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Move to Allow Patients to Request 'Refund' Appealing and Risky
We’ve all seen hundreds of commercials from companies advertising products and services with a money-back guarantee. The Men’s Warehouse, for example, has been promising men across the globe for over a decade, “You’re going to like the way you look. I guarantee it!” But to date, no one has made such a “guarantee” in the healthcare industry. Buying a suit is not exactly like getting your gallbladder removed.
We know that medical diagnoses and treatments are filled with uncertainty in expected processes and outcomes, because the factors that are dependent on these processes and outcomes are endless. These include patient factors (overall health, functional status, comorbid conditions), procedural factors (emergency versus elective, time of day or night), and facility factors (having the optimal team with skills that match the patient need, having all the right products and equipment). Although we know that many medical procedures have a relatively predictable risk of complications, unpredictable complications still occur, so how can we ever offer a guarantee for the interventions we perform on patients?
First of Its Kind
David Feinberg, MD, MBA, president and CEO of Geisinger Health System, is doing just that. This healthcare system has developed an application, called the Geisinger ProvenExperience, which can be downloaded onto a smartphone. After a procedure, each patient is given a code for the condition that was treated. With that code, the patient can enter feedback on the services provided and can then request a refund if they are not fully satisfied.
Most remarkably, the request for a refund is based on the judgment of the recipient, not on that of the provider(s). At a recent public meeting, Dr. Feinberg said of the new program: “We’re going to do everything right. That’s our job, that’s our promise to you … and you’re the judge. If you don’t think so, we’re going to apologize, we’re going to try to fix it for the next guy, and, as a small token of appreciation, we’re going to give you some money back.”1
Although many are skeptical about whether or not the program will be successful, much less viable, Dr. Feinberg contends that early feedback on the program has shown that most patients don’t actually want their money back. Instead, if their needs have not been met, most have just wanted a sincere apology and a commitment to make things better for others. Dr. Feinberg also contests that even if this is not the best or only approach to improving healthcare (quickly), we should all feel compelled to do something about our repeated failures in meeting patient expectations in the quality and/or experience of their care; and because no other industry works this way, other than healthcare. Typically, when consumers get fed up with poor service in other industries, disruptive innovations (Uber, for example) are created to satisfy customers’ desires.
A New Paradigm?
In healthcare, patients certainly should be dissatisfied if they experience a preventable harm event. Some types of harm are considered “always preventable,” such as wrong-site surgery. These events are extremely rare and, thus, do not constitute most cases of harm in hospitals these days. Such “never events” are relatively well defined and have been adopted for nonpayment by Medicare and other insurers, which can serve to buffer a patient’s financial liability in the small number of these cases. For other, more common, types of preventable harm, some hospitals have instituted apology and disclosure policies, and some will also relieve the patient of the portion of the bill attributable to the preventable harm. But not all hospitals have adopted such policies, despite the fact that they are widely endorsed by influential agencies, including The Joint Commission, the American Medical Association, Leapfrog Group, the National Quality Forum, and the Agency for Healthcare Research and Quality.
And, even for hospitals that have adopted such “best practice” policies, there is not always clear consensus on what constitutes preventable harm. Generally, the “judgment call” about what constitutes preventable harm is made by healthcare systems and providers—not patients. In addition, many cases of harm that are not necessarily preventable can often result in great dissatisfaction for the patient. There are countless stories of patients who are unfortunately harmed in the course of medical procedures, but who were informed of the possible risks of the procedure and consented to have the procedure performed despite the risks. These situations, which are agonizingly difficult for the system, the providers, and the patients, have no good solutions. Systems cannot “own” all harm, such as those resulting from the disease process itself or from risky and invasive procedures intended to benefit the patient. And there is ongoing inconsistency in healthcare systems when it comes to their willingness and ability to consistently define preventable harm or to disclose, apologize, and forgive payments in such cases.
So, while this move to allow patients to ask for a “refund” seems both extremely appealing and extremely risky, it certainly seems as though it will greatly enhance the trust of patients and their families in the Geisinger Health System.
I, among others, will eagerly follow the results of this program; while getting a cholecystectomy is not the same as buying a men’s suit, I do hope that someday, I will be able to say to every patient entering my healthcare system that before they leave, “You’re going to like the way you feel. I guarantee it!” TH
References
1. Guydish M. Geisinger CEO: money-back guarantee for health care coming. November 6, 2015. Times Leader website. Available at: http://timesleader.com/news/492790/geisinger-ceo-money-back-guarantee-for-health-car-coming. Accessed December 5, 2015.
2. Luthra S. When something goes wrong at the hospital, who pays? November 11, 2015. Kaiser Health News. Available at: http://khn.org/news/when-something-goes-wrong-at-the-hospital-who-pays/?utm_source=Managed&utm_campaign=9e17712a95-Quality+%26+Patient+Safety+Update&utm_medium=email&utm_term=0_ebe1fa6178-9e17712a95-319388717. Accessed December 5, 2015.
We’ve all seen hundreds of commercials from companies advertising products and services with a money-back guarantee. The Men’s Warehouse, for example, has been promising men across the globe for over a decade, “You’re going to like the way you look. I guarantee it!” But to date, no one has made such a “guarantee” in the healthcare industry. Buying a suit is not exactly like getting your gallbladder removed.
We know that medical diagnoses and treatments are filled with uncertainty in expected processes and outcomes, because the factors that are dependent on these processes and outcomes are endless. These include patient factors (overall health, functional status, comorbid conditions), procedural factors (emergency versus elective, time of day or night), and facility factors (having the optimal team with skills that match the patient need, having all the right products and equipment). Although we know that many medical procedures have a relatively predictable risk of complications, unpredictable complications still occur, so how can we ever offer a guarantee for the interventions we perform on patients?
First of Its Kind
David Feinberg, MD, MBA, president and CEO of Geisinger Health System, is doing just that. This healthcare system has developed an application, called the Geisinger ProvenExperience, which can be downloaded onto a smartphone. After a procedure, each patient is given a code for the condition that was treated. With that code, the patient can enter feedback on the services provided and can then request a refund if they are not fully satisfied.
Most remarkably, the request for a refund is based on the judgment of the recipient, not on that of the provider(s). At a recent public meeting, Dr. Feinberg said of the new program: “We’re going to do everything right. That’s our job, that’s our promise to you … and you’re the judge. If you don’t think so, we’re going to apologize, we’re going to try to fix it for the next guy, and, as a small token of appreciation, we’re going to give you some money back.”1
Although many are skeptical about whether or not the program will be successful, much less viable, Dr. Feinberg contends that early feedback on the program has shown that most patients don’t actually want their money back. Instead, if their needs have not been met, most have just wanted a sincere apology and a commitment to make things better for others. Dr. Feinberg also contests that even if this is not the best or only approach to improving healthcare (quickly), we should all feel compelled to do something about our repeated failures in meeting patient expectations in the quality and/or experience of their care; and because no other industry works this way, other than healthcare. Typically, when consumers get fed up with poor service in other industries, disruptive innovations (Uber, for example) are created to satisfy customers’ desires.
A New Paradigm?
In healthcare, patients certainly should be dissatisfied if they experience a preventable harm event. Some types of harm are considered “always preventable,” such as wrong-site surgery. These events are extremely rare and, thus, do not constitute most cases of harm in hospitals these days. Such “never events” are relatively well defined and have been adopted for nonpayment by Medicare and other insurers, which can serve to buffer a patient’s financial liability in the small number of these cases. For other, more common, types of preventable harm, some hospitals have instituted apology and disclosure policies, and some will also relieve the patient of the portion of the bill attributable to the preventable harm. But not all hospitals have adopted such policies, despite the fact that they are widely endorsed by influential agencies, including The Joint Commission, the American Medical Association, Leapfrog Group, the National Quality Forum, and the Agency for Healthcare Research and Quality.
And, even for hospitals that have adopted such “best practice” policies, there is not always clear consensus on what constitutes preventable harm. Generally, the “judgment call” about what constitutes preventable harm is made by healthcare systems and providers—not patients. In addition, many cases of harm that are not necessarily preventable can often result in great dissatisfaction for the patient. There are countless stories of patients who are unfortunately harmed in the course of medical procedures, but who were informed of the possible risks of the procedure and consented to have the procedure performed despite the risks. These situations, which are agonizingly difficult for the system, the providers, and the patients, have no good solutions. Systems cannot “own” all harm, such as those resulting from the disease process itself or from risky and invasive procedures intended to benefit the patient. And there is ongoing inconsistency in healthcare systems when it comes to their willingness and ability to consistently define preventable harm or to disclose, apologize, and forgive payments in such cases.
So, while this move to allow patients to ask for a “refund” seems both extremely appealing and extremely risky, it certainly seems as though it will greatly enhance the trust of patients and their families in the Geisinger Health System.
I, among others, will eagerly follow the results of this program; while getting a cholecystectomy is not the same as buying a men’s suit, I do hope that someday, I will be able to say to every patient entering my healthcare system that before they leave, “You’re going to like the way you feel. I guarantee it!” TH
References
1. Guydish M. Geisinger CEO: money-back guarantee for health care coming. November 6, 2015. Times Leader website. Available at: http://timesleader.com/news/492790/geisinger-ceo-money-back-guarantee-for-health-car-coming. Accessed December 5, 2015.
2. Luthra S. When something goes wrong at the hospital, who pays? November 11, 2015. Kaiser Health News. Available at: http://khn.org/news/when-something-goes-wrong-at-the-hospital-who-pays/?utm_source=Managed&utm_campaign=9e17712a95-Quality+%26+Patient+Safety+Update&utm_medium=email&utm_term=0_ebe1fa6178-9e17712a95-319388717. Accessed December 5, 2015.
We’ve all seen hundreds of commercials from companies advertising products and services with a money-back guarantee. The Men’s Warehouse, for example, has been promising men across the globe for over a decade, “You’re going to like the way you look. I guarantee it!” But to date, no one has made such a “guarantee” in the healthcare industry. Buying a suit is not exactly like getting your gallbladder removed.
We know that medical diagnoses and treatments are filled with uncertainty in expected processes and outcomes, because the factors that are dependent on these processes and outcomes are endless. These include patient factors (overall health, functional status, comorbid conditions), procedural factors (emergency versus elective, time of day or night), and facility factors (having the optimal team with skills that match the patient need, having all the right products and equipment). Although we know that many medical procedures have a relatively predictable risk of complications, unpredictable complications still occur, so how can we ever offer a guarantee for the interventions we perform on patients?
First of Its Kind
David Feinberg, MD, MBA, president and CEO of Geisinger Health System, is doing just that. This healthcare system has developed an application, called the Geisinger ProvenExperience, which can be downloaded onto a smartphone. After a procedure, each patient is given a code for the condition that was treated. With that code, the patient can enter feedback on the services provided and can then request a refund if they are not fully satisfied.
Most remarkably, the request for a refund is based on the judgment of the recipient, not on that of the provider(s). At a recent public meeting, Dr. Feinberg said of the new program: “We’re going to do everything right. That’s our job, that’s our promise to you … and you’re the judge. If you don’t think so, we’re going to apologize, we’re going to try to fix it for the next guy, and, as a small token of appreciation, we’re going to give you some money back.”1
Although many are skeptical about whether or not the program will be successful, much less viable, Dr. Feinberg contends that early feedback on the program has shown that most patients don’t actually want their money back. Instead, if their needs have not been met, most have just wanted a sincere apology and a commitment to make things better for others. Dr. Feinberg also contests that even if this is not the best or only approach to improving healthcare (quickly), we should all feel compelled to do something about our repeated failures in meeting patient expectations in the quality and/or experience of their care; and because no other industry works this way, other than healthcare. Typically, when consumers get fed up with poor service in other industries, disruptive innovations (Uber, for example) are created to satisfy customers’ desires.
A New Paradigm?
In healthcare, patients certainly should be dissatisfied if they experience a preventable harm event. Some types of harm are considered “always preventable,” such as wrong-site surgery. These events are extremely rare and, thus, do not constitute most cases of harm in hospitals these days. Such “never events” are relatively well defined and have been adopted for nonpayment by Medicare and other insurers, which can serve to buffer a patient’s financial liability in the small number of these cases. For other, more common, types of preventable harm, some hospitals have instituted apology and disclosure policies, and some will also relieve the patient of the portion of the bill attributable to the preventable harm. But not all hospitals have adopted such policies, despite the fact that they are widely endorsed by influential agencies, including The Joint Commission, the American Medical Association, Leapfrog Group, the National Quality Forum, and the Agency for Healthcare Research and Quality.
And, even for hospitals that have adopted such “best practice” policies, there is not always clear consensus on what constitutes preventable harm. Generally, the “judgment call” about what constitutes preventable harm is made by healthcare systems and providers—not patients. In addition, many cases of harm that are not necessarily preventable can often result in great dissatisfaction for the patient. There are countless stories of patients who are unfortunately harmed in the course of medical procedures, but who were informed of the possible risks of the procedure and consented to have the procedure performed despite the risks. These situations, which are agonizingly difficult for the system, the providers, and the patients, have no good solutions. Systems cannot “own” all harm, such as those resulting from the disease process itself or from risky and invasive procedures intended to benefit the patient. And there is ongoing inconsistency in healthcare systems when it comes to their willingness and ability to consistently define preventable harm or to disclose, apologize, and forgive payments in such cases.
So, while this move to allow patients to ask for a “refund” seems both extremely appealing and extremely risky, it certainly seems as though it will greatly enhance the trust of patients and their families in the Geisinger Health System.
I, among others, will eagerly follow the results of this program; while getting a cholecystectomy is not the same as buying a men’s suit, I do hope that someday, I will be able to say to every patient entering my healthcare system that before they leave, “You’re going to like the way you feel. I guarantee it!” TH
References
1. Guydish M. Geisinger CEO: money-back guarantee for health care coming. November 6, 2015. Times Leader website. Available at: http://timesleader.com/news/492790/geisinger-ceo-money-back-guarantee-for-health-car-coming. Accessed December 5, 2015.
2. Luthra S. When something goes wrong at the hospital, who pays? November 11, 2015. Kaiser Health News. Available at: http://khn.org/news/when-something-goes-wrong-at-the-hospital-who-pays/?utm_source=Managed&utm_campaign=9e17712a95-Quality+%26+Patient+Safety+Update&utm_medium=email&utm_term=0_ebe1fa6178-9e17712a95-319388717. Accessed December 5, 2015.
Hospitalist Jaime Upegui, MD, Links Passion for Work to Love of Motorcycle Travel, Sports, Dance
Hospitalist Jaime Upegui, MD, division president at Apogee Physicians in Coeur d’Alene, Idaho, knows exactly what he wants to do when he retires years from now: sell everything he owns and ride his motorcycle around the world.
