied.

Overall, it’s become quite a popular drug with the cardiologists in my neck of the woods. GERD can be a bothersome side effect. I avoid using it in patients older than 80, or in a patient with any renal dysfunction. Also, remember that it is not approved for VTE prevention or treatment.

• Rivaroxaban (Xarelto): An oral factor Xa inhibitor. Usually taken once daily at 10 mg for VTE prevention (RECORD trials). It is dosed at 20 mg/day for stroke prevention in afib (ROCKET-AF trial). Just recently, it was approved by the FDA for use in the acute treatment of DVT and PE (EINSTEIN trial), dosed at 15 mg BID for the first 21 days, and then continued at 20 mg daily after the initial period (see “Game-Changer,” p. 41). It is more hepatically metabolized than dabigatran, but it still has a significant renal clearance component. When compared to lovenox in orthopedic patients, it’s as effective but with a slightly higher risk of bleeding. I would avoid using it in any patients with significant renal or hepatic dysfunction.
• Apixaban (Eliquis): Another oral factor Xa inhibitor. Studied at 2.5 mg BID for VTE prevention in orthopedic patients (ADVANCE trials). Studied at 5 mg BID for stroke prevention in afib (ARISTOTLE trial). It is not yet approved in the U.S for any indication, but a final decision is expected from the FDA by March. Overall, the data are fairly compelling, and it looks like a strong candidate. The data show a drug that is potentially more effective than lovenox, with less risk of bleeding for orthopedic patients. It is mainly hepatically metabolized.

So, with no drug company relationships to disclose, here are my general observations: For starters, I think dabigatran is being overused in older patients with renal dysfunction. I seem to stop it more than I recommend it, and it is far from my favorite drug. With rivaroxaban, it looks appropriate for VTE prevention, and now having the option of being able to transition patients who develop a clot onto a treatment dose of the drug is appealing. Apixaban’s data look the best out of all three agents in terms of both efficacy and bleeding, and although it is yet to be approved here, I imagine that will change in the near future. For all of these drugs, remember that we have no long-term safety data, and no reversal agents. It will be interesting to see how this plays out and which of these drugs have staying power. For all of warfarin’s faults, at least we know how to measure it and how to stop it.

INFLUENZA VACCINE EFFECTIVENESS VARIES BY AGE

Case-control study of the 2010-2011 influenza vaccine found overall vaccine effectiveness to be 60%, ranging from 69% in those ages 3 to 8 to just 36% in those 65 or older.

Citation: Treanor JJ, Talbot HK, Ohmit SE, et al. Effectiveness of seasonal influenza vaccines in the United States during a season with circulation of all three vaccine strains. Clin Infect Dis. 2012;55:951-959.

NSAIDS INCREASE CV RISK AFTER MI, REGARDLESS OF LENGTH OF TIME

A nationwide cohort study in Denmark shows increased coronary risk with NSAID use for at least five years after first-time myocardial infarction.

Citation: Olsen AM, Fosbøl EL, Lindhardsen J, et al. Long-term cardiovascular risk of nonsteroidal anti-inflammatory drug use according to time passed after first-time myocardial infarction: a nationwide cohort study. Circulation. 2012;126:1955-1963.

PATIENTS WITH METASTATIC CANCER OFTEN OVERESTIMATE CHEMOTHERAPEUTIC EFFICACY

Survey of patients with metastatic solid tumors reveals significant misunderstanding regarding the curative potential of chemotherapy, and an inverse relationship between level of understanding and patients’ satisfaction with physician communication.

Citation: Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:1616-1625.

RISKS ASSOCIATED WITH SYNTHETIC CANNABINOID ABUSE

This case series from the National Poison Data System indicates that adverse effects of synthetic cannabinoids are generally mild and self-limited, though rare reports of life-threatening seizures were identified.

Citation: Hoyte CO, Jacob J, Monte AA, Al-Jumaan M, Bronstein AC, Heard KJ. A characterization of synthetic cannabinoid exposures reported to the National Poison Data System in 2010. Ann Emerg Med. 2012;60:435-438.

FDA APPROVES FIRST SUBCUTANEOUS HEART DEFIBRILLATOR

Based on a multicenter study of 321 patients, the FDA approved the first subcutaneous heart defibrillator, which might be useful for patients in whom intravascular lead placement is problematic.

Citation: Bolek M. FDA approves first subcutaneous heart defibrillator. Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm321755.htm. Accessed Jan. 2, 2013.

ADD PCV13 TO THE LIST OF ADULT IMMUNIZATIONS

Thirteen-valent pneumococcal conjugate vaccine (PCV13) is now recommended in addition to 23-valent pneumococcal polysaccharide vaccine in adults 19 and older with immunocompromising conditions to decrease the risk of invasive pneumococcal disease.

Citation: Bennett NM, Whitney CG, Moore M, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the advisory committee on immunization practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012;61:816-819.

INFLUENZA VACCINE EFFECTIVENESS VARIES BY AGE

Case-control study of the 2010-2011 influenza vaccine found overall vaccine effectiveness to be 60%, ranging from 69% in those ages 3 to 8 to just 36% in those 65 or older.

Citation: Treanor JJ, Talbot HK, Ohmit SE, et al. Effectiveness of seasonal influenza vaccines in the United States during a season with circulation of all three vaccine strains. Clin Infect Dis. 2012;55:951-959.

NSAIDS INCREASE CV RISK AFTER MI, REGARDLESS OF LENGTH OF TIME

A nationwide cohort study in Denmark shows increased coronary risk with NSAID use for at least five years after first-time myocardial infarction.

Citation: Olsen AM, Fosbøl EL, Lindhardsen J, et al. Long-term cardiovascular risk of nonsteroidal anti-inflammatory drug use according to time passed after first-time myocardial infarction: a nationwide cohort study. Circulation. 2012;126:1955-1963.

PATIENTS WITH METASTATIC CANCER OFTEN OVERESTIMATE CHEMOTHERAPEUTIC EFFICACY

Survey of patients with metastatic solid tumors reveals significant misunderstanding regarding the curative potential of chemotherapy, and an inverse relationship between level of understanding and patients’ satisfaction with physician communication.

Citation: Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:1616-1625.

RISKS ASSOCIATED WITH SYNTHETIC CANNABINOID ABUSE

This case series from the National Poison Data System indicates that adverse effects of synthetic cannabinoids are generally mild and self-limited, though rare reports of life-threatening seizures were identified.

Citation: Hoyte CO, Jacob J, Monte AA, Al-Jumaan M, Bronstein AC, Heard KJ. A characterization of synthetic cannabinoid exposures reported to the National Poison Data System in 2010. Ann Emerg Med. 2012;60:435-438.

FDA APPROVES FIRST SUBCUTANEOUS HEART DEFIBRILLATOR

Based on a multicenter study of 321 patients, the FDA approved the first subcutaneous heart defibrillator, which might be useful for patients in whom intravascular lead placement is problematic.

Citation: Bolek M. FDA approves first subcutaneous heart defibrillator. Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm321755.htm. Accessed Jan. 2, 2013.

ADD PCV13 TO THE LIST OF ADULT IMMUNIZATIONS

Thirteen-valent pneumococcal conjugate vaccine (PCV13) is now recommended in addition to 23-valent pneumococcal polysaccharide vaccine in adults 19 and older with immunocompromising conditions to decrease the risk of invasive pneumococcal disease.

Citation: Bennett NM, Whitney CG, Moore M, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the advisory committee on immunization practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012;61:816-819.

INFLUENZA VACCINE EFFECTIVENESS VARIES BY AGE

Case-control study of the 2010-2011 influenza vaccine found overall vaccine effectiveness to be 60%, ranging from 69% in those ages 3 to 8 to just 36% in those 65 or older.

Citation: Treanor JJ, Talbot HK, Ohmit SE, et al. Effectiveness of seasonal influenza vaccines in the United States during a season with circulation of all three vaccine strains. Clin Infect Dis. 2012;55:951-959.

NSAIDS INCREASE CV RISK AFTER MI, REGARDLESS OF LENGTH OF TIME

A nationwide cohort study in Denmark shows increased coronary risk with NSAID use for at least five years after first-time myocardial infarction.

Citation: Olsen AM, Fosbøl EL, Lindhardsen J, et al. Long-term cardiovascular risk of nonsteroidal anti-inflammatory drug use according to time passed after first-time myocardial infarction: a nationwide cohort study. Circulation. 2012;126:1955-1963.

PATIENTS WITH METASTATIC CANCER OFTEN OVERESTIMATE CHEMOTHERAPEUTIC EFFICACY

Survey of patients with metastatic solid tumors reveals significant misunderstanding regarding the curative potential of chemotherapy, and an inverse relationship between level of understanding and patients’ satisfaction with physician communication.

Citation: Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:1616-1625.

RISKS ASSOCIATED WITH SYNTHETIC CANNABINOID ABUSE

This case series from the National Poison Data System indicates that adverse effects of synthetic cannabinoids are generally mild and self-limited, though rare reports of life-threatening seizures were identified.

Citation: Hoyte CO, Jacob J, Monte AA, Al-Jumaan M, Bronstein AC, Heard KJ. A characterization of synthetic cannabinoid exposures reported to the National Poison Data System in 2010. Ann Emerg Med. 2012;60:435-438.

FDA APPROVES FIRST SUBCUTANEOUS HEART DEFIBRILLATOR

Based on a multicenter study of 321 patients, the FDA approved the first subcutaneous heart defibrillator, which might be useful for patients in whom intravascular lead placement is problematic.

Citation: Bolek M. FDA approves first subcutaneous heart defibrillator. Food and Drug Administration website. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm321755.htm. Accessed Jan. 2, 2013.

ADD PCV13 TO THE LIST OF ADULT IMMUNIZATIONS

Thirteen-valent pneumococcal conjugate vaccine (PCV13) is now recommended in addition to 23-valent pneumococcal polysaccharide vaccine in adults 19 and older with immunocompromising conditions to decrease the risk of invasive pneumococcal disease.

Citation: Bennett NM, Whitney CG, Moore M, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the advisory committee on immunization practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012;61:816-819.

Clinical question: What is the relationship between procalcitonin (ProCT) levels and radiographic abnormalities in patients with suspected pneumonia?

Background: Pneumonia is a common clinical diagnosis and reason for admission to the hospital. In a number of cases, however, chest X-rays might not conclusively show an infiltrate. The correlation between ProCT levels and X-ray findings has not been well studied.

Study design: Prospective cohort study.

Setting: Tertiary-care U.S. hospital.

Synopsis: In all, 528 patients with acute respiratory illness were enrolled in the study. Both a blinded radiologist and a pulmonologist involved in the care of each patient reviewed the chest films independently. The pulmonologist was more likely to judge that an infiltrate was present. ProCT levels correlated well with the diagnosis of pneumonia and the presence of an infiltrate by chest X-ray. For patients with an indeterminant film, as determined by the radiologist, ProCT levels were higher in those patients in whom the pulmonologist judged an infiltrate was indeed present. Nearly every patient with an indeterminant film received antibiotics.

One limitation of the study was the lack of a clear gold standard for the determination of a pneumonia diagnosis. And as an observational study, it is uncertain what the effect might be of withholding antibiotics from patients with an indeterminant film and low ProCT levels.

Bottom line: Serum procalcitonin levels correlate well with the presence of an infiltrate by chest X-ray and might have a future role for determining whether patients with indeterminant films can be safely treated without antimicrobials.

Citation: Walsh EE, Swinburne AJ, Becker KL, et al. Can serum procalcitonin levels help interpret indeterminate chest radiographs in patients hospitalized with acute respiratory illness? J Hosp Med. 2012. doi:10.1002/jhm.1984 [Epub ahead of print].

Clinical question: What is the relationship between procalcitonin (ProCT) levels and radiographic abnormalities in patients with suspected pneumonia?

Background: Pneumonia is a common clinical diagnosis and reason for admission to the hospital. In a number of cases, however, chest X-rays might not conclusively show an infiltrate. The correlation between ProCT levels and X-ray findings has not been well studied.

Study design: Prospective cohort study.

Setting: Tertiary-care U.S. hospital.

Synopsis: In all, 528 patients with acute respiratory illness were enrolled in the study. Both a blinded radiologist and a pulmonologist involved in the care of each patient reviewed the chest films independently. The pulmonologist was more likely to judge that an infiltrate was present. ProCT levels correlated well with the diagnosis of pneumonia and the presence of an infiltrate by chest X-ray. For patients with an indeterminant film, as determined by the radiologist, ProCT levels were higher in those patients in whom the pulmonologist judged an infiltrate was indeed present. Nearly every patient with an indeterminant film received antibiotics.

One limitation of the study was the lack of a clear gold standard for the determination of a pneumonia diagnosis. And as an observational study, it is uncertain what the effect might be of withholding antibiotics from patients with an indeterminant film and low ProCT levels.

Bottom line: Serum procalcitonin levels correlate well with the presence of an infiltrate by chest X-ray and might have a future role for determining whether patients with indeterminant films can be safely treated without antimicrobials.

Citation: Walsh EE, Swinburne AJ, Becker KL, et al. Can serum procalcitonin levels help interpret indeterminate chest radiographs in patients hospitalized with acute respiratory illness? J Hosp Med. 2012. doi:10.1002/jhm.1984 [Epub ahead of print].

Clinical question: What is the relationship between procalcitonin (ProCT) levels and radiographic abnormalities in patients with suspected pneumonia?

Background: Pneumonia is a common clinical diagnosis and reason for admission to the hospital. In a number of cases, however, chest X-rays might not conclusively show an infiltrate. The correlation between ProCT levels and X-ray findings has not been well studied.

Study design: Prospective cohort study.

Setting: Tertiary-care U.S. hospital.

Synopsis: In all, 528 patients with acute respiratory illness were enrolled in the study. Both a blinded radiologist and a pulmonologist involved in the care of each patient reviewed the chest films independently. The pulmonologist was more likely to judge that an infiltrate was present. ProCT levels correlated well with the diagnosis of pneumonia and the presence of an infiltrate by chest X-ray. For patients with an indeterminant film, as determined by the radiologist, ProCT levels were higher in those patients in whom the pulmonologist judged an infiltrate was indeed present. Nearly every patient with an indeterminant film received antibiotics.

One limitation of the study was the lack of a clear gold standard for the determination of a pneumonia diagnosis. And as an observational study, it is uncertain what the effect might be of withholding antibiotics from patients with an indeterminant film and low ProCT levels.

Bottom line: Serum procalcitonin levels correlate well with the presence of an infiltrate by chest X-ray and might have a future role for determining whether patients with indeterminant films can be safely treated without antimicrobials.

Citation: Walsh EE, Swinburne AJ, Becker KL, et al. Can serum procalcitonin levels help interpret indeterminate chest radiographs in patients hospitalized with acute respiratory illness? J Hosp Med. 2012. doi:10.1002/jhm.1984 [Epub ahead of print].

Clinical question: How frequently are patients readmitted after an initial inpatient stay for an injury, and what factors might predict readmission?

Background: Readmission to the hospital is a vexing healthcare problem prompting substantial investigation into factors that predict readmission after a medical or surgical illness. Data regarding readmission rates following injuries are lacking, as is our understanding of the factors that predict these readmissions.

Study design: Retrospective cohort study.

Setting: Hospitals in 11 U.S. states participating in the 2006 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases.

Synopsis: The authors studied more than 200,000 patients aged 65 and older admitted to the hospital with an injury. Fracture was the most common injury (75%) and falls were the most common mechanism of injury (75%). The overall 30-day readmission rate was 13.7%, or about 1 in 7, which is below the rate commonly seen with medical illnesses.

The most common reasons for readmission were surgery (7.4%) and pneumonia (7.2%). Factors that predicted readmission included an initially “moderate” or “severe” injury, as defined by the validated New Injury Severity Score, the need for blood transfusion during admission, the presence of an infection, and the occurrence of a patient safety event, such as a fall. Discharge to a nursing home was associated with increased risk for readmission.

Bottom line: Readmission after an acute injury is less common than after a medical illness but still occurred in 1 in 7 patients.

Citation: Spector WD, Mutter R, Owens P, Limcangco R. Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay. Med Care. 2012;50:863-869.