Dr. Upegui is a modern-day explorer who enjoys making the journey as much as getting to the destination. Riding is his personal form of yoga, a meditative experience that demands he stay in the moment and allows him to escape life’s daily frustrations. Ever since he started riding motorcycles at age five, he’s been hooked and has no plans of shifting into neutral.
Driven by Change
Every day at work, Dr. Upegui, an internal medicine specialist, helps hospitalists thrive in a changing medical world where they’re constantly being pushed and pulled in multiple directions. “It’s an exciting career that’s full of unexpected changes,” he says. “I work hard every day on building great teams that produce stellar results.”
He brings that same level of enthusiasm to his after-work activities, which include skydiving, tango dancing, scuba diving, snowboarding, and rock climbing. His passion for change and adventure stems from his childhood.
Listen to more of our interview with Dr. Upegui.
Dr. Upegui was born in Colombia and raised predominantly in the cities of Cali and Medellín. His mother, Rocio, was a painter and ballet dancer; his father, Jaime Sr., was a poet and musician. He spent most of his childhood with his mother, who moved frequently in search of new inspirations. During his childhood, he attended 13 different schools and lived in more than 30 different homes in the U.S., Colombia, and Spain. In 2003, he finished medical school, graduating from Universidad Pontificia Bolivariana in Medellín. He worked as an attending physician in the emergency department there for three years before moving to New York City to complete his residency in internal medicine at St. Luke’s–Roosevelt Hospital Center.
Throughout medical school and his residency, Dr. Upegui’s personal interests extended beyond motorcycling to skydiving and tango dancing, a skill he initially learned to love from his father. Dr. Upegui says he enjoys nothing more than learning, so he’s attracted to activities that require a high degree of training or technical expertise.
“I like to do things that make me feel like I’m proficient at something that’s difficult,” he says.
He vividly remembers the first time he jumped out of a plane, in 2002.
“It was thrilling, it was exciting, it was ego-boosting, it was self-gratifying, it was an adrenaline rush,” Dr. Upegui explains, adding that he taught English to the owner of the skydiving center in Colombia in exchange for free jumps. “The most exciting part is the decision to take the leap. That critical moment still gives me butterflies.”
Over the next six years, he jumped approximately 150 times, then stopped for roughly seven years to handle the demands of school and work, and to avoid the actual cost of skydiving, which is pricey at roughly a few hundred dollars per jump. But, over the years, he missed it, so he resumed skydiving earlier this year.
In between, he learned to tango through private and group lessons. Last year, he traveled to Buenos Aires, Argentina, for an intensive weeklong course and an international tango gathering. He also travels to “milongas,” get-togethers for professional and student tango dancers that are held in various cities worldwide.
“Tango has two core elements: showing your intention to move forward and allowing your partner to accept the invitation to follow your lead,” he says. “It’s a beautiful combination of assertiveness, determination, and then negotiation, followed by permission to proceed, depending upon how the conversation is going during the dance.”
No Regrets
Procrastination is not a familiar word to Dr. Upegui.
“The time frame between something that I want to do and [actually] doing it is very short,” he says. “If I want to do something, I just look at how I can get to it as soon as it’s available.”
Motorcycling ranks as his number one passion. Last year, he completed a 7,000-mile trip without taking any time off from his current job, which requires him to lead, manage, and often meet with hospitalist teams nationwide. He traveled via back roads on weekends to a major city, left his bike at the airport, and then hopped on a plane to wherever he needed to be for work. Instead of flying home for the weekend, he’d return to the airport to pick up his bike and travel to the next city he wanted to visit, which could be 1,000 miles away.
“The cool thing about the road is that random people help you,” he says. “The hotels would keep my clothes and luggage, and airport parking employees would help me park my motorcycle in a safe place and keep my helmet in their office.”
Dr. Upegui says childhood experiences that focused on momentum and movement laid the foundation for his mobile and adventuresome lifestyle. Movement, variability, and change have become the guiding factors in his life. Perhaps that’s why he chose to be a hospitalist. Among the youngest fields in medicine, the specialty is always growing, changing, and evolving.
“If you take any change in life as just a new stage of a new moment and you just perform your best in this current situation, then that will allow you to always be flexible to what’s happening in front of you,” Dr. Upegui says. “I love my work, family, Apogee, and the opportunities I have had. I could die completely satisfied today, knowing that I’ve done the best I could and searched for happiness every day.”
Hospitalist Jaime Upegui, MD, division president at Apogee Physicians in Coeur d’Alene, Idaho, knows exactly what he wants to do when he retires years from now: sell everything he owns and ride his motorcycle around the world.
Dr. Upegui is a modern-day explorer who enjoys making the journey as much as getting to the destination. Riding is his personal form of yoga, a meditative experience that demands he stay in the moment and allows him to escape life’s daily frustrations. Ever since he started riding motorcycles at age five, he’s been hooked and has no plans of shifting into neutral.
Driven by Change
Every day at work, Dr. Upegui, an internal medicine specialist, helps hospitalists thrive in a changing medical world where they’re constantly being pushed and pulled in multiple directions. “It’s an exciting career that’s full of unexpected changes,” he says. “I work hard every day on building great teams that produce stellar results.”
He brings that same level of enthusiasm to his after-work activities, which include skydiving, tango dancing, scuba diving, snowboarding, and rock climbing. His passion for change and adventure stems from his childhood.
Listen to more of our interview with Dr. Upegui.
Dr. Upegui was born in Colombia and raised predominantly in the cities of Cali and Medellín. His mother, Rocio, was a painter and ballet dancer; his father, Jaime Sr., was a poet and musician. He spent most of his childhood with his mother, who moved frequently in search of new inspirations. During his childhood, he attended 13 different schools and lived in more than 30 different homes in the U.S., Colombia, and Spain. In 2003, he finished medical school, graduating from Universidad Pontificia Bolivariana in Medellín. He worked as an attending physician in the emergency department there for three years before moving to New York City to complete his residency in internal medicine at St. Luke’s–Roosevelt Hospital Center.
Throughout medical school and his residency, Dr. Upegui’s personal interests extended beyond motorcycling to skydiving and tango dancing, a skill he initially learned to love from his father. Dr. Upegui says he enjoys nothing more than learning, so he’s attracted to activities that require a high degree of training or technical expertise.
“I like to do things that make me feel like I’m proficient at something that’s difficult,” he says.
He vividly remembers the first time he jumped out of a plane, in 2002.
“It was thrilling, it was exciting, it was ego-boosting, it was self-gratifying, it was an adrenaline rush,” Dr. Upegui explains, adding that he taught English to the owner of the skydiving center in Colombia in exchange for free jumps. “The most exciting part is the decision to take the leap. That critical moment still gives me butterflies.”
Over the next six years, he jumped approximately 150 times, then stopped for roughly seven years to handle the demands of school and work, and to avoid the actual cost of skydiving, which is pricey at roughly a few hundred dollars per jump. But, over the years, he missed it, so he resumed skydiving earlier this year.
In between, he learned to tango through private and group lessons. Last year, he traveled to Buenos Aires, Argentina, for an intensive weeklong course and an international tango gathering. He also travels to “milongas,” get-togethers for professional and student tango dancers that are held in various cities worldwide.
“Tango has two core elements: showing your intention to move forward and allowing your partner to accept the invitation to follow your lead,” he says. “It’s a beautiful combination of assertiveness, determination, and then negotiation, followed by permission to proceed, depending upon how the conversation is going during the dance.”
No Regrets
Procrastination is not a familiar word to Dr. Upegui.
“The time frame between something that I want to do and [actually] doing it is very short,” he says. “If I want to do something, I just look at how I can get to it as soon as it’s available.”
Motorcycling ranks as his number one passion. Last year, he completed a 7,000-mile trip without taking any time off from his current job, which requires him to lead, manage, and often meet with hospitalist teams nationwide. He traveled via back roads on weekends to a major city, left his bike at the airport, and then hopped on a plane to wherever he needed to be for work. Instead of flying home for the weekend, he’d return to the airport to pick up his bike and travel to the next city he wanted to visit, which could be 1,000 miles away.
“The cool thing about the road is that random people help you,” he says. “The hotels would keep my clothes and luggage, and airport parking employees would help me park my motorcycle in a safe place and keep my helmet in their office.”
Dr. Upegui says childhood experiences that focused on momentum and movement laid the foundation for his mobile and adventuresome lifestyle. Movement, variability, and change have become the guiding factors in his life. Perhaps that’s why he chose to be a hospitalist. Among the youngest fields in medicine, the specialty is always growing, changing, and evolving.
“If you take any change in life as just a new stage of a new moment and you just perform your best in this current situation, then that will allow you to always be flexible to what’s happening in front of you,” Dr. Upegui says. “I love my work, family, Apogee, and the opportunities I have had. I could die completely satisfied today, knowing that I’ve done the best I could and searched for happiness every day.”
Hospitalist Jaime Upegui, MD, division president at Apogee Physicians in Coeur d’Alene, Idaho, knows exactly what he wants to do when he retires years from now: sell everything he owns and ride his motorcycle around the world.
Dr. Upegui is a modern-day explorer who enjoys making the journey as much as getting to the destination. Riding is his personal form of yoga, a meditative experience that demands he stay in the moment and allows him to escape life’s daily frustrations. Ever since he started riding motorcycles at age five, he’s been hooked and has no plans of shifting into neutral.
Driven by Change
Every day at work, Dr. Upegui, an internal medicine specialist, helps hospitalists thrive in a changing medical world where they’re constantly being pushed and pulled in multiple directions. “It’s an exciting career that’s full of unexpected changes,” he says. “I work hard every day on building great teams that produce stellar results.”
He brings that same level of enthusiasm to his after-work activities, which include skydiving, tango dancing, scuba diving, snowboarding, and rock climbing. His passion for change and adventure stems from his childhood.
Listen to more of our interview with Dr. Upegui.
Dr. Upegui was born in Colombia and raised predominantly in the cities of Cali and Medellín. His mother, Rocio, was a painter and ballet dancer; his father, Jaime Sr., was a poet and musician. He spent most of his childhood with his mother, who moved frequently in search of new inspirations. During his childhood, he attended 13 different schools and lived in more than 30 different homes in the U.S., Colombia, and Spain. In 2003, he finished medical school, graduating from Universidad Pontificia Bolivariana in Medellín. He worked as an attending physician in the emergency department there for three years before moving to New York City to complete his residency in internal medicine at St. Luke’s–Roosevelt Hospital Center.
Throughout medical school and his residency, Dr. Upegui’s personal interests extended beyond motorcycling to skydiving and tango dancing, a skill he initially learned to love from his father. Dr. Upegui says he enjoys nothing more than learning, so he’s attracted to activities that require a high degree of training or technical expertise.
“I like to do things that make me feel like I’m proficient at something that’s difficult,” he says.
He vividly remembers the first time he jumped out of a plane, in 2002.
“It was thrilling, it was exciting, it was ego-boosting, it was self-gratifying, it was an adrenaline rush,” Dr. Upegui explains, adding that he taught English to the owner of the skydiving center in Colombia in exchange for free jumps. “The most exciting part is the decision to take the leap. That critical moment still gives me butterflies.”
Over the next six years, he jumped approximately 150 times, then stopped for roughly seven years to handle the demands of school and work, and to avoid the actual cost of skydiving, which is pricey at roughly a few hundred dollars per jump. But, over the years, he missed it, so he resumed skydiving earlier this year.
In between, he learned to tango through private and group lessons. Last year, he traveled to Buenos Aires, Argentina, for an intensive weeklong course and an international tango gathering. He also travels to “milongas,” get-togethers for professional and student tango dancers that are held in various cities worldwide.
“Tango has two core elements: showing your intention to move forward and allowing your partner to accept the invitation to follow your lead,” he says. “It’s a beautiful combination of assertiveness, determination, and then negotiation, followed by permission to proceed, depending upon how the conversation is going during the dance.”
No Regrets
Procrastination is not a familiar word to Dr. Upegui.
“The time frame between something that I want to do and [actually] doing it is very short,” he says. “If I want to do something, I just look at how I can get to it as soon as it’s available.”
Motorcycling ranks as his number one passion. Last year, he completed a 7,000-mile trip without taking any time off from his current job, which requires him to lead, manage, and often meet with hospitalist teams nationwide. He traveled via back roads on weekends to a major city, left his bike at the airport, and then hopped on a plane to wherever he needed to be for work. Instead of flying home for the weekend, he’d return to the airport to pick up his bike and travel to the next city he wanted to visit, which could be 1,000 miles away.
“The cool thing about the road is that random people help you,” he says. “The hotels would keep my clothes and luggage, and airport parking employees would help me park my motorcycle in a safe place and keep my helmet in their office.”
Dr. Upegui says childhood experiences that focused on momentum and movement laid the foundation for his mobile and adventuresome lifestyle. Movement, variability, and change have become the guiding factors in his life. Perhaps that’s why he chose to be a hospitalist. Among the youngest fields in medicine, the specialty is always growing, changing, and evolving.
“If you take any change in life as just a new stage of a new moment and you just perform your best in this current situation, then that will allow you to always be flexible to what’s happening in front of you,” Dr. Upegui says. “I love my work, family, Apogee, and the opportunities I have had. I could die completely satisfied today, knowing that I’ve done the best I could and searched for happiness every day.”
Frailty in HSCT population not dependent on age
Photo by Peter Griffin
ORLANDO, FL—Frailty after hematopoietic stem cell transplant (HSCT), while associated with higher mortality, is not necessarily a function of age, according to investigators studying the impact of frailty on transplant outcomes.
Instead, other factors, such as increasing time from transplant, employment status, medical leave or disability, and limitations of social activities, were significantly associated with higher odds of frailty.
The investigators prospectively studied 96 HSCT recipients, age 40 and older, to determine the prevalence of frailty in HSCT populations and its impact on outcomes, including early post-transplant non-relapse mortality (NRM).
Mukta Arora, MD, of the University of Minnesota in Minneapolis, reported the findings at the 2015 ASH Annual Meeting (abstract 388*).
The investigators defined frailty as the presence of 3 or more of the following criteria: low grip strength, exhaustion, slowed walking speed, low physical activity, and unintentional weight loss. They defined pre-frailty as having 1 or 2 of these characteristics.
The investigators conducted multi-domain geriatric assessments of patients prior to HSCT and after transplant at 100 days, 6 months, and 1 year. The assessment included function, comorbidity, cognition, psychological state, social activity/support, nutritional status, and demographic, transplant, and disease-related information.
Forty-eight patients were in the younger age group (40–59), and 48 were in the older age group (60–74). All had undergone HSCT between February 2014 and April 2015.