Clinical question: How frequently are patients readmitted after an initial inpatient stay for an injury, and what factors might predict readmission?

Background: Readmission to the hospital is a vexing healthcare problem prompting substantial investigation into factors that predict readmission after a medical or surgical illness. Data regarding readmission rates following injuries are lacking, as is our understanding of the factors that predict these readmissions.

Study design: Retrospective cohort study.

Setting: Hospitals in 11 U.S. states participating in the 2006 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases.

Synopsis: The authors studied more than 200,000 patients aged 65 and older admitted to the hospital with an injury. Fracture was the most common injury (75%) and falls were the most common mechanism of injury (75%). The overall 30-day readmission rate was 13.7%, or about 1 in 7, which is below the rate commonly seen with medical illnesses.

The most common reasons for readmission were surgery (7.4%) and pneumonia (7.2%). Factors that predicted readmission included an initially “moderate” or “severe” injury, as defined by the validated New Injury Severity Score, the need for blood transfusion during admission, the presence of an infection, and the occurrence of a patient safety event, such as a fall. Discharge to a nursing home was associated with increased risk for readmission.

Bottom line: Readmission after an acute injury is less common than after a medical illness but still occurred in 1 in 7 patients.

Citation: Spector WD, Mutter R, Owens P, Limcangco R. Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay. Med Care. 2012;50:863-869.

Clinical question: How frequently are patients readmitted after an initial inpatient stay for an injury, and what factors might predict readmission?

Background: Readmission to the hospital is a vexing healthcare problem prompting substantial investigation into factors that predict readmission after a medical or surgical illness. Data regarding readmission rates following injuries are lacking, as is our understanding of the factors that predict these readmissions.

Study design: Retrospective cohort study.

Setting: Hospitals in 11 U.S. states participating in the 2006 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases.

Synopsis: The authors studied more than 200,000 patients aged 65 and older admitted to the hospital with an injury. Fracture was the most common injury (75%) and falls were the most common mechanism of injury (75%). The overall 30-day readmission rate was 13.7%, or about 1 in 7, which is below the rate commonly seen with medical illnesses.

The most common reasons for readmission were surgery (7.4%) and pneumonia (7.2%). Factors that predicted readmission included an initially “moderate” or “severe” injury, as defined by the validated New Injury Severity Score, the need for blood transfusion during admission, the presence of an infection, and the occurrence of a patient safety event, such as a fall. Discharge to a nursing home was associated with increased risk for readmission.

Bottom line: Readmission after an acute injury is less common than after a medical illness but still occurred in 1 in 7 patients.

Citation: Spector WD, Mutter R, Owens P, Limcangco R. Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay. Med Care. 2012;50:863-869.

Clinical question: Does sedation by protocol, in combination with daily sedative interruption, reduce the duration of mechanical ventilation and ICU stay?

Background: Limiting excessive sedation in mechanically ventilated adults is associated with shorter duration of mechanical ventilation and lower risk of delirium. Two strategies to minimize sedation are daily sedation interruptions and protocolized sedation. These strategies have not been evaluated in combination.

Study design: Randomized controlled trial.

Setting: Tertiary-care medical and surgical ICUs in Canada and the U.S.

Synopsis: This randomized controlled trial conducted in 430 critically ill, mechanically ventilated adults at 16 tertiary-care ICUs showed no difference in time to extubation (mean seven days in each group) or ICU length of stay (mean 10 days in each group) in protocolized sedation and sedation interruption compared with protocolized sedation alone. The daily interruption group received higher mean daily doses of midazolam and fentanyl, increased number of boluses of benzodiazepines and opiates, and required increased nurse workload. There was no difference in unintentional endotracheal tube removal or rate of delirium.

A limitation of this study was the use of continuous opioid and/or benzodiazepine infusions instead of bolus dosing. Hospitalists involved in critical care should be careful about changing their practice based on this study alone.

Bottom line: The addition of daily sedation interruptions in mechanically ventilated patients treated with protocolized sedation does not reduce duration of ventilation or ICU stay.

Citation: Mehta S, Burry L, Cook D, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol. JAMA. 2012;308:1985-1992.

Clinical question: Does sedation by protocol, in combination with daily sedative interruption, reduce the duration of mechanical ventilation and ICU stay?

Background: Limiting excessive sedation in mechanically ventilated adults is associated with shorter duration of mechanical ventilation and lower risk of delirium. Two strategies to minimize sedation are daily sedation interruptions and protocolized sedation. These strategies have not been evaluated in combination.

Study design: Randomized controlled trial.

Setting: Tertiary-care medical and surgical ICUs in Canada and the U.S.

Synopsis: This randomized controlled trial conducted in 430 critically ill, mechanically ventilated adults at 16 tertiary-care ICUs showed no difference in time to extubation (mean seven days in each group) or ICU length of stay (mean 10 days in each group) in protocolized sedation and sedation interruption compared with protocolized sedation alone. The daily interruption group received higher mean daily doses of midazolam and fentanyl, increased number of boluses of benzodiazepines and opiates, and required increased nurse workload. There was no difference in unintentional endotracheal tube removal or rate of delirium.

A limitation of this study was the use of continuous opioid and/or benzodiazepine infusions instead of bolus dosing. Hospitalists involved in critical care should be careful about changing their practice based on this study alone.

Bottom line: The addition of daily sedation interruptions in mechanically ventilated patients treated with protocolized sedation does not reduce duration of ventilation or ICU stay.

Citation: Mehta S, Burry L, Cook D, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol. JAMA. 2012;308:1985-1992.

Clinical question: Does sedation by protocol, in combination with daily sedative interruption, reduce the duration of mechanical ventilation and ICU stay?

Background: Limiting excessive sedation in mechanically ventilated adults is associated with shorter duration of mechanical ventilation and lower risk of delirium. Two strategies to minimize sedation are daily sedation interruptions and protocolized sedation. These strategies have not been evaluated in combination.

Study design: Randomized controlled trial.

Setting: Tertiary-care medical and surgical ICUs in Canada and the U.S.

Synopsis: This randomized controlled trial conducted in 430 critically ill, mechanically ventilated adults at 16 tertiary-care ICUs showed no difference in time to extubation (mean seven days in each group) or ICU length of stay (mean 10 days in each group) in protocolized sedation and sedation interruption compared with protocolized sedation alone. The daily interruption group received higher mean daily doses of midazolam and fentanyl, increased number of boluses of benzodiazepines and opiates, and required increased nurse workload. There was no difference in unintentional endotracheal tube removal or rate of delirium.

A limitation of this study was the use of continuous opioid and/or benzodiazepine infusions instead of bolus dosing. Hospitalists involved in critical care should be careful about changing their practice based on this study alone.

Bottom line: The addition of daily sedation interruptions in mechanically ventilated patients treated with protocolized sedation does not reduce duration of ventilation or ICU stay.

Citation: Mehta S, Burry L, Cook D, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol. JAMA. 2012;308:1985-1992.

Clinical question: Do patients on oral anticoagulation with high fall risk have an increased incidence of major bleeding?

Background: Despite proven efficacy, oral anticoagulation remains underprescribed. The most commonly cited reasons for not providing oral anticoagulation when clinically indicated are risk of falls and concern for major bleeding.

Study design: Prospective cohort study.

Setting: Internal-medicine inpatient and outpatient services of a university hospital in Switzerland.

Synopsis: This study followed 515 patients on oral anticoagulation for 12 months. Patients at high risk for falls were identified using validated questions known to predict fall risk. Overall, 35 patients had a first major bleed. In multivariate analysis, high fall risk was not associated with an increased incidence of major bleeding (hazard ratio 1.09; 95% confidence interval, 0.54-2.21). Only 1 in 3 fall-related bleeds occurred in the high-fall-risk group.

This study was limited significantly by selection bias. The majority of patients studied already were on anticoagulation therapy for at least three months prior to enrolling in the study, presumably without major bleeding. It is probable that some higher-risk patients were not offered anticoagulation at all and would have been ineligible for the study. This study cohort might have had a lower bleeding risk than members of the general population being started on anticoagulation.

Bottom line: This prospective cohort study shows that patients on oral anticoagulation at high risk of falls did not have significantly increased rates of major bleeding; however, selection bias might have led to an underestimation of bleeding risk. Hospitalists should continue to individualize anticoagulation decisions.

Citation: Donzé J, Clair C, Hug B, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med. 2012;125:773-778.

Clinical question: Do patients on oral anticoagulation with high fall risk have an increased incidence of major bleeding?

Background: Despite proven efficacy, oral anticoagulation remains underprescribed. The most commonly cited reasons for not providing oral anticoagulation when clinically indicated are risk of falls and concern for major bleeding.

Study design: Prospective cohort study.

Setting: Internal-medicine inpatient and outpatient services of a university hospital in Switzerland.

Synopsis: This study followed 515 patients on oral anticoagulation for 12 months. Patients at high risk for falls were identified using validated questions known to predict fall risk. Overall, 35 patients had a first major bleed. In multivariate analysis, high fall risk was not associated with an increased incidence of major bleeding (hazard ratio 1.09; 95% confidence interval, 0.54-2.21). Only 1 in 3 fall-related bleeds occurred in the high-fall-risk group.

This study was limited significantly by selection bias. The majority of patients studied already were on anticoagulation therapy for at least three months prior to enrolling in the study, presumably without major bleeding. It is probable that some higher-risk patients were not offered anticoagulation at all and would have been ineligible for the study. This study cohort might have had a lower bleeding risk than members of the general population being started on anticoagulation.

Bottom line: This prospective cohort study shows that patients on oral anticoagulation at high risk of falls did not have significantly increased rates of major bleeding; however, selection bias might have led to an underestimation of bleeding risk. Hospitalists should continue to individualize anticoagulation decisions.

Citation: Donzé J, Clair C, Hug B, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med. 2012;125:773-778.

Clinical question: Do patients on oral anticoagulation with high fall risk have an increased incidence of major bleeding?

Background: Despite proven efficacy, oral anticoagulation remains underprescribed. The most commonly cited reasons for not providing oral anticoagulation when clinically indicated are risk of falls and concern for major bleeding.

Study design: Prospective cohort study.

Setting: Internal-medicine inpatient and outpatient services of a university hospital in Switzerland.

Synopsis: This study followed 515 patients on oral anticoagulation for 12 months. Patients at high risk for falls were identified using validated questions known to predict fall risk. Overall, 35 patients had a first major bleed. In multivariate analysis, high fall risk was not associated with an increased incidence of major bleeding (hazard ratio 1.09; 95% confidence interval, 0.54-2.21). Only 1 in 3 fall-related bleeds occurred in the high-fall-risk group.

This study was limited significantly by selection bias. The majority of patients studied already were on anticoagulation therapy for at least three months prior to enrolling in the study, presumably without major bleeding. It is probable that some higher-risk patients were not offered anticoagulation at all and would have been ineligible for the study. This study cohort might have had a lower bleeding risk than members of the general population being started on anticoagulation.

Bottom line: This prospective cohort study shows that patients on oral anticoagulation at high risk of falls did not have significantly increased rates of major bleeding; however, selection bias might have led to an underestimation of bleeding risk. Hospitalists should continue to individualize anticoagulation decisions.

Citation: Donzé J, Clair C, Hug B, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med. 2012;125:773-778.

Clinical question: Can a multidisciplinary focus group identify “best practices” for ensuring efficient and effective transitions of care between the ED and the inpatient setting?

Background: In the admission process, communication failures can lead to preventable adverse effects. Little has been done to evaluate or improve the interservice handoff between the ED physician and the HM physician.

Study design: Concept article.

Synopsis: Handoffs between ED physicians and HM physicians are complex due to differing pressures, cultures, and expectations. The authors recommend an interactive handoff conversation that is organized, focuses on key principles, and is accompanied by a mutual understanding of the differences between specialties. ED physicians and hospitalists should work together to develop joint expectations on content, delivery, and timing of patient handoffs.

One proposed method includes the current clinical condition of the patient, a working problem statement with degree of certainty and rationale, essential aspects of the history and physical, a brief summary of the ED course, analysis of key tests, pending data with unambiguous assignment for follow-up, and any unusual circumstances. Further research is required to determine if these suggestions improve patient outcomes.

Bottom line: Joint expectations and standardized handoff methods between emergency physicians and hospitalists are likely to foster improved communication and patient care.

Citation: Beach C, Cheung DS, Apker J, et al. Improving inter-unit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach. Acad Emerg Med. 2012;19:1188-1195.

Clinical question: Can a multidisciplinary focus group identify “best practices” for ensuring efficient and effective transitions of care between the ED and the inpatient setting?

Background: In the admission process, communication failures can lead to preventable adverse effects. Little has been done to evaluate or improve the interservice handoff between the ED physician and the HM physician.

Study design: Concept article.

Synopsis: Handoffs between ED physicians and HM physicians are complex due to differing pressures, cultures, and expectations. The authors recommend an interactive handoff conversation that is organized, focuses on key principles, and is accompanied by a mutual understanding of the differences between specialties. ED physicians and hospitalists should work together to develop joint expectations on content, delivery, and timing of patient handoffs.

One proposed method includes the current clinical condition of the patient, a working problem statement with degree of certainty and rationale, essential aspects of the history and physical, a brief summary of the ED course, analysis of key tests, pending data with unambiguous assignment for follow-up, and any unusual circumstances. Further research is required to determine if these suggestions improve patient outcomes.

Bottom line: Joint expectations and standardized handoff methods between emergency physicians and hospitalists are likely to foster improved communication and patient care.

Citation: Beach C, Cheung DS, Apker J, et al. Improving inter-unit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach. Acad Emerg Med. 2012;19:1188-1195.

Clinical question: Can a multidisciplinary focus group identify “best practices” for ensuring efficient and effective transitions of care between the ED and the inpatient setting?

Background: In the admission process, communication failures can lead to preventable adverse effects. Little has been done to evaluate or improve the interservice handoff between the ED physician and the HM physician.

Study design: Concept article.

Synopsis: Handoffs between ED physicians and HM physicians are complex due to differing pressures, cultures, and expectations. The authors recommend an interactive handoff conversation that is organized, focuses on key principles, and is accompanied by a mutual understanding of the differences between specialties. ED physicians and hospitalists should work together to develop joint expectations on content, delivery, and timing of patient handoffs.

One proposed method includes the current clinical condition of the patient, a working problem statement with degree of certainty and rationale, essential aspects of the history and physical, a brief summary of the ED course, analysis of key tests, pending data with unambiguous assignment for follow-up, and any unusual circumstances. Further research is required to determine if these suggestions improve patient outcomes.

Bottom line: Joint expectations and standardized handoff methods between emergency physicians and hospitalists are likely to foster improved communication and patient care.

Citation: Beach C, Cheung DS, Apker J, et al. Improving inter-unit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach. Acad Emerg Med. 2012;19:1188-1195.

Opioid overuse can spell the onset of onerous consequences. The analgesics can slow breathing to dangerous levels and lead to dizziness, nausea, and falls.

Citing these concerns, The Joint Commission issued a Sentinel Event Alert in August 2012 that urged hospitals to take specific measures to help avoid serious complications and even deaths from the use of such opioids as morphine, oxycodone, and methadone.

“The Joint Commission recognizes that there is an opportunity to improve the care of patients on opioids in acute-care settings,” spokeswoman Elizabeth Eaken Zhani says. “Healthcare workers need to be aware of the risks to patients in prescribing opioids.”

Adverse events involving opioids include dosing errors and improper monitoring of patients and drug interactions. Patients who have sleep apnea, are obese, or very ill—with such conditions as pulmonary disease, congestive heart failure, or impaired renal function—might be at higher risk for harm from opioids.

Getting opioid pain relief right is critically important, as lives are hanging in the balance on both sides of this problem: Too little pain relief and millions will suffer; too much and lives are at risk.

—Beth B. Murinson, MS, MD, PhD, associate professor, director of pain education, department of neurology, The Johns University Hopkins School of Medicine, Baltimore

“The alert was issued in response to concerns that opioid analgesics are among the top three drugs in which medication-related adverse events are reported to The Joint Commission,” Zhani says. “They also rank among the drugs most frequently associated with adverse drug events.”