Patient demographics
Patients in the younger group were a median age of 54 (range, 40–59) at transplant. Sixty-five percent were male, 58% had an autologous transplant, and 79% received myeloablative conditioning.
Patients in the older group were a median age of 65 (range, 60–73) at transplant. Fifty-four percent were male, 46% had an autologous transplant, and 46% had myeloablative conditioning.
The difference between the older and younger groups in their conditioning regimen was significant (P<0.01).
The groups were comparable in terms of the HSCT comorbidity index but were significantly different in employment status (P<0.01).
“As expected,” Dr Arora said, “there were more patients who were retired in the older group.”
In the younger group, 31% were employed, 3% retired, 56% on medical leave or disabled, and 10% unemployed.
In the older group, 6% were employed, 62% retired, 28% on medical leave or disabled, and 4% unemployed.
“There was no difference in the social activity and social support scores between the 2 groups,” Dr Arora observed.
Frailty assessments
In the younger group, at baseline, the prevalence of pre-frailty was 47%, and the prevalence of frailty was 11%. At 6 months after HSCT, the prevalence of pre-frailty was 45%, and the prevalence of frailty was 41% (P<0.01).
In the older group, at baseline, the prevalence of pre-frailty was 42%, and the prevalence of frailty was 6%. At 6 months, the prevalence of pre-frailty was 44%, and the prevalence of frailty was 38% (P<0.01).
The investigators then estimated the predictors of frailty.
Significant predictors of frailty included time since HSCT (odds ratio [OR]=3.7, 95% CI: 1.9-7.2, P<0.01), employment status (retired: OR=7.3, 95% CI 1.2 – 46.2, P=0.03), on medical leave or disabled (OR=11.2, 95% CI: 1.8 – 67.7, P=0.01), limitations in social activities (OR=1.04, 95% CI: 1.01 – 1.08, P=0.01), and baseline pre-frailty (OR=3.1, 95% CI: 2.3 – 45.5, P<0.01).
Allogeneic transplant was associated with higher odds of frailty than autologous (OR=3.1, 95% CI: 0.9 – 10.2), although it did not reach significance (P=0.06).
Investigators next estimated the impact of frailty or pre-frailty on NRM and identified a trend toward increased NRM in frail patients.
The 46 patients classified as not frail at baseline had a 7% cumulative incidence of NRM (P=0.07). The 42 patients classified as pre-frail had a 23% cumulative incidence of NRM, while the 8 patients classified as frail at baseline had a 28% cumulative incidence of NRM.
“So, to conclude, in this early study, frailty was noted in 8% and pre-frailty in 44% of the transplant population prior to transplant, and was not dependent on age,” Dr Arora said. “Frailty is a transitional state and appears to reflect a dynamic progression from robustness to functional decline with time since [HSCT].”
Because frailty is associated with higher mortality, the investigators believe vulnerable populations should be identified and their need for specific interventions defined.
This research was funded by the Leukemia & Lymphoma Society. 
*Data in the abstract differ from the presentation.
Photo by Peter Griffin
ORLANDO, FL—Frailty after hematopoietic stem cell transplant (HSCT), while associated with higher mortality, is not necessarily a function of age, according to investigators studying the impact of frailty on transplant outcomes.
Instead, other factors, such as increasing time from transplant, employment status, medical leave or disability, and limitations of social activities, were significantly associated with higher odds of frailty.
The investigators prospectively studied 96 HSCT recipients, age 40 and older, to determine the prevalence of frailty in HSCT populations and its impact on outcomes, including early post-transplant non-relapse mortality (NRM).
Mukta Arora, MD, of the University of Minnesota in Minneapolis, reported the findings at the 2015 ASH Annual Meeting (abstract 388*).
The investigators defined frailty as the presence of 3 or more of the following criteria: low grip strength, exhaustion, slowed walking speed, low physical activity, and unintentional weight loss. They defined pre-frailty as having 1 or 2 of these characteristics.
The investigators conducted multi-domain geriatric assessments of patients prior to HSCT and after transplant at 100 days, 6 months, and 1 year. The assessment included function, comorbidity, cognition, psychological state, social activity/support, nutritional status, and demographic, transplant, and disease-related information.
Forty-eight patients were in the younger age group (40–59), and 48 were in the older age group (60–74). All had undergone HSCT between February 2014 and April 2015.
Patient demographics
Patients in the younger group were a median age of 54 (range, 40–59) at transplant. Sixty-five percent were male, 58% had an autologous transplant, and 79% received myeloablative conditioning.
Patients in the older group were a median age of 65 (range, 60–73) at transplant. Fifty-four percent were male, 46% had an autologous transplant, and 46% had myeloablative conditioning.
The difference between the older and younger groups in their conditioning regimen was significant (P<0.01).
The groups were comparable in terms of the HSCT comorbidity index but were significantly different in employment status (P<0.01).
“As expected,” Dr Arora said, “there were more patients who were retired in the older group.”
In the younger group, 31% were employed, 3% retired, 56% on medical leave or disabled, and 10% unemployed.
In the older group, 6% were employed, 62% retired, 28% on medical leave or disabled, and 4% unemployed.
“There was no difference in the social activity and social support scores between the 2 groups,” Dr Arora observed.
Frailty assessments
In the younger group, at baseline, the prevalence of pre-frailty was 47%, and the prevalence of frailty was 11%. At 6 months after HSCT, the prevalence of pre-frailty was 45%, and the prevalence of frailty was 41% (P<0.01).
In the older group, at baseline, the prevalence of pre-frailty was 42%, and the prevalence of frailty was 6%. At 6 months, the prevalence of pre-frailty was 44%, and the prevalence of frailty was 38% (P<0.01).
The investigators then estimated the predictors of frailty.
Significant predictors of frailty included time since HSCT (odds ratio [OR]=3.7, 95% CI: 1.9-7.2, P<0.01), employment status (retired: OR=7.3, 95% CI 1.2 – 46.2, P=0.03), on medical leave or disabled (OR=11.2, 95% CI: 1.8 – 67.7, P=0.01), limitations in social activities (OR=1.04, 95% CI: 1.01 – 1.08, P=0.01), and baseline pre-frailty (OR=3.1, 95% CI: 2.3 – 45.5, P<0.01).
Allogeneic transplant was associated with higher odds of frailty than autologous (OR=3.1, 95% CI: 0.9 – 10.2), although it did not reach significance (P=0.06).
Investigators next estimated the impact of frailty or pre-frailty on NRM and identified a trend toward increased NRM in frail patients.
The 46 patients classified as not frail at baseline had a 7% cumulative incidence of NRM (P=0.07). The 42 patients classified as pre-frail had a 23% cumulative incidence of NRM, while the 8 patients classified as frail at baseline had a 28% cumulative incidence of NRM.
“So, to conclude, in this early study, frailty was noted in 8% and pre-frailty in 44% of the transplant population prior to transplant, and was not dependent on age,” Dr Arora said. “Frailty is a transitional state and appears to reflect a dynamic progression from robustness to functional decline with time since [HSCT].”
Because frailty is associated with higher mortality, the investigators believe vulnerable populations should be identified and their need for specific interventions defined.
This research was funded by the Leukemia & Lymphoma Society.
*Data in the abstract differ from the presentation.
Photo by Peter Griffin
ORLANDO, FL—Frailty after hematopoietic stem cell transplant (HSCT), while associated with higher mortality, is not necessarily a function of age, according to investigators studying the impact of frailty on transplant outcomes.
Instead, other factors, such as increasing time from transplant, employment status, medical leave or disability, and limitations of social activities, were significantly associated with higher odds of frailty.
The investigators prospectively studied 96 HSCT recipients, age 40 and older, to determine the prevalence of frailty in HSCT populations and its impact on outcomes, including early post-transplant non-relapse mortality (NRM).
Mukta Arora, MD, of the University of Minnesota in Minneapolis, reported the findings at the 2015 ASH Annual Meeting (abstract 388*).
The investigators defined frailty as the presence of 3 or more of the following criteria: low grip strength, exhaustion, slowed walking speed, low physical activity, and unintentional weight loss. They defined pre-frailty as having 1 or 2 of these characteristics.
The investigators conducted multi-domain geriatric assessments of patients prior to HSCT and after transplant at 100 days, 6 months, and 1 year. The assessment included function, comorbidity, cognition, psychological state, social activity/support, nutritional status, and demographic, transplant, and disease-related information.
Forty-eight patients were in the younger age group (40–59), and 48 were in the older age group (60–74). All had undergone HSCT between February 2014 and April 2015.
Patient demographics
Patients in the younger group were a median age of 54 (range, 40–59) at transplant. Sixty-five percent were male, 58% had an autologous transplant, and 79% received myeloablative conditioning.
Patients in the older group were a median age of 65 (range, 60–73) at transplant. Fifty-four percent were male, 46% had an autologous transplant, and 46% had myeloablative conditioning.
The difference between the older and younger groups in their conditioning regimen was significant (P<0.01).
The groups were comparable in terms of the HSCT comorbidity index but were significantly different in employment status (P<0.01).
“As expected,” Dr Arora said, “there were more patients who were retired in the older group.”
In the younger group, 31% were employed, 3% retired, 56% on medical leave or disabled, and 10% unemployed.
In the older group, 6% were employed, 62% retired, 28% on medical leave or disabled, and 4% unemployed.
“There was no difference in the social activity and social support scores between the 2 groups,” Dr Arora observed.
Frailty assessments
In the younger group, at baseline, the prevalence of pre-frailty was 47%, and the prevalence of frailty was 11%. At 6 months after HSCT, the prevalence of pre-frailty was 45%, and the prevalence of frailty was 41% (P<0.01).
In the older group, at baseline, the prevalence of pre-frailty was 42%, and the prevalence of frailty was 6%. At 6 months, the prevalence of pre-frailty was 44%, and the prevalence of frailty was 38% (P<0.01).
The investigators then estimated the predictors of frailty.
Significant predictors of frailty included time since HSCT (odds ratio [OR]=3.7, 95% CI: 1.9-7.2, P<0.01), employment status (retired: OR=7.3, 95% CI 1.2 – 46.2, P=0.03), on medical leave or disabled (OR=11.2, 95% CI: 1.8 – 67.7, P=0.01), limitations in social activities (OR=1.04, 95% CI: 1.01 – 1.08, P=0.01), and baseline pre-frailty (OR=3.1, 95% CI: 2.3 – 45.5, P<0.01).
Allogeneic transplant was associated with higher odds of frailty than autologous (OR=3.1, 95% CI: 0.9 – 10.2), although it did not reach significance (P=0.06).
Investigators next estimated the impact of frailty or pre-frailty on NRM and identified a trend toward increased NRM in frail patients.
The 46 patients classified as not frail at baseline had a 7% cumulative incidence of NRM (P=0.07). The 42 patients classified as pre-frail had a 23% cumulative incidence of NRM, while the 8 patients classified as frail at baseline had a 28% cumulative incidence of NRM.
“So, to conclude, in this early study, frailty was noted in 8% and pre-frailty in 44% of the transplant population prior to transplant, and was not dependent on age,” Dr Arora said. “Frailty is a transitional state and appears to reflect a dynamic progression from robustness to functional decline with time since [HSCT].”
Because frailty is associated with higher mortality, the investigators believe vulnerable populations should be identified and their need for specific interventions defined.
This research was funded by the Leukemia & Lymphoma Society.
*Data in the abstract differ from the presentation.
Combo deepens responses and improves PFS in MM
Photo courtesy of the
University of Navarra
ORLANDO, FL—The addition of panobinostat to bortezomib-dexamethasone therapy in relapsed or refractory multiple myeloma (MM) patients can double the rate of deep responses and prolong progression-free survival (PFS), according to an updated analysis of data from the PANORMA 1 trial.
Panobinostat, a pan-deacetylase inhibitor, was the first agent of its class to produce a statistically significant and clinically meaningful increase in the median PFS of patients with relapsed/refractory MM in a phase 3 trial, noted Jesús F. San-Miguel, MD, PhD, of the University of Navarra in Pamplona, Spain.
Dr San-Miguel presented results of the updated analysis at the 2015 ASH Annual Meeting (abstract 4230).
In the PANORAMA 1 trial, patients receiving panobinostat plus bortezomib and dexamethasone had a significantly prolonged median PFS of 12 months versus 8.1 months in patients treated with placebo-bortezomib-dexamethasone.
A subgroup analysis showed that the PFS benefit was improved in patients with previous exposure to bortezomib and immunomodulatory drugs (IMiDs). The addition of panobinostat to bortezomib-dexamethasone also led to a significant increase in high-quality responses.
With their analysis, Dr San-Miguel and his colleagues set out to determine the effect of responses on clinical outcomes of patients treated in PANORAMA 1, including those with prior exposure to bortezomib and IMiDs.
The researchers conducted a landmark analysis at 12, 18, and 24 weeks to assess the median PFS in patients who achieved a complete response (CR)/near complete response (nCR) or partial response (PR).
“For the total study population, the rates of high-quality responses [CR/nCR rate] were significantly higher in the panobinostat-bortezomib-dexamethasone arm [28%] than in the control arm [16%],” Dr San-Miguel said.
Among the subgroup with prior exposure to bortezomib and IMiDs, the CR/nCR rate was also higher in the triple-drug arm (22.3%) than in the 2-drug arm (9.9%).
Among patients who took panobinostat-bortezomib-dexamethasone, the duration of response was twice as long in those who achieved CR/nCR (18.4 months) as in those who achieved a PR (9 months).
The median PFS at 12 weeks for patients who received panobinostat-bortezomib-dexamethasone was increased in patients achieving high-quality responses: 16.5 months for nCR as compared to 10.3 months for PR.
The subgroup of patients with prior exposure to bortezomib and IMiDs who achieved deeper responses also demonstrated longer PFS at 12 weeks: a median of 13.7 months for nCR and 8.1 months for PR.
“In both the overall study population and the subgroup of patients with prior exposure to bortezomib and IMiDs, a 2-fold increase in deep responses was achieved with panobinostat-bortezomib-dexamethasone compared with placebo-bortezomib-dexamethasone,” Dr San-Miguel said. “In both groups, deep responses were associated with a prolonged PFS and a longer duration of response.”
He noted that the magnitude of benefit at each time point appeared greater among patients who received the triple-drug combination.
“These data further support achievement of deeper responses as a treatment goal and a robust and consistent benefit of panobinostat in the phase 3 study in patients with relapsed/refractory multiple myeloma, including those with prior exposure to bortezomib and IMiDs,” Dr San-Miguel said.
The PANORAMA 1 trial was sponsored by Novartis, the company developing panobinostat. Three researchers involved in the current analysis are employees of Novartis, and other researchers reported having relationships (receiving research funding, consulting, etc.) with a range of other pharmaceutical companies.