Opioids are associated with numerous problems—underprescribing, overprescribing, tolerance, dependence, and drug abuse. To prevent accidental overuse, The Joint Commission recommends that healthcare organizations provide ongoing oversight of patients receiving these drugs. Pain-management specialists or pharmacists should review treatment plans and also track incidents involving opioids.

Harnessing available technology also helps improve prescribing safety. In addition to creating alerts for dosing limits, The Joint Commission suggests using “tall man” lettering in electronic ordering systems, conversion support to calculate correct dosages, and patient-controlled analgesia. Education and training in the safe use of opioids should be provided for clinicians, staff, and patients. And standardized tools should be employed to screen patients for risk factors, such as oversedation and respiratory depression.

Dr. Liao

“Opioids aren’t dangerous in themselves,” says Solomon Liao, MD, FAAHPM, a hospitalist and director of palliative-care services at the University of California at Irvine. “Opioids are dangerous when prescribers don’t know what they’re doing. It’s like the old saying, ‘Guns don’t kill people; people kill people.’”

Overdose deaths from opioid pain relievers have escalated, nearly quadrupling from 1999 to 2008. These deaths now exceed fatalities due to heroin and cocaine combined. In 2008, drug overdoses in the United States caused 36,450 deaths; opioid analgesics were involved in 14,800 (73.8%) of 20,044 prescription drug overdose deaths, according to the Centers for Disease Control and Prevention.¹

Vital statistics data suggest that methadone is involved in one-third of opioid pain-reliever-related overdose deaths, even though it accounts for only a small percentage of prescriptions for opioid analgesics. The rate of methadone overdose deaths in the U.S. in 2009 was 5.5 times the rate in 1999, prompting an urgent call for interventions to address misuse and abuse.²

“The greatest safety concern The Joint Commission’s report cites is that sedation precedes respiratory depression in many cases, and clinicians need to pay more attention to that side effect and patients who are inherently at risk for developing respiratory problems related to opioids,” says Paul Arnstein, RN, PhD, FAAN, Connell Nursing Research Scholar and clinical nurse specialist for pain relief at Massachusetts General Hospital in Boston.

A Double-Edged Sword

Opioids deliver good pain control with minimal adverse effects for some patients but not for others, and there is insufficient evidence to foresee who will fare well and who won’t. “What we can predict,” Arnstein says, “is that certain patients—the very old, very young, very ill, and those receiving medicines that interact with opioids—are vulnerable to some of the more dangerous effects.”

The risk of respiratory depression also mounts in those who are opioid-naïve, as well as in an increasingly obese population.

“This does not mean we withhold pain relief,” says Judith A. Paice, PhD, RN, a contributor to The Joint Commission’s alert and director of the cancer pain program in the hematology-oncology division at Northwestern University’s Feinberg School of Medicine. Instead, “we need to determine the most effective monitoring techniques in a setting where hospitals are cutting back on staffing,” she adds.

Other risk factors for respiratory depression include sleep apnea (correlated with obesity but also possible in the absence of excess weight), large thoracic or abdominal incisions, and use of other sedating drugs. Among patients in the chronic cancer pain or palliative-care setting, respiratory depression is highly unusual because dosages are increased gradually, Paice says. Strong consensus supports prescribing opioids for acute episodes of pain, as well as chronic management of cancer and other life-threatening illnesses, including HIV/AIDS and cardiac and neuromuscular conditions.

Considerable variations exist in screening for risk of opioid-induced sedation and hospital monitoring practices. There is also a shortage of information and no consensus on the advantages of costly technology-supported monitoring, such as pulse oximetry (measuring oxygen saturation) and capnography (measuring end-tidal carbon dioxide), in hospitalized patients receiving opioids for pain therapy, according to guidelines from the American Society for Pain Management Nursing.³

 Jarzyna

Although technological monitoring adds valuable data to patient status, it does not replace frequent assessments—the most important intervention in detecting sedation before respiratory depression. Technological monitoring should be considered for patients at high risk for decline, says the guidelines’ lead author, Donna Jarzyna, MS, RN-BC, CNS-BC, an adult health clinical nurse specialist consulting in an alumna role for the University of Arizona Medical Center in Tucson. “Many organizations are currently making an effort,” she says, “to determine which patients should be monitored with a higher degree of intensity and with greater frequency.”

Patient-controlled analgesia (PCA) also has some limitations. In theory, it offers built-in safety features—if patients become too sedated, they can’t push a button for extra doses—but that isn’t always the case. For instance, some patients may have “stacked” three to four doses before sedation and respiratory depression develop. “When things go wrong with PCA, patients are four times more likely to be seriously harmed than when nurses administer the medications,” says Arnstein, who is a past president of the American Society for Pain Management Nursing. “Thus, vigilant nurse-supervised opioid therapy is vitally important.”

What we can predict is that certain patients—the very old, very young, very ill, and those receiving medicines that interact with opioids—are vulnerable to some of the more dangerous effects of the drug.

—Paul Arnstein, RN, PhD, FAAN, Connell Nursing Research Scholar, clinical nurse specialist for pain relief, Massachusetts General Hospital, Boston

Simple Steps Save Lives

Most critical events associated with opioids occur during the first 24 hours of post-operative care. Combined with close monitoring, understanding the risk factors for respiratory depression and making adjustments based on an individual’s needs and response helps prevent a precarious situation in which a patient vacillates quickly from a wide-awake status to a sleepy state.

“There’s a very progressive amount of sedation,” says Deb Gordon, RN, DNP, FAAN, a contributor to The Joint Commission’s alert and a teaching associate in the department of anesthesiology and pain medicine at the University of Washington in Seattle.

Dr. Gordon

Developing a pain treatment plan with a reassessment component is essential to exercising caution against potential harm from opioids.

“The Joint Commission’s guidance is wonderfully helpful and will benefit patients,” says Beth B. Murinson, MS, MD, PhD, associate professor and director of pain education in the department of neurology at Johns Hopkins University School of Medicine in Baltimore. “Getting opioid pain relief right is critically important as lives are hanging in the balance on both sides of this problem: Too little pain relief and millions will suffer; too much and lives are at risk.”

Hospitalists should be familiar with a few opioids that they feel comfortable prescribing, Dr. Murinson says. Be prepared to easily identify the major idiosyncratic effects and ordinary side effects of these medications and become well versed in opioid conversion.

“This is a classic problem in the field because, although the opioids are generally similar in their efficacy against pain, they have markedly different potencies against pain,” she explains. “A dose of 2 mg of morphine may need to be ‘converted’ to X mg of another opioid, depending on local practice patterns and preferences.”

Some drugs pose special risks. For example, transdermal fentanyl is “appropriate only for use in people who need opioid-level analgesia for an extended period of time and whose analgesic requirements are stable. This is not the case for folks with acute pain or who are just starting on opioids,” cautions Scott Strassels, PhD, PharmD, BCPS, assistant professor in the College of Pharmacy at the University of Texas in Austin and a board member of the American Pain Society. “Similarly, methadone is a good analgesic, but it requires very careful use due to its pharmacokinetic profile.”

Healthcare professionals from a variety of disciplines should be involved in pain-management efforts within a hospital setting. As for who takes the initiative, “it probably should be the person who is most qualified—be it a physician, nurse, or pharmacist,” Strassels says. “I’ve seen pharmacist-led teams, nurse-led teams, and those with physicians leading the effort.”

Clinicians who prescribe pain medications should be cognizant of nonpharmacologic alternatives to opioids. Multimodal options include physical therapy, acupuncture, manipulation or massage, and non-narcotic analgesics, such as acetaminophen and muscle relaxants. Non-narcotics may lower the dose of opioids needed to effectively manage pain, according to The Joint Commission.

The alert also provides information on suggested actions to avoid unintended consequences of using opioids. Hospitals should fully inform and provide written instructions to the patient and family or caregiver about the potential risks of tolerance, addiction, physical dependency, and withdrawal from opioids. When providing this information at discharge, the hospital also should list phone numbers to call if there are any questions.

In some unfortunate cases, opioids prescribed for pain also are used by patients’ family members, friends, and others. In such instances, says Northwestern’s Paice, usage occurs commonly with polypharmacy and without monitoring, and this contributes to an increased risk of death associated with opioids.

“There is concern that drugs prescribed for legitimate purposes are reaching the wrong hands,” Paice says. “We need to make the public, particularly patients and their family members, aware of safety strategies.”

Susan Kreimer is a freelance writer in New York City.

References

1. Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492.
2. Centers for Disease Control and Prevention. Vital signs: risk for overdose from methadone used for pain relief—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2012;61(26):493-497.
3. Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12(3):118-145.

Opioid overuse can spell the onset of onerous consequences. The analgesics can slow breathing to dangerous levels and lead to dizziness, nausea, and falls.

Citing these concerns, The Joint Commission issued a Sentinel Event Alert in August 2012 that urged hospitals to take specific measures to help avoid serious complications and even deaths from the use of such opioids as morphine, oxycodone, and methadone.

“The Joint Commission recognizes that there is an opportunity to improve the care of patients on opioids in acute-care settings,” spokeswoman Elizabeth Eaken Zhani says. “Healthcare workers need to be aware of the risks to patients in prescribing opioids.”

Adverse events involving opioids include dosing errors and improper monitoring of patients and drug interactions. Patients who have sleep apnea, are obese, or very ill—with such conditions as pulmonary disease, congestive heart failure, or impaired renal function—might be at higher risk for harm from opioids.

Getting opioid pain relief right is critically important, as lives are hanging in the balance on both sides of this problem: Too little pain relief and millions will suffer; too much and lives are at risk.

—Beth B. Murinson, MS, MD, PhD, associate professor, director of pain education, department of neurology, The Johns University Hopkins School of Medicine, Baltimore

“The alert was issued in response to concerns that opioid analgesics are among the top three drugs in which medication-related adverse events are reported to The Joint Commission,” Zhani says. “They also rank among the drugs most frequently associated with adverse drug events.”

Opioids are associated with numerous problems—underprescribing, overprescribing, tolerance, dependence, and drug abuse. To prevent accidental overuse, The Joint Commission recommends that healthcare organizations provide ongoing oversight of patients receiving these drugs. Pain-management specialists or pharmacists should review treatment plans and also track incidents involving opioids.

Harnessing available technology also helps improve prescribing safety. In addition to creating alerts for dosing limits, The Joint Commission suggests using “tall man” lettering in electronic ordering systems, conversion support to calculate correct dosages, and patient-controlled analgesia. Education and training in the safe use of opioids should be provided for clinicians, staff, and patients. And standardized tools should be employed to screen patients for risk factors, such as oversedation and respiratory depression.

Dr. Liao

“Opioids aren’t dangerous in themselves,” says Solomon Liao, MD, FAAHPM, a hospitalist and director of palliative-care services at the University of California at Irvine. “Opioids are dangerous when prescribers don’t know what they’re doing. It’s like the old saying, ‘Guns don’t kill people; people kill people.’”

Overdose deaths from opioid pain relievers have escalated, nearly quadrupling from 1999 to 2008. These deaths now exceed fatalities due to heroin and cocaine combined. In 2008, drug overdoses in the United States caused 36,450 deaths; opioid analgesics were involved in 14,800 (73.8%) of 20,044 prescription drug overdose deaths, according to the Centers for Disease Control and Prevention.¹

Vital statistics data suggest that methadone is involved in one-third of opioid pain-reliever-related overdose deaths, even though it accounts for only a small percentage of prescriptions for opioid analgesics. The rate of methadone overdose deaths in the U.S. in 2009 was 5.5 times the rate in 1999, prompting an urgent call for interventions to address misuse and abuse.²

“The greatest safety concern The Joint Commission’s report cites is that sedation precedes respiratory depression in many cases, and clinicians need to pay more attention to that side effect and patients who are inherently at risk for developing respiratory problems related to opioids,” says Paul Arnstein, RN, PhD, FAAN, Connell Nursing Research Scholar and clinical nurse specialist for pain relief at Massachusetts General Hospital in Boston.

A Double-Edged Sword

Opioids deliver good pain control with minimal adverse effects for some patients but not for others, and there is insufficient evidence to foresee who will fare well and who won’t. “What we can predict,” Arnstein says, “is that certain patients—the very old, very young, very ill, and those receiving medicines that interact with opioids—are vulnerable to some of the more dangerous effects.”

The risk of respiratory depression also mounts in those who are opioid-naïve, as well as in an increasingly obese population.

“This does not mean we withhold pain relief,” says Judith A. Paice, PhD, RN, a contributor to The Joint Commission’s alert and director of the cancer pain program in the hematology-oncology division at Northwestern University’s Feinberg School of Medicine. Instead, “we need to determine the most effective monitoring techniques in a setting where hospitals are cutting back on staffing,” she adds.

Other risk factors for respiratory depression include sleep apnea (correlated with obesity but also possible in the absence of excess weight), large thoracic or abdominal incisions, and use of other sedating drugs. Among patients in the chronic cancer pain or palliative-care setting, respiratory depression is highly unusual because dosages are increased gradually, Paice says. Strong consensus supports prescribing opioids for acute episodes of pain, as well as chronic management of cancer and other life-threatening illnesses, including HIV/AIDS and cardiac and neuromuscular conditions.

Considerable variations exist in screening for risk of opioid-induced sedation and hospital monitoring practices. There is also a shortage of information and no consensus on the advantages of costly technology-supported monitoring, such as pulse oximetry (measuring oxygen saturation) and capnography (measuring end-tidal carbon dioxide), in hospitalized patients receiving opioids for pain therapy, according to guidelines from the American Society for Pain Management Nursing.³

 Jarzyna

Although technological monitoring adds valuable data to patient status, it does not replace frequent assessments—the most important intervention in detecting sedation before respiratory depression. Technological monitoring should be considered for patients at high risk for decline, says the guidelines’ lead author, Donna Jarzyna, MS, RN-BC, CNS-BC, an adult health clinical nurse specialist consulting in an alumna role for the University of Arizona Medical Center in Tucson. “Many organizations are currently making an effort,” she says, “to determine which patients should be monitored with a higher degree of intensity and with greater frequency.”

Patient-controlled analgesia (PCA) also has some limitations. In theory, it offers built-in safety features—if patients become too sedated, they can’t push a button for extra doses—but that isn’t always the case. For instance, some patients may have “stacked” three to four doses before sedation and respiratory depression develop. “When things go wrong with PCA, patients are four times more likely to be seriously harmed than when nurses administer the medications,” says Arnstein, who is a past president of the American Society for Pain Management Nursing. “Thus, vigilant nurse-supervised opioid therapy is vitally important.”

What we can predict is that certain patients—the very old, very young, very ill, and those receiving medicines that interact with opioids—are vulnerable to some of the more dangerous effects of the drug.

—Paul Arnstein, RN, PhD, FAAN, Connell Nursing Research Scholar, clinical nurse specialist for pain relief, Massachusetts General Hospital, Boston

Simple Steps Save Lives

Most critical events associated with opioids occur during the first 24 hours of post-operative care. Combined with close monitoring, understanding the risk factors for respiratory depression and making adjustments based on an individual’s needs and response helps prevent a precarious situation in which a patient vacillates quickly from a wide-awake status to a sleepy state.

“There’s a very progressive amount of sedation,” says Deb Gordon, RN, DNP, FAAN, a contributor to The Joint Commission’s alert and a teaching associate in the department of anesthesiology and pain medicine at the University of Washington in Seattle.

Dr. Gordon

Developing a pain treatment plan with a reassessment component is essential to exercising caution against potential harm from opioids.

“The Joint Commission’s guidance is wonderfully helpful and will benefit patients,” says Beth B. Murinson, MS, MD, PhD, associate professor and director of pain education in the department of neurology at Johns Hopkins University School of Medicine in Baltimore. “Getting opioid pain relief right is critically important as lives are hanging in the balance on both sides of this problem: Too little pain relief and millions will suffer; too much and lives are at risk.”

Hospitalists should be familiar with a few opioids that they feel comfortable prescribing, Dr. Murinson says. Be prepared to easily identify the major idiosyncratic effects and ordinary side effects of these medications and become well versed in opioid conversion.

“This is a classic problem in the field because, although the opioids are generally similar in their efficacy against pain, they have markedly different potencies against pain,” she explains. “A dose of 2 mg of morphine may need to be ‘converted’ to X mg of another opioid, depending on local practice patterns and preferences.”