Photo courtesy of the
University of Navarra
ORLANDO, FL—The addition of panobinostat to bortezomib-dexamethasone therapy in relapsed or refractory multiple myeloma (MM) patients can double the rate of deep responses and prolong progression-free survival (PFS), according to an updated analysis of data from the PANORMA 1 trial.
Panobinostat, a pan-deacetylase inhibitor, was the first agent of its class to produce a statistically significant and clinically meaningful increase in the median PFS of patients with relapsed/refractory MM in a phase 3 trial, noted Jesús F. San-Miguel, MD, PhD, of the University of Navarra in Pamplona, Spain.
Dr San-Miguel presented results of the updated analysis at the 2015 ASH Annual Meeting (abstract 4230).
In the PANORAMA 1 trial, patients receiving panobinostat plus bortezomib and dexamethasone had a significantly prolonged median PFS of 12 months versus 8.1 months in patients treated with placebo-bortezomib-dexamethasone.
A subgroup analysis showed that the PFS benefit was improved in patients with previous exposure to bortezomib and immunomodulatory drugs (IMiDs). The addition of panobinostat to bortezomib-dexamethasone also led to a significant increase in high-quality responses.
With their analysis, Dr San-Miguel and his colleagues set out to determine the effect of responses on clinical outcomes of patients treated in PANORAMA 1, including those with prior exposure to bortezomib and IMiDs.
The researchers conducted a landmark analysis at 12, 18, and 24 weeks to assess the median PFS in patients who achieved a complete response (CR)/near complete response (nCR) or partial response (PR).
“For the total study population, the rates of high-quality responses [CR/nCR rate] were significantly higher in the panobinostat-bortezomib-dexamethasone arm [28%] than in the control arm [16%],” Dr San-Miguel said.
Among the subgroup with prior exposure to bortezomib and IMiDs, the CR/nCR rate was also higher in the triple-drug arm (22.3%) than in the 2-drug arm (9.9%).
Among patients who took panobinostat-bortezomib-dexamethasone, the duration of response was twice as long in those who achieved CR/nCR (18.4 months) as in those who achieved a PR (9 months).
The median PFS at 12 weeks for patients who received panobinostat-bortezomib-dexamethasone was increased in patients achieving high-quality responses: 16.5 months for nCR as compared to 10.3 months for PR.
The subgroup of patients with prior exposure to bortezomib and IMiDs who achieved deeper responses also demonstrated longer PFS at 12 weeks: a median of 13.7 months for nCR and 8.1 months for PR.
“In both the overall study population and the subgroup of patients with prior exposure to bortezomib and IMiDs, a 2-fold increase in deep responses was achieved with panobinostat-bortezomib-dexamethasone compared with placebo-bortezomib-dexamethasone,” Dr San-Miguel said. “In both groups, deep responses were associated with a prolonged PFS and a longer duration of response.”
He noted that the magnitude of benefit at each time point appeared greater among patients who received the triple-drug combination.
“These data further support achievement of deeper responses as a treatment goal and a robust and consistent benefit of panobinostat in the phase 3 study in patients with relapsed/refractory multiple myeloma, including those with prior exposure to bortezomib and IMiDs,” Dr San-Miguel said.
The PANORAMA 1 trial was sponsored by Novartis, the company developing panobinostat. Three researchers involved in the current analysis are employees of Novartis, and other researchers reported having relationships (receiving research funding, consulting, etc.) with a range of other pharmaceutical companies.
Photo courtesy of the
University of Navarra
ORLANDO, FL—The addition of panobinostat to bortezomib-dexamethasone therapy in relapsed or refractory multiple myeloma (MM) patients can double the rate of deep responses and prolong progression-free survival (PFS), according to an updated analysis of data from the PANORMA 1 trial.
Panobinostat, a pan-deacetylase inhibitor, was the first agent of its class to produce a statistically significant and clinically meaningful increase in the median PFS of patients with relapsed/refractory MM in a phase 3 trial, noted Jesús F. San-Miguel, MD, PhD, of the University of Navarra in Pamplona, Spain.
Dr San-Miguel presented results of the updated analysis at the 2015 ASH Annual Meeting (abstract 4230).
In the PANORAMA 1 trial, patients receiving panobinostat plus bortezomib and dexamethasone had a significantly prolonged median PFS of 12 months versus 8.1 months in patients treated with placebo-bortezomib-dexamethasone.
A subgroup analysis showed that the PFS benefit was improved in patients with previous exposure to bortezomib and immunomodulatory drugs (IMiDs). The addition of panobinostat to bortezomib-dexamethasone also led to a significant increase in high-quality responses.
With their analysis, Dr San-Miguel and his colleagues set out to determine the effect of responses on clinical outcomes of patients treated in PANORAMA 1, including those with prior exposure to bortezomib and IMiDs.
The researchers conducted a landmark analysis at 12, 18, and 24 weeks to assess the median PFS in patients who achieved a complete response (CR)/near complete response (nCR) or partial response (PR).
“For the total study population, the rates of high-quality responses [CR/nCR rate] were significantly higher in the panobinostat-bortezomib-dexamethasone arm [28%] than in the control arm [16%],” Dr San-Miguel said.
Among the subgroup with prior exposure to bortezomib and IMiDs, the CR/nCR rate was also higher in the triple-drug arm (22.3%) than in the 2-drug arm (9.9%).
Among patients who took panobinostat-bortezomib-dexamethasone, the duration of response was twice as long in those who achieved CR/nCR (18.4 months) as in those who achieved a PR (9 months).
The median PFS at 12 weeks for patients who received panobinostat-bortezomib-dexamethasone was increased in patients achieving high-quality responses: 16.5 months for nCR as compared to 10.3 months for PR.
The subgroup of patients with prior exposure to bortezomib and IMiDs who achieved deeper responses also demonstrated longer PFS at 12 weeks: a median of 13.7 months for nCR and 8.1 months for PR.
“In both the overall study population and the subgroup of patients with prior exposure to bortezomib and IMiDs, a 2-fold increase in deep responses was achieved with panobinostat-bortezomib-dexamethasone compared with placebo-bortezomib-dexamethasone,” Dr San-Miguel said. “In both groups, deep responses were associated with a prolonged PFS and a longer duration of response.”
He noted that the magnitude of benefit at each time point appeared greater among patients who received the triple-drug combination.
“These data further support achievement of deeper responses as a treatment goal and a robust and consistent benefit of panobinostat in the phase 3 study in patients with relapsed/refractory multiple myeloma, including those with prior exposure to bortezomib and IMiDs,” Dr San-Miguel said.
The PANORAMA 1 trial was sponsored by Novartis, the company developing panobinostat. Three researchers involved in the current analysis are employees of Novartis, and other researchers reported having relationships (receiving research funding, consulting, etc.) with a range of other pharmaceutical companies.
Factors predict low accrual in cancer clinical trials
for a clinical trial
Photo by Esther Dyson
Twelve factors may predict low patient accrual in cancer clinical trials, according to research published in JNCI.
Many studies have been conducted to investigate the perceived barriers to clinical trial accrual from the patient or provider perspective.
However, researchers have rarely taken a trial-level view and investigated why certain trials are able to accrue patients faster than expected while others fail to attract even a fraction of the intended number of participants.
Caroline S. Bennette, PhD, of the University of Washington in Seattle, and her colleagues conducted their study to do just that.
They analyzed information on 787 phase 2/3 clinical trials sponsored by the National Clinical Trials Network (NCTN; formerly the Cooperative Group Program) launched between 2000 and 2011.
After excluding trials that closed because of toxicity or interim results, the researchers found that 145 (18%) NCTN trials closed with low accrual or were accruing at less than 50% of target accrual 3 years or more after opening.
The team identified potential risk factors from the literature and interviews with clinical trial experts and found multiple trial-level factors that were associated with poor accrual to NCTN trials, such as increased competition for patients from currently ongoing trials, planning to enroll a higher proportion of the available patient population, and not evaluating a new investigational agent or targeted therapy.
The researchers then developed a multivariable prediction model of low accrual using 12 trial-level risk factors. The team said these factors had good agreement between predicted and observed risks of low accrual in a preliminary validation using 46 trials opened between 2012 and 2013.
Those 12 risk factors are:
- The number of competing trials per 10,000 eligible patients per year (odds ratio [OR]=1.88)
- Phase 3 vs phase 2 trial (OR=1.86)
- Enrollment as percentage of eligible population for targeted therapy (OR=0.57)
- Enrollment as percentage of eligible population for radiation therapy (OR=1.81)
- Annual incidence of clinical condition(s) per 10,000 (OR=0.99)
- Tissue sample required to assess eligibility (OR=1.26)
- Investigational new drug (OR=0.34)
- Metastatic setting (OR=1.46)
- Sample size per 100 (OR=0.95)
- More than one condition evaluated (OR=1.98)
- Common solid cancer (prostate, breast, lung, or colon) vs liquid or rare solid cancers (OR=2.32)
- Interaction term (phase 3 x investigational new drug, OR=2.47).
The researchers concluded that systematically considering the overall influence of these risk factors could aid in the design and prioritization of future clinical trials.
for a clinical trial
Photo by Esther Dyson
Twelve factors may predict low patient accrual in cancer clinical trials, according to research published in JNCI.
Many studies have been conducted to investigate the perceived barriers to clinical trial accrual from the patient or provider perspective.
However, researchers have rarely taken a trial-level view and investigated why certain trials are able to accrue patients faster than expected while others fail to attract even a fraction of the intended number of participants.
Caroline S. Bennette, PhD, of the University of Washington in Seattle, and her colleagues conducted their study to do just that.
They analyzed information on 787 phase 2/3 clinical trials sponsored by the National Clinical Trials Network (NCTN; formerly the Cooperative Group Program) launched between 2000 and 2011.
After excluding trials that closed because of toxicity or interim results, the researchers found that 145 (18%) NCTN trials closed with low accrual or were accruing at less than 50% of target accrual 3 years or more after opening.
The team identified potential risk factors from the literature and interviews with clinical trial experts and found multiple trial-level factors that were associated with poor accrual to NCTN trials, such as increased competition for patients from currently ongoing trials, planning to enroll a higher proportion of the available patient population, and not evaluating a new investigational agent or targeted therapy.
The researchers then developed a multivariable prediction model of low accrual using 12 trial-level risk factors. The team said these factors had good agreement between predicted and observed risks of low accrual in a preliminary validation using 46 trials opened between 2012 and 2013.
Those 12 risk factors are:
- The number of competing trials per 10,000 eligible patients per year (odds ratio [OR]=1.88)
- Phase 3 vs phase 2 trial (OR=1.86)
- Enrollment as percentage of eligible population for targeted therapy (OR=0.57)
- Enrollment as percentage of eligible population for radiation therapy (OR=1.81)
- Annual incidence of clinical condition(s) per 10,000 (OR=0.99)
- Tissue sample required to assess eligibility (OR=1.26)
- Investigational new drug (OR=0.34)
- Metastatic setting (OR=1.46)
- Sample size per 100 (OR=0.95)
- More than one condition evaluated (OR=1.98)
- Common solid cancer (prostate, breast, lung, or colon) vs liquid or rare solid cancers (OR=2.32)
- Interaction term (phase 3 x investigational new drug, OR=2.47).
The researchers concluded that systematically considering the overall influence of these risk factors could aid in the design and prioritization of future clinical trials.
for a clinical trial
Photo by Esther Dyson
Twelve factors may predict low patient accrual in cancer clinical trials, according to research published in JNCI.
Many studies have been conducted to investigate the perceived barriers to clinical trial accrual from the patient or provider perspective.
However, researchers have rarely taken a trial-level view and investigated why certain trials are able to accrue patients faster than expected while others fail to attract even a fraction of the intended number of participants.
Caroline S. Bennette, PhD, of the University of Washington in Seattle, and her colleagues conducted their study to do just that.
They analyzed information on 787 phase 2/3 clinical trials sponsored by the National Clinical Trials Network (NCTN; formerly the Cooperative Group Program) launched between 2000 and 2011.
After excluding trials that closed because of toxicity or interim results, the researchers found that 145 (18%) NCTN trials closed with low accrual or were accruing at less than 50% of target accrual 3 years or more after opening.
The team identified potential risk factors from the literature and interviews with clinical trial experts and found multiple trial-level factors that were associated with poor accrual to NCTN trials, such as increased competition for patients from currently ongoing trials, planning to enroll a higher proportion of the available patient population, and not evaluating a new investigational agent or targeted therapy.
The researchers then developed a multivariable prediction model of low accrual using 12 trial-level risk factors. The team said these factors had good agreement between predicted and observed risks of low accrual in a preliminary validation using 46 trials opened between 2012 and 2013.
Those 12 risk factors are:
- The number of competing trials per 10,000 eligible patients per year (odds ratio [OR]=1.88)
- Phase 3 vs phase 2 trial (OR=1.86)
- Enrollment as percentage of eligible population for targeted therapy (OR=0.57)
- Enrollment as percentage of eligible population for radiation therapy (OR=1.81)
- Annual incidence of clinical condition(s) per 10,000 (OR=0.99)
- Tissue sample required to assess eligibility (OR=1.26)
- Investigational new drug (OR=0.34)
- Metastatic setting (OR=1.46)
- Sample size per 100 (OR=0.95)
- More than one condition evaluated (OR=1.98)
- Common solid cancer (prostate, breast, lung, or colon) vs liquid or rare solid cancers (OR=2.32)
- Interaction term (phase 3 x investigational new drug, OR=2.47).
The researchers concluded that systematically considering the overall influence of these risk factors could aid in the design and prioritization of future clinical trials.
Why it’s hard to develop immunity against malaria
Diana Hansen, PhD
Photo courtesy of the Walter
and Eliza Hall Institute
Results of preclinical research appear to explain how the malaria parasite Plasmodium falciparum causes an inflammatory reaction that sabotages the body’s ability to protect itself from malaria.
Researchers found evidence to suggest that the same inflammatory molecules that drive the immune response in clinical and severe malaria also prevent the body from developing protective antibodies against the parasite.
They said this discovery opens up the possibility of improving new or existing malaria vaccines by boosting immune cells needed for long-lasting immunity.
Diana Hansen, PhD, of the Walter and Eliza Hall Institute of Medical Research in Parkville, Victoria, Australia, and her colleagues described this work in Cell Reports.
Dr Hansen said this is the first time scientists have pinpointed why the immune system fails to develop immunity during malaria infection.
“With many infections, a single exposure to the pathogen is enough to induce production of antibodies that will protect you for the rest of your life,” she explained. “However, with malaria, it can take up to 20 years for someone to build up sufficient immunity to be protected.”
The fact that the body is not good at developing long-lasting immunity to the parasite has hampered vaccine development, Dr Hansen added.
“This was complicated by the fact that we didn’t know whether it was the malaria parasite itself or the inflammatory reaction to malaria that was actually inhibiting the ability to develop protective immunity,” she said.
“We have now shown that it was a double-edged sword. The strong inflammatory reaction that accompanies and, in fact, drives severe clinical malaria is also responsible for silencing the key immune cells needed for long-term protection against the parasite.”
Dr Hansen and her colleagues conducted experiments in mouse models of malaria and found that inflammatory molecules released by the body to fight the infection were preventing protective antibodies from being made.
“Specialized immune cells called helper T cells join forces with B cells to generate these protective antibodies,” said Axel Kallies, PhD, of the Walter and Eliza Hall Institute of Medical Research.
“However, we showed that, during malaria infection, critical inflammatory molecules actually arrest development of helper T cells, and, therefore, the B cells don’t get the necessary instructions to make antibodies.”
Specifically, the researchers found that severe malaria infection inhibited the establishment of germinal centers in the spleens of the mice. And malaria infection induced high frequencies of T-follicular-helper cell precursors but resulted in impaired T-follicular-helper cell differentiation.
Precursor T-follicular-helper cells induced during infection had low levels of PD-1 and CXCR5 and co-expressed Th1-associated molecules such as T-bet and CXCR3.
However, when the researchers blocked the inflammatory cytokines TNF and IFN-γ or deleted T-bet, they were able to restore T-follicular-helper cell differentiation and germinal center responses to infection.
Dr Hansen said these findings could lead to new avenues in the search for effective malaria vaccines.
“This research opens the door to therapeutic approaches to accelerate development of protective immunity to malaria and improve efficacy of malaria vaccines,” she said.
“Until now, malaria vaccines have had disappointing results. We can now see a way of improving these responses by tailoring or augmenting the vaccine to boost development of helper T cells that will enable the body to make protective antibodies that target the malaria parasites.”
Diana Hansen, PhD
Photo courtesy of the Walter
and Eliza Hall Institute
Results of preclinical research appear to explain how the malaria parasite Plasmodium falciparum causes an inflammatory reaction that sabotages the body’s ability to protect itself from malaria.
Researchers found evidence to suggest that the same inflammatory molecules that drive the immune response in clinical and severe malaria also prevent the body from developing protective antibodies against the parasite.
They said this discovery opens up the possibility of improving new or existing malaria vaccines by boosting immune cells needed for long-lasting immunity.
Diana Hansen, PhD, of the Walter and Eliza Hall Institute of Medical Research in Parkville, Victoria, Australia, and her colleagues described this work in Cell Reports.
Dr Hansen said this is the first time scientists have pinpointed why the immune system fails to develop immunity during malaria infection.
“With many infections, a single exposure to the pathogen is enough to induce production of antibodies that will protect you for the rest of your life,” she explained. “However, with malaria, it can take up to 20 years for someone to build up sufficient immunity to be protected.”
The fact that the body is not good at developing long-lasting immunity to the parasite has hampered vaccine development, Dr Hansen added.
“This was complicated by the fact that we didn’t know whether it was the malaria parasite itself or the inflammatory reaction to malaria that was actually inhibiting the ability to develop protective immunity,” she said.
“We have now shown that it was a double-edged sword. The strong inflammatory reaction that accompanies and, in fact, drives severe clinical malaria is also responsible for silencing the key immune cells needed for long-term protection against the parasite.”
Dr Hansen and her colleagues conducted experiments in mouse models of malaria and found that inflammatory molecules released by the body to fight the infection were preventing protective antibodies from being made.
“Specialized immune cells called helper T cells join forces with B cells to generate these protective antibodies,” said Axel Kallies, PhD, of the Walter and Eliza Hall Institute of Medical Research.
“However, we showed that, during malaria infection, critical inflammatory molecules actually arrest development of helper T cells, and, therefore, the B cells don’t get the necessary instructions to make antibodies.”
Specifically, the researchers found that severe malaria infection inhibited the establishment of germinal centers in the spleens of the mice. And malaria infection induced high frequencies of T-follicular-helper cell precursors but resulted in impaired T-follicular-helper cell differentiation.
Precursor T-follicular-helper cells induced during infection had low levels of PD-1 and CXCR5 and co-expressed Th1-associated molecules such as T-bet and CXCR3.
However, when the researchers blocked the inflammatory cytokines TNF and IFN-γ or deleted T-bet, they were able to restore T-follicular-helper cell differentiation and germinal center responses to infection.
Dr Hansen said these findings could lead to new avenues in the search for effective malaria vaccines.
“This research opens the door to therapeutic approaches to accelerate development of protective immunity to malaria and improve efficacy of malaria vaccines,” she said.
“Until now, malaria vaccines have had disappointing results. We can now see a way of improving these responses by tailoring or augmenting the vaccine to boost development of helper T cells that will enable the body to make protective antibodies that target the malaria parasites.”
Diana Hansen, PhD
Photo courtesy of the Walter
and Eliza Hall Institute
Results of preclinical research appear to explain how the malaria parasite Plasmodium falciparum causes an inflammatory reaction that sabotages the body’s ability to protect itself from malaria.
Researchers found evidence to suggest that the same inflammatory molecules that drive the immune response in clinical and severe malaria also prevent the body from developing protective antibodies against the parasite.
They said this discovery opens up the possibility of improving new or existing malaria vaccines by boosting immune cells needed for long-lasting immunity.
Diana Hansen, PhD, of the Walter and Eliza Hall Institute of Medical Research in Parkville, Victoria, Australia, and her colleagues described this work in Cell Reports.
Dr Hansen said this is the first time scientists have pinpointed why the immune system fails to develop immunity during malaria infection.
“With many infections, a single exposure to the pathogen is enough to induce production of antibodies that will protect you for the rest of your life,” she explained. “However, with malaria, it can take up to 20 years for someone to build up sufficient immunity to be protected.”
The fact that the body is not good at developing long-lasting immunity to the parasite has hampered vaccine development, Dr Hansen added.
“This was complicated by the fact that we didn’t know whether it was the malaria parasite itself or the inflammatory reaction to malaria that was actually inhibiting the ability to develop protective immunity,” she said.
“We have now shown that it was a double-edged sword. The strong inflammatory reaction that accompanies and, in fact, drives severe clinical malaria is also responsible for silencing the key immune cells needed for long-term protection against the parasite.”
Dr Hansen and her colleagues conducted experiments in mouse models of malaria and found that inflammatory molecules released by the body to fight the infection were preventing protective antibodies from being made.
“Specialized immune cells called helper T cells join forces with B cells to generate these protective antibodies,” said Axel Kallies, PhD, of the Walter and Eliza Hall Institute of Medical Research.
“However, we showed that, during malaria infection, critical inflammatory molecules actually arrest development of helper T cells, and, therefore, the B cells don’t get the necessary instructions to make antibodies.”
Specifically, the researchers found that severe malaria infection inhibited the establishment of germinal centers in the spleens of the mice. And malaria infection induced high frequencies of T-follicular-helper cell precursors but resulted in impaired T-follicular-helper cell differentiation.
Precursor T-follicular-helper cells induced during infection had low levels of PD-1 and CXCR5 and co-expressed Th1-associated molecules such as T-bet and CXCR3.
However, when the researchers blocked the inflammatory cytokines TNF and IFN-γ or deleted T-bet, they were able to restore T-follicular-helper cell differentiation and germinal center responses to infection.
Dr Hansen said these findings could lead to new avenues in the search for effective malaria vaccines.
“This research opens the door to therapeutic approaches to accelerate development of protective immunity to malaria and improve efficacy of malaria vaccines,” she said.
“Until now, malaria vaccines have had disappointing results. We can now see a way of improving these responses by tailoring or augmenting the vaccine to boost development of helper T cells that will enable the body to make protective antibodies that target the malaria parasites.”
Association Between DCBN and LOS
Slow hospital throughputthe process whereby a patient is admitted, placed in a room, and eventually dischargedcan worsen outcomes if admitted patients are boarded in emergency rooms or postanesthesia units.[1] One potential method to improve throughput is to discharge patients earlier in the day,[2] freeing up available beds and conceivably reducing hospital length of stay (LOS).
To quantify throughput, hospitals are beginning to measure the proportion of patients discharged before noon (DCBN). One study, looking at discharges on a single medical floor in an urban academic medical center, suggested that increasing the percentage of patients discharged by noon decreased observed‐to‐expected LOS in hospitalized medicine patients,[3] and a follow‐up study demonstrated that it was associated with admissions from the emergency department occurring earlier in the day.[4] However, these studies did not adjust for changes in case mix index (CMI) and other patient‐level characteristics that may also have affected these outcomes. Concerns persist that more efforts to discharge patients by noon could inadvertently increase LOS if staff chose to keep patients overnight for an early discharge the following day.
We undertook a retrospective analysis of data from patients discharged from a large academic medical center where an institution‐wide emphasis was placed on discharging more patients by noon. Using these data, we examined the association between discharges before noon and LOS in medical and surgical inpatients.
METHODS
Site and Subjects
Our study was based at the University of California, San Francisco (UCSF) Medical Center, a 400‐bed academic hospital located in San Francisco, California. We examined adult medical and surgical discharges from July 2012 through April 2015. Patients who stayed less than 24 hours or more than 20 days were excluded. Discharges from the hospital medicine service and the following surgical services were included in the analysis: cardiac surgery, colorectal surgery, cardiothoracic surgery, general surgery, gynecologic oncology, gynecology, neurosurgery, orthopedics, otolaryngology, head and neck surgery, plastic surgery, thoracic surgery, urology, and vascular surgery. No exclusions were made based on patient status (eg, observation vs inpatient). UCSF's institutional review board approved our study.
During the time of our study, discharges before noon time became an institutional priority. To this end, rates of DCBN were tracked using retrospective data, and various units undertook efforts such as informal afternoon meetings to prompt planning for the next morning's discharges. These efforts did not differentially affect medical or surgical units or emergent or nonemergent admissions, and no financial incentives or other changes in workflow were in place to increase DCBN rates.
Data Sources
We used the cost accounting system at UCSF (Enterprise Performance System Inc. [EPSI], Chicago, IL) to collect demographic information about each patient, including age, sex, primary race, and primary ethnicity. This system was also used to collect characteristics of each hospitalization including LOS (calculated from admission date time and discharge date time), hospital service at discharge, the discharge attending, discharge disposition of the patient, and the CMI, a marker of the severity of illness of the patient during that hospitalization. EPSI was also used to collect data on the admission type of all patients, either emergent, urgent, or routine, and the insurance status of the patient during that hospitalization.
Data on time of discharge were entered by the discharging nurse or unit assistant to reflect the time the patient left the hospital. Using these data, we defined a before‐noon discharge as one taking place between 8:00 am and 12:00 pm.
Statistical Analysis
Wilcoxon rank sum test and 2 statistics were used to compare baseline characteristics of hospitalizations of patients discharged before and after noon.
We used generalized linear models to assess the association of a discharge before noon on the LOS with gamma models. We accounted for clustering of discharge attendings using generalized estimating equations with exchangeable working correlation and robust standard errors. After the initial unadjusted analyses, covariates were included in the adjusted analysis if they were associated with an LOS at P < 0.05 or reasons of face validity. These variables are shown in Table 1. Because an effort to increase the discharges before noon was started in the 2014 academic year, we added an interaction term between the date of discharge and whether a discharge occurred before noon. The interaction term was included by dividing the study period into time periods corresponding to sequential 6‐month intervals. A new variable was defined by a categorical variable that indicated in which of these time periods a discharge occurred.
| Discharged Before Noon | Discharged After Noon | P Value | |
|---|---|---|---|
| |||
| Median LOS (IQR) | 3.4 (2.25.9) | 3.7 (2.36.3) | <0.0005 |
| Median CMI (IQR) | 1.8 (1.12.4) | 1.7 (1.12.5) | 0.006 |
| Service type, N (%) | |||
| Hospital medicine | 1,919 (29.6) | 11,290 (35.4) | |
| Surgical services | 4,565 (70.4) | 20,591 (64.6) | <0.0005 |
| Discharged before noon, N (%) | 6,484 (16.9) | 31,881 (83.1) | |
| Discharged on weekend, N (%) | |||
| Yes | 1,543 (23.8) | 7,411 (23.3) | |
| No | 4,941 (76.2) | 24,470 (76.8) | 0.34 |
| Discharge disposition, N (%) | |||
| Home with home health | 748 (11.5) | 5,774 (18.1) | |
| Home without home health | 3,997 (61.6) | 17,862 (56.0) | |
| SNF | 837 (12.9) | 3,082 (9.7) | |
| Other | 902 (13.9) | 5,163 (16.2) | <0.0005 |
| 6‐month interval, N (%) | |||
| JulyDecember 2012 | 993 (15.3) | 5,596 (17.6) | |
| JanuaryJune 2013 | 980 (15.1) | 5,721 (17.9) | |
| JulyDecember 2013 | 1,088 (16.8) | 5,690 (17.9) | |
| JanuaryJune 2014 | 1,288 (19.9) | 5,441 (17.1) | |
| JulyDecember 2014 | 1,275 (19.7) | 5,656 (17.7) | |
| JanuaryApril 2015 | 860 (13.3) | 3,777 (11.9) | <0.0005 |
| Age category, N (%) | |||
| 1864 years | 4,177 (64.4) | 20,044 (62.9) | |
| 65+ years | 2,307 (35.6) | 11,837 (37.1) | 0.02 |
| Male, N (%) | 3,274 (50.5) | 15,596 (48.9) | |
| Female, N (%) | 3,210 (49.5) | 16,284 (51.1) | 0.06 |
| Race, N (%) | |||
| White or Caucasian | 4,133 (63.7) | 18,798 (59.0) | |
| African American | 518 (8.0) | 3,020 (9.5) | |
| Asian | 703 (10.8) | 4,052 (12.7) | |
| Other | 1,130 (17.4) | 6,011 (18.9) | <0.0005 |
| Ethnicity, N (%) | |||
| Hispanic or Latino | 691 (10.7) | 3,713 (11.7) | |
| Not Hispanic or Latino | 5,597 (86.3) | 27,209 (85.4) | |
| Unknown/declined | 196 (3.0) | 959 (3.0) | 0.07 |
| Admission type, N (%) | |||
| Elective | 3,494 (53.9) | 13,881 (43.5) | |
| Emergency | 2,047 (31.6) | 12,145 (38.1) | |
| Urgent | 889 (13.7) | 5,459 (17.1) | |
| Other | 54 (0.8) | 396 (1.2) | <0.0005 |
| Payor class, N (%) | |||
| Medicare | 2,648 (40.8) | 13,808 (43.3) | |
| Medi‐Cal | 1,060 (16.4) | 5,913 (18.6) | |
| Commercial | 2,633 (40.6) | 11,242 (35.3) | |
| Other | 143 (2.2) | 918 (2.9) | <0.0005 |
We conducted a sensitivity analysis using propensity scores. The propensity score was based on demographic and clinical variables (as listed in Table 1) that exhibited P < 0.2 in bivariate analysis between the variable and being discharged before noon. We then used the propensity score as a covariate in a generalized linear model of the LOS with a gamma distribution and with generalized estimating equations as described above.