Some drugs pose special risks. For example, transdermal fentanyl is “appropriate only for use in people who need opioid-level analgesia for an extended period of time and whose analgesic requirements are stable. This is not the case for folks with acute pain or who are just starting on opioids,” cautions Scott Strassels, PhD, PharmD, BCPS, assistant professor in the College of Pharmacy at the University of Texas in Austin and a board member of the American Pain Society. “Similarly, methadone is a good analgesic, but it requires very careful use due to its pharmacokinetic profile.”

Healthcare professionals from a variety of disciplines should be involved in pain-management efforts within a hospital setting. As for who takes the initiative, “it probably should be the person who is most qualified—be it a physician, nurse, or pharmacist,” Strassels says. “I’ve seen pharmacist-led teams, nurse-led teams, and those with physicians leading the effort.”

Clinicians who prescribe pain medications should be cognizant of nonpharmacologic alternatives to opioids. Multimodal options include physical therapy, acupuncture, manipulation or massage, and non-narcotic analgesics, such as acetaminophen and muscle relaxants. Non-narcotics may lower the dose of opioids needed to effectively manage pain, according to The Joint Commission.

The alert also provides information on suggested actions to avoid unintended consequences of using opioids. Hospitals should fully inform and provide written instructions to the patient and family or caregiver about the potential risks of tolerance, addiction, physical dependency, and withdrawal from opioids. When providing this information at discharge, the hospital also should list phone numbers to call if there are any questions.

In some unfortunate cases, opioids prescribed for pain also are used by patients’ family members, friends, and others. In such instances, says Northwestern’s Paice, usage occurs commonly with polypharmacy and without monitoring, and this contributes to an increased risk of death associated with opioids.

“There is concern that drugs prescribed for legitimate purposes are reaching the wrong hands,” Paice says. “We need to make the public, particularly patients and their family members, aware of safety strategies.”

Susan Kreimer is a freelance writer in New York City.

References

1. Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492.
2. Centers for Disease Control and Prevention. Vital signs: risk for overdose from methadone used for pain relief—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2012;61(26):493-497.
3. Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12(3):118-145.

Opioid overuse can spell the onset of onerous consequences. The analgesics can slow breathing to dangerous levels and lead to dizziness, nausea, and falls.

Citing these concerns, The Joint Commission issued a Sentinel Event Alert in August 2012 that urged hospitals to take specific measures to help avoid serious complications and even deaths from the use of such opioids as morphine, oxycodone, and methadone.

“The Joint Commission recognizes that there is an opportunity to improve the care of patients on opioids in acute-care settings,” spokeswoman Elizabeth Eaken Zhani says. “Healthcare workers need to be aware of the risks to patients in prescribing opioids.”

Adverse events involving opioids include dosing errors and improper monitoring of patients and drug interactions. Patients who have sleep apnea, are obese, or very ill—with such conditions as pulmonary disease, congestive heart failure, or impaired renal function—might be at higher risk for harm from opioids.

Getting opioid pain relief right is critically important, as lives are hanging in the balance on both sides of this problem: Too little pain relief and millions will suffer; too much and lives are at risk.

—Beth B. Murinson, MS, MD, PhD, associate professor, director of pain education, department of neurology, The Johns University Hopkins School of Medicine, Baltimore

“The alert was issued in response to concerns that opioid analgesics are among the top three drugs in which medication-related adverse events are reported to The Joint Commission,” Zhani says. “They also rank among the drugs most frequently associated with adverse drug events.”

Opioids are associated with numerous problems—underprescribing, overprescribing, tolerance, dependence, and drug abuse. To prevent accidental overuse, The Joint Commission recommends that healthcare organizations provide ongoing oversight of patients receiving these drugs. Pain-management specialists or pharmacists should review treatment plans and also track incidents involving opioids.

Harnessing available technology also helps improve prescribing safety. In addition to creating alerts for dosing limits, The Joint Commission suggests using “tall man” lettering in electronic ordering systems, conversion support to calculate correct dosages, and patient-controlled analgesia. Education and training in the safe use of opioids should be provided for clinicians, staff, and patients. And standardized tools should be employed to screen patients for risk factors, such as oversedation and respiratory depression.

Dr. Liao

“Opioids aren’t dangerous in themselves,” says Solomon Liao, MD, FAAHPM, a hospitalist and director of palliative-care services at the University of California at Irvine. “Opioids are dangerous when prescribers don’t know what they’re doing. It’s like the old saying, ‘Guns don’t kill people; people kill people.’”

Overdose deaths from opioid pain relievers have escalated, nearly quadrupling from 1999 to 2008. These deaths now exceed fatalities due to heroin and cocaine combined. In 2008, drug overdoses in the United States caused 36,450 deaths; opioid analgesics were involved in 14,800 (73.8%) of 20,044 prescription drug overdose deaths, according to the Centers for Disease Control and Prevention.¹

Vital statistics data suggest that methadone is involved in one-third of opioid pain-reliever-related overdose deaths, even though it accounts for only a small percentage of prescriptions for opioid analgesics. The rate of methadone overdose deaths in the U.S. in 2009 was 5.5 times the rate in 1999, prompting an urgent call for interventions to address misuse and abuse.²

“The greatest safety concern The Joint Commission’s report cites is that sedation precedes respiratory depression in many cases, and clinicians need to pay more attention to that side effect and patients who are inherently at risk for developing respiratory problems related to opioids,” says Paul Arnstein, RN, PhD, FAAN, Connell Nursing Research Scholar and clinical nurse specialist for pain relief at Massachusetts General Hospital in Boston.

A Double-Edged Sword

Opioids deliver good pain control with minimal adverse effects for some patients but not for others, and there is insufficient evidence to foresee who will fare well and who won’t. “What we can predict,” Arnstein says, “is that certain patients—the very old, very young, very ill, and those receiving medicines that interact with opioids—are vulnerable to some of the more dangerous effects.”

The risk of respiratory depression also mounts in those who are opioid-naïve, as well as in an increasingly obese population.

“This does not mean we withhold pain relief,” says Judith A. Paice, PhD, RN, a contributor to The Joint Commission’s alert and director of the cancer pain program in the hematology-oncology division at Northwestern University’s Feinberg School of Medicine. Instead, “we need to determine the most effective monitoring techniques in a setting where hospitals are cutting back on staffing,” she adds.

Other risk factors for respiratory depression include sleep apnea (correlated with obesity but also possible in the absence of excess weight), large thoracic or abdominal incisions, and use of other sedating drugs. Among patients in the chronic cancer pain or palliative-care setting, respiratory depression is highly unusual because dosages are increased gradually, Paice says. Strong consensus supports prescribing opioids for acute episodes of pain, as well as chronic management of cancer and other life-threatening illnesses, including HIV/AIDS and cardiac and neuromuscular conditions.

Considerable variations exist in screening for risk of opioid-induced sedation and hospital monitoring practices. There is also a shortage of information and no consensus on the advantages of costly technology-supported monitoring, such as pulse oximetry (measuring oxygen saturation) and capnography (measuring end-tidal carbon dioxide), in hospitalized patients receiving opioids for pain therapy, according to guidelines from the American Society for Pain Management Nursing.³

 Jarzyna

Although technological monitoring adds valuable data to patient status, it does not replace frequent assessments—the most important intervention in detecting sedation before respiratory depression. Technological monitoring should be considered for patients at high risk for decline, says the guidelines’ lead author, Donna Jarzyna, MS, RN-BC, CNS-BC, an adult health clinical nurse specialist consulting in an alumna role for the University of Arizona Medical Center in Tucson. “Many organizations are currently making an effort,” she says, “to determine which patients should be monitored with a higher degree of intensity and with greater frequency.”

Patient-controlled analgesia (PCA) also has some limitations. In theory, it offers built-in safety features—if patients become too sedated, they can’t push a button for extra doses—but that isn’t always the case. For instance, some patients may have “stacked” three to four doses before sedation and respiratory depression develop. “When things go wrong with PCA, patients are four times more likely to be seriously harmed than when nurses administer the medications,” says Arnstein, who is a past president of the American Society for Pain Management Nursing. “Thus, vigilant nurse-supervised opioid therapy is vitally important.”