Finally, we performed prespecified secondary subset analyses of patients admitted emergently and nonemergently.
Statistical modeling and analysis was completed using Stata version 13 (StataCorp, College Station, TX).
RESULTS
Patient Demographics and Discharge Before Noon
Our study population comprised 27,983 patients for a total of 38,365 hospitalizations with a median LOS of 3.7 days. We observed 6484 discharges before noon (16.9%) and 31,881 discharges after noon (83.1%). The characteristics of the hospitalizations are shown in Table 1.
Patients who were discharged before noon tended to be younger, white, and discharged with a disposition to home without home health. The median CMI was slightly higher in discharges before noon (1.81, P = 0.006), and elective admissions were more likely than emergent to be discharged before noon (53.9% vs 31.6%, P < 0.0005).
Multivariable Analysis
A discharge before noon was associated with a 4.3% increase in LOS (adjusted odds ratio [OR]: 1.043, 95% confidence interval [CI]: 1.003‐1.086), adjusting for CMI, the service type, discharge on the weekend, discharge disposition, age, sex, ethnicity, race, urgency of admission, payor class, and a full interaction with the date of discharge (in 6‐month intervals). In preplanned subset analyses, the association between longer LOS and DCBN was more pronounced in patients admitted emergently (adjusted OR: 1.14, 95% CI: 1.033‐1.249) and less pronounced for patients not admitted emergently (adjusted OR: 1.03, 95% CI: 0.988‐1.074), although the latter did not meet statistical significance. In patients admitted emergently, this corresponds to approximately a 12‐hour increase in LOS. The interaction term of discharge date and DCBN was significant in the model. In further subset analyses, the association between longer LOS and DCBN was more pronounced in medicine patients (adjusted OR: 1.116, 95% CI: 1.014‐1.228) than in surgical patients (adjusted OR: 1.030, 95% CI: 0.989‐1.074), although the relationship in surgical patients did not meet statistical significance.
We also undertook sensitivity analyses utilizing propensity scores as a covariate in our base multivariable models. Results from these analyses did not differ from the base models and are not presented here. Results also did not differ when comparing discharges before and after the initiation of an attending only service.
DISCUSSION AND CONCLUSION
In our retrospective study of patients discharged from an academic medical center, discharge before noon was associated with a longer LOS, with the effect more pronounced in patients admitted emergently in the hospital. Our results suggest that efforts to discharge patients earlier in the day may have varying degrees of success depending on patient characteristics. Conceivably, elective admissions recover according to predictable plans, allowing for discharges earlier in the day. In contrast, patients discharged from emergent hospitalizations may have ongoing evolution of their care plan, making plans for discharging before noon more challenging.
Our results differ from a previous study,[3] which suggested that increasing the proportion of before‐noon discharges was associated with a fall in observed‐to‐expected LOS. However, observational studies of DCBN are challenging, because the association between early discharge and LOS is potentially bidirectional. One interpretation, for example, is that patients were kept longer in order to be discharged by noon the following day, which for the subgroups of patients admitted emergently corresponded to a roughly 12‐hour increase in LOS. However, it is also plausible that patients who stayed longer also had more time to plan for an early discharge. In either scenario, the ability of managers to utilize LOS as a key metric of throughput efforts may be flawed, and suggests that alternatives (eg, number of patients waiting for beds off unit) may be a more reasonable measure of throughput. Our results have several limitations. As in any observational study, our results are vulnerable to biases from unmeasured covariates that confound the analysis. We caution that a causal relationship between a discharge before noon and LOS cannot be determined from the nature of the study. Our results are also limited in that we were unable to adjust for day‐to‐day hospital capacity and other variables that affect LOS including caregiver and transportation availability, bed capacity at receiving care facilities, and patient consent to discharge. Finally, as a single‐site study, our findings may not be applicable to nonacademic settings.
In conclusion, our observational study discerned an association between discharging patients before noon and longer LOS. We believe our findings suggest a rationale for alternate approaches to measuring an early discharge program's effectiveness, namely, that the evaluation of the success of an early discharge initiative should consider multiple evaluation metrics including the effect on emergency department wait times, intensive care unit or postanesthesia transitions, and on patient reported experiences of care transitions.
Disclosures
Andrew Auerbach, MD, is supported by a K24 grant from the National Heart, Lung, and Blood Institute: K24HL098372. The authors report no conflicts of interest.
- , , , et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009;16(1):1–10.
- Centers for Medicare 2013.
- , , , et al. Discharge before noon: an achievable hospital goal. J Hosp Med. 2014;9(4):210–214.
- , , , et al. Discharge before noon: effect on throughput and sustainability. J Hosp Med. 2015;10(10):664–669.
Slow hospital throughputthe process whereby a patient is admitted, placed in a room, and eventually dischargedcan worsen outcomes if admitted patients are boarded in emergency rooms or postanesthesia units.[1] One potential method to improve throughput is to discharge patients earlier in the day,[2] freeing up available beds and conceivably reducing hospital length of stay (LOS).
To quantify throughput, hospitals are beginning to measure the proportion of patients discharged before noon (DCBN). One study, looking at discharges on a single medical floor in an urban academic medical center, suggested that increasing the percentage of patients discharged by noon decreased observed‐to‐expected LOS in hospitalized medicine patients,[3] and a follow‐up study demonstrated that it was associated with admissions from the emergency department occurring earlier in the day.[4] However, these studies did not adjust for changes in case mix index (CMI) and other patient‐level characteristics that may also have affected these outcomes. Concerns persist that more efforts to discharge patients by noon could inadvertently increase LOS if staff chose to keep patients overnight for an early discharge the following day.
We undertook a retrospective analysis of data from patients discharged from a large academic medical center where an institution‐wide emphasis was placed on discharging more patients by noon. Using these data, we examined the association between discharges before noon and LOS in medical and surgical inpatients.
METHODS
Site and Subjects
Our study was based at the University of California, San Francisco (UCSF) Medical Center, a 400‐bed academic hospital located in San Francisco, California. We examined adult medical and surgical discharges from July 2012 through April 2015. Patients who stayed less than 24 hours or more than 20 days were excluded. Discharges from the hospital medicine service and the following surgical services were included in the analysis: cardiac surgery, colorectal surgery, cardiothoracic surgery, general surgery, gynecologic oncology, gynecology, neurosurgery, orthopedics, otolaryngology, head and neck surgery, plastic surgery, thoracic surgery, urology, and vascular surgery. No exclusions were made based on patient status (eg, observation vs inpatient). UCSF's institutional review board approved our study.
During the time of our study, discharges before noon time became an institutional priority. To this end, rates of DCBN were tracked using retrospective data, and various units undertook efforts such as informal afternoon meetings to prompt planning for the next morning's discharges. These efforts did not differentially affect medical or surgical units or emergent or nonemergent admissions, and no financial incentives or other changes in workflow were in place to increase DCBN rates.
Data Sources
We used the cost accounting system at UCSF (Enterprise Performance System Inc. [EPSI], Chicago, IL) to collect demographic information about each patient, including age, sex, primary race, and primary ethnicity. This system was also used to collect characteristics of each hospitalization including LOS (calculated from admission date time and discharge date time), hospital service at discharge, the discharge attending, discharge disposition of the patient, and the CMI, a marker of the severity of illness of the patient during that hospitalization. EPSI was also used to collect data on the admission type of all patients, either emergent, urgent, or routine, and the insurance status of the patient during that hospitalization.
Data on time of discharge were entered by the discharging nurse or unit assistant to reflect the time the patient left the hospital. Using these data, we defined a before‐noon discharge as one taking place between 8:00 am and 12:00 pm.
Statistical Analysis
Wilcoxon rank sum test and 2 statistics were used to compare baseline characteristics of hospitalizations of patients discharged before and after noon.
We used generalized linear models to assess the association of a discharge before noon on the LOS with gamma models. We accounted for clustering of discharge attendings using generalized estimating equations with exchangeable working correlation and robust standard errors. After the initial unadjusted analyses, covariates were included in the adjusted analysis if they were associated with an LOS at P < 0.05 or reasons of face validity. These variables are shown in Table 1. Because an effort to increase the discharges before noon was started in the 2014 academic year, we added an interaction term between the date of discharge and whether a discharge occurred before noon. The interaction term was included by dividing the study period into time periods corresponding to sequential 6‐month intervals. A new variable was defined by a categorical variable that indicated in which of these time periods a discharge occurred.
| Discharged Before Noon | Discharged After Noon | P Value | |
|---|---|---|---|
| |||
| Median LOS (IQR) | 3.4 (2.25.9) | 3.7 (2.36.3) | <0.0005 |
| Median CMI (IQR) | 1.8 (1.12.4) | 1.7 (1.12.5) | 0.006 |
| Service type, N (%) | |||
| Hospital medicine | 1,919 (29.6) | 11,290 (35.4) | |
| Surgical services | 4,565 (70.4) | 20,591 (64.6) | <0.0005 |
| Discharged before noon, N (%) | 6,484 (16.9) | 31,881 (83.1) | |
| Discharged on weekend, N (%) | |||
| Yes | 1,543 (23.8) | 7,411 (23.3) | |
| No | 4,941 (76.2) | 24,470 (76.8) | 0.34 |
| Discharge disposition, N (%) | |||
| Home with home health | 748 (11.5) | 5,774 (18.1) | |
| Home without home health | 3,997 (61.6) | 17,862 (56.0) | |
| SNF | 837 (12.9) | 3,082 (9.7) | |
| Other | 902 (13.9) | 5,163 (16.2) | <0.0005 |
| 6‐month interval, N (%) | |||
| JulyDecember 2012 | 993 (15.3) | 5,596 (17.6) | |
| JanuaryJune 2013 | 980 (15.1) | 5,721 (17.9) | |
| JulyDecember 2013 | 1,088 (16.8) | 5,690 (17.9) | |
| JanuaryJune 2014 | 1,288 (19.9) | 5,441 (17.1) | |
| JulyDecember 2014 | 1,275 (19.7) | 5,656 (17.7) | |
| JanuaryApril 2015 | 860 (13.3) | 3,777 (11.9) | <0.0005 |
| Age category, N (%) | |||
| 1864 years | 4,177 (64.4) | 20,044 (62.9) | |
| 65+ years | 2,307 (35.6) | 11,837 (37.1) | 0.02 |
| Male, N (%) | 3,274 (50.5) | 15,596 (48.9) | |
| Female, N (%) | 3,210 (49.5) | 16,284 (51.1) | 0.06 |
| Race, N (%) | |||
| White or Caucasian | 4,133 (63.7) | 18,798 (59.0) | |
| African American | 518 (8.0) | 3,020 (9.5) | |
| Asian | 703 (10.8) | 4,052 (12.7) | |
| Other | 1,130 (17.4) | 6,011 (18.9) | <0.0005 |
| Ethnicity, N (%) | |||
| Hispanic or Latino | 691 (10.7) | 3,713 (11.7) | |
| Not Hispanic or Latino | 5,597 (86.3) | 27,209 (85.4) | |
| Unknown/declined | 196 (3.0) | 959 (3.0) | 0.07 |
| Admission type, N (%) | |||
| Elective | 3,494 (53.9) | 13,881 (43.5) | |
| Emergency | 2,047 (31.6) | 12,145 (38.1) | |
| Urgent | 889 (13.7) | 5,459 (17.1) | |
| Other | 54 (0.8) | 396 (1.2) | <0.0005 |
| Payor class, N (%) | |||
| Medicare | 2,648 (40.8) | 13,808 (43.3) | |
| Medi‐Cal | 1,060 (16.4) | 5,913 (18.6) | |
| Commercial | 2,633 (40.6) | 11,242 (35.3) | |
| Other | 143 (2.2) | 918 (2.9) | <0.0005 |
We conducted a sensitivity analysis using propensity scores. The propensity score was based on demographic and clinical variables (as listed in Table 1) that exhibited P < 0.2 in bivariate analysis between the variable and being discharged before noon. We then used the propensity score as a covariate in a generalized linear model of the LOS with a gamma distribution and with generalized estimating equations as described above.
Finally, we performed prespecified secondary subset analyses of patients admitted emergently and nonemergently.
Statistical modeling and analysis was completed using Stata version 13 (StataCorp, College Station, TX).
RESULTS
Patient Demographics and Discharge Before Noon
Our study population comprised 27,983 patients for a total of 38,365 hospitalizations with a median LOS of 3.7 days. We observed 6484 discharges before noon (16.9%) and 31,881 discharges after noon (83.1%). The characteristics of the hospitalizations are shown in Table 1.
Patients who were discharged before noon tended to be younger, white, and discharged with a disposition to home without home health. The median CMI was slightly higher in discharges before noon (1.81, P = 0.006), and elective admissions were more likely than emergent to be discharged before noon (53.9% vs 31.6%, P < 0.0005).
Multivariable Analysis
A discharge before noon was associated with a 4.3% increase in LOS (adjusted odds ratio [OR]: 1.043, 95% confidence interval [CI]: 1.003‐1.086), adjusting for CMI, the service type, discharge on the weekend, discharge disposition, age, sex, ethnicity, race, urgency of admission, payor class, and a full interaction with the date of discharge (in 6‐month intervals). In preplanned subset analyses, the association between longer LOS and DCBN was more pronounced in patients admitted emergently (adjusted OR: 1.14, 95% CI: 1.033‐1.249) and less pronounced for patients not admitted emergently (adjusted OR: 1.03, 95% CI: 0.988‐1.074), although the latter did not meet statistical significance. In patients admitted emergently, this corresponds to approximately a 12‐hour increase in LOS. The interaction term of discharge date and DCBN was significant in the model. In further subset analyses, the association between longer LOS and DCBN was more pronounced in medicine patients (adjusted OR: 1.116, 95% CI: 1.014‐1.228) than in surgical patients (adjusted OR: 1.030, 95% CI: 0.989‐1.074), although the relationship in surgical patients did not meet statistical significance.
We also undertook sensitivity analyses utilizing propensity scores as a covariate in our base multivariable models. Results from these analyses did not differ from the base models and are not presented here. Results also did not differ when comparing discharges before and after the initiation of an attending only service.
DISCUSSION AND CONCLUSION
In our retrospective study of patients discharged from an academic medical center, discharge before noon was associated with a longer LOS, with the effect more pronounced in patients admitted emergently in the hospital. Our results suggest that efforts to discharge patients earlier in the day may have varying degrees of success depending on patient characteristics. Conceivably, elective admissions recover according to predictable plans, allowing for discharges earlier in the day. In contrast, patients discharged from emergent hospitalizations may have ongoing evolution of their care plan, making plans for discharging before noon more challenging.
Our results differ from a previous study,[3] which suggested that increasing the proportion of before‐noon discharges was associated with a fall in observed‐to‐expected LOS. However, observational studies of DCBN are challenging, because the association between early discharge and LOS is potentially bidirectional. One interpretation, for example, is that patients were kept longer in order to be discharged by noon the following day, which for the subgroups of patients admitted emergently corresponded to a roughly 12‐hour increase in LOS. However, it is also plausible that patients who stayed longer also had more time to plan for an early discharge. In either scenario, the ability of managers to utilize LOS as a key metric of throughput efforts may be flawed, and suggests that alternatives (eg, number of patients waiting for beds off unit) may be a more reasonable measure of throughput. Our results have several limitations. As in any observational study, our results are vulnerable to biases from unmeasured covariates that confound the analysis. We caution that a causal relationship between a discharge before noon and LOS cannot be determined from the nature of the study. Our results are also limited in that we were unable to adjust for day‐to‐day hospital capacity and other variables that affect LOS including caregiver and transportation availability, bed capacity at receiving care facilities, and patient consent to discharge. Finally, as a single‐site study, our findings may not be applicable to nonacademic settings.
In conclusion, our observational study discerned an association between discharging patients before noon and longer LOS. We believe our findings suggest a rationale for alternate approaches to measuring an early discharge program's effectiveness, namely, that the evaluation of the success of an early discharge initiative should consider multiple evaluation metrics including the effect on emergency department wait times, intensive care unit or postanesthesia transitions, and on patient reported experiences of care transitions.
Disclosures
Andrew Auerbach, MD, is supported by a K24 grant from the National Heart, Lung, and Blood Institute: K24HL098372. The authors report no conflicts of interest.
Slow hospital throughputthe process whereby a patient is admitted, placed in a room, and eventually dischargedcan worsen outcomes if admitted patients are boarded in emergency rooms or postanesthesia units.[1] One potential method to improve throughput is to discharge patients earlier in the day,[2] freeing up available beds and conceivably reducing hospital length of stay (LOS).
To quantify throughput, hospitals are beginning to measure the proportion of patients discharged before noon (DCBN). One study, looking at discharges on a single medical floor in an urban academic medical center, suggested that increasing the percentage of patients discharged by noon decreased observed‐to‐expected LOS in hospitalized medicine patients,[3] and a follow‐up study demonstrated that it was associated with admissions from the emergency department occurring earlier in the day.[4] However, these studies did not adjust for changes in case mix index (CMI) and other patient‐level characteristics that may also have affected these outcomes. Concerns persist that more efforts to discharge patients by noon could inadvertently increase LOS if staff chose to keep patients overnight for an early discharge the following day.
We undertook a retrospective analysis of data from patients discharged from a large academic medical center where an institution‐wide emphasis was placed on discharging more patients by noon. Using these data, we examined the association between discharges before noon and LOS in medical and surgical inpatients.
METHODS
Site and Subjects
Our study was based at the University of California, San Francisco (UCSF) Medical Center, a 400‐bed academic hospital located in San Francisco, California. We examined adult medical and surgical discharges from July 2012 through April 2015. Patients who stayed less than 24 hours or more than 20 days were excluded. Discharges from the hospital medicine service and the following surgical services were included in the analysis: cardiac surgery, colorectal surgery, cardiothoracic surgery, general surgery, gynecologic oncology, gynecology, neurosurgery, orthopedics, otolaryngology, head and neck surgery, plastic surgery, thoracic surgery, urology, and vascular surgery. No exclusions were made based on patient status (eg, observation vs inpatient). UCSF's institutional review board approved our study.
During the time of our study, discharges before noon time became an institutional priority. To this end, rates of DCBN were tracked using retrospective data, and various units undertook efforts such as informal afternoon meetings to prompt planning for the next morning's discharges. These efforts did not differentially affect medical or surgical units or emergent or nonemergent admissions, and no financial incentives or other changes in workflow were in place to increase DCBN rates.
Data Sources
We used the cost accounting system at UCSF (Enterprise Performance System Inc. [EPSI], Chicago, IL) to collect demographic information about each patient, including age, sex, primary race, and primary ethnicity. This system was also used to collect characteristics of each hospitalization including LOS (calculated from admission date time and discharge date time), hospital service at discharge, the discharge attending, discharge disposition of the patient, and the CMI, a marker of the severity of illness of the patient during that hospitalization. EPSI was also used to collect data on the admission type of all patients, either emergent, urgent, or routine, and the insurance status of the patient during that hospitalization.
Data on time of discharge were entered by the discharging nurse or unit assistant to reflect the time the patient left the hospital. Using these data, we defined a before‐noon discharge as one taking place between 8:00 am and 12:00 pm.
Statistical Analysis
Wilcoxon rank sum test and 2 statistics were used to compare baseline characteristics of hospitalizations of patients discharged before and after noon.
We used generalized linear models to assess the association of a discharge before noon on the LOS with gamma models. We accounted for clustering of discharge attendings using generalized estimating equations with exchangeable working correlation and robust standard errors. After the initial unadjusted analyses, covariates were included in the adjusted analysis if they were associated with an LOS at P < 0.05 or reasons of face validity. These variables are shown in Table 1. Because an effort to increase the discharges before noon was started in the 2014 academic year, we added an interaction term between the date of discharge and whether a discharge occurred before noon. The interaction term was included by dividing the study period into time periods corresponding to sequential 6‐month intervals. A new variable was defined by a categorical variable that indicated in which of these time periods a discharge occurred.
| Discharged Before Noon | Discharged After Noon | P Value | |
|---|---|---|---|
| |||
| Median LOS (IQR) | 3.4 (2.25.9) | 3.7 (2.36.3) | <0.0005 |
| Median CMI (IQR) | 1.8 (1.12.4) | 1.7 (1.12.5) | 0.006 |
| Service type, N (%) | |||
| Hospital medicine | 1,919 (29.6) | 11,290 (35.4) | |
| Surgical services | 4,565 (70.4) | 20,591 (64.6) | <0.0005 |
| Discharged before noon, N (%) | 6,484 (16.9) | 31,881 (83.1) | |
| Discharged on weekend, N (%) | |||
| Yes | 1,543 (23.8) | 7,411 (23.3) | |
| No | 4,941 (76.2) | 24,470 (76.8) | 0.34 |
| Discharge disposition, N (%) | |||
| Home with home health | 748 (11.5) | 5,774 (18.1) | |
| Home without home health | 3,997 (61.6) | 17,862 (56.0) | |
| SNF | 837 (12.9) | 3,082 (9.7) | |
| Other | 902 (13.9) | 5,163 (16.2) | <0.0005 |
| 6‐month interval, N (%) | |||
| JulyDecember 2012 | 993 (15.3) | 5,596 (17.6) | |
| JanuaryJune 2013 | 980 (15.1) | 5,721 (17.9) | |
| JulyDecember 2013 | 1,088 (16.8) | 5,690 (17.9) | |
| JanuaryJune 2014 | 1,288 (19.9) | 5,441 (17.1) | |
| JulyDecember 2014 | 1,275 (19.7) | 5,656 (17.7) | |
| JanuaryApril 2015 | 860 (13.3) | 3,777 (11.9) | <0.0005 |
| Age category, N (%) | |||
| 1864 years | 4,177 (64.4) | 20,044 (62.9) | |
| 65+ years | 2,307 (35.6) | 11,837 (37.1) | 0.02 |
| Male, N (%) | 3,274 (50.5) | 15,596 (48.9) | |
| Female, N (%) | 3,210 (49.5) | 16,284 (51.1) | 0.06 |
| Race, N (%) | |||
| White or Caucasian | 4,133 (63.7) | 18,798 (59.0) | |
| African American | 518 (8.0) | 3,020 (9.5) | |
| Asian | 703 (10.8) | 4,052 (12.7) | |
| Other | 1,130 (17.4) | 6,011 (18.9) | <0.0005 |
| Ethnicity, N (%) | |||
| Hispanic or Latino | 691 (10.7) | 3,713 (11.7) | |
| Not Hispanic or Latino | 5,597 (86.3) | 27,209 (85.4) | |
| Unknown/declined | 196 (3.0) | 959 (3.0) | 0.07 |
| Admission type, N (%) | |||
| Elective | 3,494 (53.9) | 13,881 (43.5) | |
| Emergency | 2,047 (31.6) | 12,145 (38.1) | |
| Urgent | 889 (13.7) | 5,459 (17.1) | |
| Other | 54 (0.8) | 396 (1.2) | <0.0005 |
| Payor class, N (%) | |||
| Medicare | 2,648 (40.8) | 13,808 (43.3) | |
| Medi‐Cal | 1,060 (16.4) | 5,913 (18.6) | |
| Commercial | 2,633 (40.6) | 11,242 (35.3) | |
| Other | 143 (2.2) | 918 (2.9) | <0.0005 |
We conducted a sensitivity analysis using propensity scores. The propensity score was based on demographic and clinical variables (as listed in Table 1) that exhibited P < 0.2 in bivariate analysis between the variable and being discharged before noon. We then used the propensity score as a covariate in a generalized linear model of the LOS with a gamma distribution and with generalized estimating equations as described above.
Finally, we performed prespecified secondary subset analyses of patients admitted emergently and nonemergently.
Statistical modeling and analysis was completed using Stata version 13 (StataCorp, College Station, TX).
RESULTS
Patient Demographics and Discharge Before Noon
Our study population comprised 27,983 patients for a total of 38,365 hospitalizations with a median LOS of 3.7 days. We observed 6484 discharges before noon (16.9%) and 31,881 discharges after noon (83.1%). The characteristics of the hospitalizations are shown in Table 1.
Patients who were discharged before noon tended to be younger, white, and discharged with a disposition to home without home health. The median CMI was slightly higher in discharges before noon (1.81, P = 0.006), and elective admissions were more likely than emergent to be discharged before noon (53.9% vs 31.6%, P < 0.0005).
Multivariable Analysis
A discharge before noon was associated with a 4.3% increase in LOS (adjusted odds ratio [OR]: 1.043, 95% confidence interval [CI]: 1.003‐1.086), adjusting for CMI, the service type, discharge on the weekend, discharge disposition, age, sex, ethnicity, race, urgency of admission, payor class, and a full interaction with the date of discharge (in 6‐month intervals). In preplanned subset analyses, the association between longer LOS and DCBN was more pronounced in patients admitted emergently (adjusted OR: 1.14, 95% CI: 1.033‐1.249) and less pronounced for patients not admitted emergently (adjusted OR: 1.03, 95% CI: 0.988‐1.074), although the latter did not meet statistical significance. In patients admitted emergently, this corresponds to approximately a 12‐hour increase in LOS. The interaction term of discharge date and DCBN was significant in the model. In further subset analyses, the association between longer LOS and DCBN was more pronounced in medicine patients (adjusted OR: 1.116, 95% CI: 1.014‐1.228) than in surgical patients (adjusted OR: 1.030, 95% CI: 0.989‐1.074), although the relationship in surgical patients did not meet statistical significance.
We also undertook sensitivity analyses utilizing propensity scores as a covariate in our base multivariable models. Results from these analyses did not differ from the base models and are not presented here. Results also did not differ when comparing discharges before and after the initiation of an attending only service.
DISCUSSION AND CONCLUSION
In our retrospective study of patients discharged from an academic medical center, discharge before noon was associated with a longer LOS, with the effect more pronounced in patients admitted emergently in the hospital. Our results suggest that efforts to discharge patients earlier in the day may have varying degrees of success depending on patient characteristics. Conceivably, elective admissions recover according to predictable plans, allowing for discharges earlier in the day. In contrast, patients discharged from emergent hospitalizations may have ongoing evolution of their care plan, making plans for discharging before noon more challenging.
Our results differ from a previous study,[3] which suggested that increasing the proportion of before‐noon discharges was associated with a fall in observed‐to‐expected LOS. However, observational studies of DCBN are challenging, because the association between early discharge and LOS is potentially bidirectional. One interpretation, for example, is that patients were kept longer in order to be discharged by noon the following day, which for the subgroups of patients admitted emergently corresponded to a roughly 12‐hour increase in LOS. However, it is also plausible that patients who stayed longer also had more time to plan for an early discharge. In either scenario, the ability of managers to utilize LOS as a key metric of throughput efforts may be flawed, and suggests that alternatives (eg, number of patients waiting for beds off unit) may be a more reasonable measure of throughput. Our results have several limitations. As in any observational study, our results are vulnerable to biases from unmeasured covariates that confound the analysis. We caution that a causal relationship between a discharge before noon and LOS cannot be determined from the nature of the study. Our results are also limited in that we were unable to adjust for day‐to‐day hospital capacity and other variables that affect LOS including caregiver and transportation availability, bed capacity at receiving care facilities, and patient consent to discharge. Finally, as a single‐site study, our findings may not be applicable to nonacademic settings.
In conclusion, our observational study discerned an association between discharging patients before noon and longer LOS. We believe our findings suggest a rationale for alternate approaches to measuring an early discharge program's effectiveness, namely, that the evaluation of the success of an early discharge initiative should consider multiple evaluation metrics including the effect on emergency department wait times, intensive care unit or postanesthesia transitions, and on patient reported experiences of care transitions.
Disclosures
Andrew Auerbach, MD, is supported by a K24 grant from the National Heart, Lung, and Blood Institute: K24HL098372. The authors report no conflicts of interest.
- , , , et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009;16(1):1–10.
- Centers for Medicare 2013.
- , , , et al. Discharge before noon: an achievable hospital goal. J Hosp Med. 2014;9(4):210–214.
- , , , et al. Discharge before noon: effect on throughput and sustainability. J Hosp Med. 2015;10(10):664–669.
- , , , et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009;16(1):1–10.
- Centers for Medicare 2013.
- , , , et al. Discharge before noon: an achievable hospital goal. J Hosp Med. 2014;9(4):210–214.
- , , , et al. Discharge before noon: effect on throughput and sustainability. J Hosp Med. 2015;10(10):664–669.