What we can predict is that certain patients—the very old, very young, very ill, and those receiving medicines that interact with opioids—are vulnerable to some of the more dangerous effects of the drug.

—Paul Arnstein, RN, PhD, FAAN, Connell Nursing Research Scholar, clinical nurse specialist for pain relief, Massachusetts General Hospital, Boston

Simple Steps Save Lives

Most critical events associated with opioids occur during the first 24 hours of post-operative care. Combined with close monitoring, understanding the risk factors for respiratory depression and making adjustments based on an individual’s needs and response helps prevent a precarious situation in which a patient vacillates quickly from a wide-awake status to a sleepy state.

“There’s a very progressive amount of sedation,” says Deb Gordon, RN, DNP, FAAN, a contributor to The Joint Commission’s alert and a teaching associate in the department of anesthesiology and pain medicine at the University of Washington in Seattle.

Dr. Gordon

Developing a pain treatment plan with a reassessment component is essential to exercising caution against potential harm from opioids.

“The Joint Commission’s guidance is wonderfully helpful and will benefit patients,” says Beth B. Murinson, MS, MD, PhD, associate professor and director of pain education in the department of neurology at Johns Hopkins University School of Medicine in Baltimore. “Getting opioid pain relief right is critically important as lives are hanging in the balance on both sides of this problem: Too little pain relief and millions will suffer; too much and lives are at risk.”

Hospitalists should be familiar with a few opioids that they feel comfortable prescribing, Dr. Murinson says. Be prepared to easily identify the major idiosyncratic effects and ordinary side effects of these medications and become well versed in opioid conversion.

“This is a classic problem in the field because, although the opioids are generally similar in their efficacy against pain, they have markedly different potencies against pain,” she explains. “A dose of 2 mg of morphine may need to be ‘converted’ to X mg of another opioid, depending on local practice patterns and preferences.”

Some drugs pose special risks. For example, transdermal fentanyl is “appropriate only for use in people who need opioid-level analgesia for an extended period of time and whose analgesic requirements are stable. This is not the case for folks with acute pain or who are just starting on opioids,” cautions Scott Strassels, PhD, PharmD, BCPS, assistant professor in the College of Pharmacy at the University of Texas in Austin and a board member of the American Pain Society. “Similarly, methadone is a good analgesic, but it requires very careful use due to its pharmacokinetic profile.”

Healthcare professionals from a variety of disciplines should be involved in pain-management efforts within a hospital setting. As for who takes the initiative, “it probably should be the person who is most qualified—be it a physician, nurse, or pharmacist,” Strassels says. “I’ve seen pharmacist-led teams, nurse-led teams, and those with physicians leading the effort.”

Clinicians who prescribe pain medications should be cognizant of nonpharmacologic alternatives to opioids. Multimodal options include physical therapy, acupuncture, manipulation or massage, and non-narcotic analgesics, such as acetaminophen and muscle relaxants. Non-narcotics may lower the dose of opioids needed to effectively manage pain, according to The Joint Commission.

The alert also provides information on suggested actions to avoid unintended consequences of using opioids. Hospitals should fully inform and provide written instructions to the patient and family or caregiver about the potential risks of tolerance, addiction, physical dependency, and withdrawal from opioids. When providing this information at discharge, the hospital also should list phone numbers to call if there are any questions.

In some unfortunate cases, opioids prescribed for pain also are used by patients’ family members, friends, and others. In such instances, says Northwestern’s Paice, usage occurs commonly with polypharmacy and without monitoring, and this contributes to an increased risk of death associated with opioids.

“There is concern that drugs prescribed for legitimate purposes are reaching the wrong hands,” Paice says. “We need to make the public, particularly patients and their family members, aware of safety strategies.”

Susan Kreimer is a freelance writer in New York City.

References

1. Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492.
2. Centers for Disease Control and Prevention. Vital signs: risk for overdose from methadone used for pain relief—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2012;61(26):493-497.
3. Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12(3):118-145.

Clinical question: How well do patients understand discharge instructions regarding post-ED care?

Background: Studies have demonstrated that patients discharged from the ED often lack appropriate understanding of their care. Knowledge deficits are particularly common in the area of post-ED care; however, it is not clear in which aspects of post-ED care these knowledge deficits are most pronounced.

Study design: Prospective cohort study.

Setting: Single-center academic urban hospital.

Synopsis: The researchers in this study discharged patients from the ED with five common diagnoses: ankle sprain, back pain, head injury, kidney stone, and laceration. Interviewers used formalized questioning to assess patient comprehension in five specific areas of post-ED care: diagnosis, medication, follow-up care, home care, and return instructions. Rates of severe knowledge deficits were most pronounced in the domains of home care (40.1%) and return instructions (50.7%). Rates of severe knowledge deficits in the domains of diagnosis, medication, and follow-up care were 3.2%, 3.2%, and 18.4%, respectively.

Though performed in the ED, the results of this study could inform the approach to inpatient discharges. However, the exclusion of patients with psychiatric disease, cognitive impairment, and multiple diagnoses suggests that the results might be even worse in a complicated inpatient cohort. The study also indicates that discharge instructions for home care and return precautions merit closer attention.

Bottom line: Patients discharged from the ED demonstrate poor comprehension of discharge instructions regarding post-ED care.

Citation: Engel KG, Buckley BA, Forth VE, et al. Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest? Acad Emerg Med. 2012;19:1035-1044.

Clinical question: How well do patients understand discharge instructions regarding post-ED care?

Background: Studies have demonstrated that patients discharged from the ED often lack appropriate understanding of their care. Knowledge deficits are particularly common in the area of post-ED care; however, it is not clear in which aspects of post-ED care these knowledge deficits are most pronounced.

Study design: Prospective cohort study.

Setting: Single-center academic urban hospital.

Synopsis: The researchers in this study discharged patients from the ED with five common diagnoses: ankle sprain, back pain, head injury, kidney stone, and laceration. Interviewers used formalized questioning to assess patient comprehension in five specific areas of post-ED care: diagnosis, medication, follow-up care, home care, and return instructions. Rates of severe knowledge deficits were most pronounced in the domains of home care (40.1%) and return instructions (50.7%). Rates of severe knowledge deficits in the domains of diagnosis, medication, and follow-up care were 3.2%, 3.2%, and 18.4%, respectively.

Though performed in the ED, the results of this study could inform the approach to inpatient discharges. However, the exclusion of patients with psychiatric disease, cognitive impairment, and multiple diagnoses suggests that the results might be even worse in a complicated inpatient cohort. The study also indicates that discharge instructions for home care and return precautions merit closer attention.

Bottom line: Patients discharged from the ED demonstrate poor comprehension of discharge instructions regarding post-ED care.

Citation: Engel KG, Buckley BA, Forth VE, et al. Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest? Acad Emerg Med. 2012;19:1035-1044.

Clinical question: How well do patients understand discharge instructions regarding post-ED care?

Background: Studies have demonstrated that patients discharged from the ED often lack appropriate understanding of their care. Knowledge deficits are particularly common in the area of post-ED care; however, it is not clear in which aspects of post-ED care these knowledge deficits are most pronounced.

Study design: Prospective cohort study.

Setting: Single-center academic urban hospital.

Synopsis: The researchers in this study discharged patients from the ED with five common diagnoses: ankle sprain, back pain, head injury, kidney stone, and laceration. Interviewers used formalized questioning to assess patient comprehension in five specific areas of post-ED care: diagnosis, medication, follow-up care, home care, and return instructions. Rates of severe knowledge deficits were most pronounced in the domains of home care (40.1%) and return instructions (50.7%). Rates of severe knowledge deficits in the domains of diagnosis, medication, and follow-up care were 3.2%, 3.2%, and 18.4%, respectively.

Though performed in the ED, the results of this study could inform the approach to inpatient discharges. However, the exclusion of patients with psychiatric disease, cognitive impairment, and multiple diagnoses suggests that the results might be even worse in a complicated inpatient cohort. The study also indicates that discharge instructions for home care and return precautions merit closer attention.

Bottom line: Patients discharged from the ED demonstrate poor comprehension of discharge instructions regarding post-ED care.

Citation: Engel KG, Buckley BA, Forth VE, et al. Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest? Acad Emerg Med. 2012;19:1035-1044.