© 2015 Society of Hospital Medicine
Assessing Vascular Nursing Experience
Peripherally inserted central catheters (PICCs) are among the most prevalent of venous access devices in hospitalized patients.[1, 2] Although growing use of these devices reflects clinical advantages, such as a reduced risk of complications during insertion and durable venous access, use of PICCs is also likely related to the growth of vascular access nursing.[3, 4] A relatively new specialty, vascular access nurses obtain, maintain, and manage venous access in hospitalized patients.[4, 5] Depending on their scope of practice, these professionals are responsible not only for insertion of devices, such as peripheral intravenous catheters and PICCs, but also nontunneled central venous catheters and arterial catheters in some settings.[6]
Although a growing number of US hospitals have introduced vascular nursing teams,[7] little is known about the experience, practice, knowledge, and beliefs of vascular access nurses. This knowledge gap is relevant for hospitalists and hospital medicine as (1) vascular access nurses increasingly represent a key partner in the care of hospitalized patients; (2) the knowledge and practice of these individuals directly affects patient safety and clinical outcomes; and (3) understanding experience, practice, and beliefs of these specialists can help inform decision making and quality‐improvement efforts related to PICCs. As hospitalists increasingly order the placement of and care for patients with PICCs, they are also well suited to improve PICC practice.
Therefore, we conducted a survey of vascular access nurses employed by hospitals that participate in the Michigan Hospital Medicine Safety (HMS) Consortium, a Blue Cross Blue Shield of Michiganfunded collaborative quality initiative.[6] We aimed to understand experience, practice, knowledge, and beliefs related to PICC care and use.
METHODS
Study Setting and Participants
To quantify vascular nursing experience, practice, knowledge, and beliefs, we conducted a Web‐based survey of vascular nurses across 47 Michigan hospitals that participate in HMS. A statewide quality‐improvement initiative, HMS aims to prevent adverse events in hospitalized medical patients through the creation of a data registry and sharing of best practices. The setting and design of this multicenter initiative have been previously described.[8, 9] Although participation is voluntary, each hospital receives payment for participating in the consortium and for data collection. Because HMS has an ongoing initiative aimed at identifying and preventing PICC‐related complications, this study was particularly relevant for participating hospitals and nurses.
Each HMS site has a designated quality‐improvement lead, physician champion, and data abstractor. To coordinate distribution and dissemination of the survey, we contacted the quality‐improvement leads at each site and enquired whether their hospital employed vascular access nurses who placed PICCs. Because we were only interested in responses from vascular access nurses, HMS hospitals that did not have these providers or stated PICCs were placed by other specialists (eg, interventional radiology) were excluded. At eligible sites, we obtained the total number of vascular nurses employed so as to determine the number of eligible respondents. In this manner, a purposeful sample of vascular nurses at participating HMS hospitals was constituted.
Participation in the survey was solicited through hospital quality leads that either distributed an electronic survey link to vascular nurses at their facilities or sent us individual email addresses to contact them directly. A cover letter explaining the rationale and the purpose of the survey along with the survey link was then sent to respondents through either of these routes. The survey was administered at all HMS sites contemporaneously and kept open for a period of 5 weeks. During the 5‐week period, 2 e‐mail reminders were sent to encourage participation. As a token of appreciation, a $10 Amazon gift card was offered to those who took the survey.
Development and Validation of the Survey
We developed the survey instrument (which we call PICC1 as we hope to administer longitudinally to track changes over time) by first conducting a literature search to identify relevant evidence‐based guidelines and studies regarding vascular access nursing practices and experiences.[10, 11, 12, 13] In addition, we consulted and involved national and international leaders in vascular access nursing to ensure validity and representativeness of the questions posed. We were specifically interested in nursing background, hospital practices, types of PICCs used, use of various technologies, relationships with healthcare providers, and management of complications. To understand participant characteristics and quantify potential variation in responses, we collected basic participant data including demographics, years in practice, number of PICCs placed, leadership roles, and vascular access certification status. Based on clinical reasoning and existing studies,[14, 15] we hypothesized that responses regarding certain practices (ultrasound use, electrocardiography [ECG] guidance system use), management of complications, or perceptions regarding leadership might vary based on years of experience, number of PICCs placed, or certification status. We therefore examined these associations as prespecified subgroup analyses.
The initial survey instrument was pilot tested with vascular nurses outside of the sampling frame. Based on feedback from the pilot testers, the instrument was refined and edited to improve clarity of the questions. In addition, specific skip patterns and logic were programmed into the final survey to reduce respondent burden and allow participants to seamlessly bypass questions that were contingent on a prior response (eg, use of ECG to place PICCs would lead to a series of questions about ECG‐assisted placement only for those respondents who used the technology). This final version of the survey was tested by members of the study team (V.C., L.K., S.L.K.) and then posted to SurveyMonkey for dissemination.
Statistical Analysis
Descriptive statistics (percentage, n/N) were used to tabulate results. In accordance with our a priori hypothesis that variation to responses might be associated with respondent characteristics, responses to questions regarding insertion practice (eg, use of ultrasound, measurement of catheter:vein ratio, trimming of catheters) and approach to complications (eg, catheter occlusion, deep vein thrombosis [DVT] notification, and PICC removal in the setting of fever) were compared by respondent years in practice (dichotomized to <5 vs >5 years), volume of PICCs placed (<999 vs 1000), and certification status (yes/no). Bivariate comparisons were made using 2 or Fisher exact tests based on the number of responses in a cell as appropriate; 2‐sided with a P value <0.05 was considered statistically significant. All statistical analyses were conducted using SAS version 9.3 (SAS Institute, Cary, NC).
Ethical and Regulatory Oversight
Because our study sought to describe existing practice without collecting any individual or facility level identifiable information, the project received a Not Regulated status by the University of Michigan Medical School Institutional Review Board (HUM00088351).
RESULTS
Of 172 vascular nurses who received invitations, 140 completed the survey for a response rate of 81%. Respondents reported working in not‐for‐profit hospitals (36%), academic medical centers (29%), and for‐profit hospitals (21%). Although multiple providers (eg, interventional radiology staff and providers, physicians) placed PICCs, 95% of those surveyed reported that they placed the majority of the PICCs at their institutions. Although most respondents placed PICCs in adult patients (86%), a few also placed PICCs in pediatric populations (17%). Vascular nursing programs were largely housed in their own department, but some reported to general nursing or subspecialties such as interventional radiology, cardiology, and critical care. Most respondents indicated their facilities had written policies regarding standard insertion and care practices (87% and 95%, respectively), but only 30% had policies regarding the necessity or appropriateness of PICCs.
Experience among respondents was variable: approximately a third had placed PICCs for <5 years (28.6%), whereas 58% reported placing PICCs for 5 years Correspondingly, 26% reported having placed 100 to 500 PICCs, whereas 34% had placed 1000 or more PICCs. Only 23% of those surveyed held a dedicated vascular access certification, such as board certified in vascular access or certified registered nurse infusion, whereas 16% indicated that they served as the vascular access lead nurse for their facility. Following placement, 94% of respondents reported that their facilities tracked the number of PICCs inserted, but only 40% indicated that dwell times of devices were also recorded. Only 30% of nurses reported that their hospitals had a written policy to evaluate PICC necessity or appropriateness following placement (Table 1).
| No.* | % | |
|---|---|---|
| ||
| Participant characteristics | ||
| For how many years have you been inserting PICCs? | ||
| <5 years | 40 | 28.6% |
| 5 years | 81 | 57.9% |
| Missing | ||
| In which of the following populations do you insert PICCs? | ||
| Adult patients | 121 | 86.4% |
| Pediatric patients | 24 | 17.1% |
| Neonatal patients | 1 | 0.7% |
| In which of the following locations do you place PICCs? (Select all that apply.) | ||
| Adult medical ward | 115 | 82.1% |
| General adult surgical ward | 110 | 78.6% |
| General pediatric medical ward | 34 | 24.3% |
| General pediatric surgical ward | 24 | 17.1% |
| Adult intensive care unit | 114 | 81.4% |
| Pediatric intensive care unit | 19 | 13.6% |
| Neonatal intensive care unit | 3 | 2.1% |
| Other intensive care unit | 59 | 42.1% |
| Outpatient clinic or emergency department | 17 | 12.1% |
| Other | 10 | 7.1% |
| Approximately how many PICCs may you have placed in your career? | ||
| 099 | 15 | 10.7% |
| 100499 | 36 | 25.7% |
| 500999 | 23 | 16.4% |
| 1,000 | 47 | 33.6% |
| Are you the vascular access lead nurse for your facility or organization? | ||
| Yes | 22 | 15.7% |
| No | 98 | 70.0% |
| Do you currently hold a dedicated vascular access certification (BC‐VA, CRNI, etc.)? | ||
| Yes | 32 | 22.9% |
| No | 89 | 63.6% |
| Facility characteristics | ||
| Which of the following best describes your primary work location? | ||
| Academic medical center | 41 | 29.3% |
| For‐profit community‐based hospital or medical center | 30 | 21.4% |
| Not‐for‐profit community‐based hospital or medical center | 50 | 35.7% |
| Who inserts the most PICCs in your facility? | ||
| Vascular access nurses | 133 | 95.0% |
| Interventional radiology or other providers | 7 | 5.0% |
| In which department is vascular access nursing located? | ||
| Vascular nursing | 76 | 54.3% |
| General nursing | 38 | 27.1% |
| Interventional radiology | 15 | 10.7% |
| Other | 11 | 7.9% |
| Using your best guess, how many PICCs do you think your facility inserts each month? | ||
| <25 | 5 | 3.6% |
| 2549 | 13 | 9.3% |
| 50100 | 39 | 27.9% |
| >100 | 78 | 55.7% |
| Unknown | 2 | 1.4% |
| How many vascular access nurses are employed by your facility? | ||
| <4 | 14 | 10.0% |
| 46 | 33 | 23.6% |
| 79 | 15 | 10.7% |
| 1015 | 25 | 17.9% |
| >15 | 53 | 37.9% |
| Does your facility track the number of PICCs placed? | ||
| Yes | 132 | 94.3% |
| No | 5 | 3.6% |
| Unknown | 3 | 2.1% |
| Does your facility track the duration or dwell time of PICCs? | ||
| Yes | 56 | 40.0% |
| No | 60 | 42.9% |
| Unknown | 24 | 17.1% |
| Does your facility have a written policy regarding standard PICC insertion practices? | ||
| Yes | 122 | 87.1% |
| No | 8 | 5.7% |
| Unknown | 7 | 5.0% |
| Does your facility have a written policy regarding standard PICC care and maintenance? | ||
| Yes | 133 | 95.0% |
| No | 3 | 2.1% |
| Unknown | 1 | 0.7% |
| Does your facility have a written process to review the necessity or appropriateness of a PICC? | ||
| Yes | 42 | 30.0% |
| No | 63 | 45.0% |
| Unknown | 20 | 14.3% |
The most commonly reported indications for PICC placement included intravenous antibiotics at discharge, difficult venous access, and placement for chemotherapy in patients with cancer. Forty‐six percent of nurses indicated they had placed a PICC in a patient receiving some form of dialysis in the past several months; however, 91% of these respondents reported receiving approval from nephrology prior to placement in these patients. Although almost all nurses (91%) used ultrasound to find a suitable vein for PICC placement, a smaller percentage used ultrasound to estimate the catheter‐to‐vein ratio to prevent thrombosis (79%), and only a few (14%) documented this figure in the medical record. Three‐quarters of those surveyed (76%) indicated they used ECG‐based systems to position PICC tips at the cavoatrial junction to prevent thrombosis. Of those who used this technology, 36% still obtained chest x‐rays to verify the position of the PICC tip. According to 84% of respondents, flushing of PICCs was performed mainly by bedside nurses, whereas scheduled weekly dressing changes were most often performed by vascular access nurses (Table 2).
| Question | No. | % |
|---|---|---|
| ||
| Do you use ultrasound to find a suitable vein prior to PICC insertion? | ||
| Yes | 128 | 91.4% |
| No | 0 | 0.0% |
| Do you use ultrasound to estimate the catheter‐to‐vein ratio prior to PICC insertion? | ||
| Yes | 110 | 78.6% |
| No | 18 | 12.9% |
| When using ultrasound, do you document the catheter‐to‐vein ratio in the PICC insertion note? | ||
| Yes | 20 | 14.3% |
| No | 89 | 63.6% |
| Do you use ECG guidance‐assisted systems to place PICCs? | ||
| Yes | 106 | 75.7% |
| No | 21 | 15.0% |
| If using ECG guidance, do you still routinely obtain a chest x‐ray to verify PICC tip position after placing the PICC using ECG guidance? | ||
| Yes | 38 | 27.1% |
| No | 68 | 48.6% |
| Who is primarily responsible for administering and adhering to a flushing protocol after PICC insertion at your facility? | ||
| Bedside nurses | 118 | 83.6% |
| Patients | 1 | 0.7% |
| Vascular access nurses | 8 | 5.7% |
| Which of the following agents are most often used to flush PICCs? | ||
| Both heparin and normal saline flushes | 61 | 43.6% |
| Normal saline only | 63 | 45.0% |
| Heparin only | 3 | 2.1% |
| Who is responsible for scheduled weekly dressing changes for PICCs? | ||
| Vascular access nurses | 110 | 78.6% |
| Bedside nurses | 14 | 10.0% |
| Other (eg, IR staff, ICU staff) | 3 | 2.1% |
| In the past few months, have you placed a PICC in a patient who was receiving a form of dialysis (eg, peritoneal or hemodialysis)? | ||
| Yes | 65 | 46.4% |
| No | 64 | 45.7% |
| If you have placed PICCs in patients on dialysis, do you discuss PICC placement or receive approval from nephrology prior to inserting the PICC? | ||
| Yes | 59 | 90.8% |
| No | 6 | 9.2% |
With respect to complications, catheter occlusion, migration, and DVT were reported as the 3 most prevalent adverse events. Interestingly, respondents did not report central lineassociated bloodstream infection (CLABSI) as a common complication. Additionally, 51% of those surveyed indicated that physicians unnecessarily removed PICCs when CLABSI was suspected but not confirmed. When managing catheter occlusion, 50% of respondents began with normal saline flushes but used tissue‐plasminogen activator if saline failed to resolve occlusion. Management of catheter migration varied based on degree of device movement: when the PICC had migrated <5 cm, most respondents (77%) indicated they would first obtain a chest x‐ray to determine the position of the PICC tip, with few (4%) performing catheter exchange. However, if the PICC had migrated more than 5 cm, a significantly greater proportion of respondents (21%) indicated they would perform a catheter exchange. With regard to managing DVT, most vascular nurses reported they notified nurses and physicians to continue using the PICC but recommended tests to confirm the diagnosis.
To better understand the experiences of vascular nurses, we asked for their perceptions regarding appropriateness of PICC use and relationships with bedside nurses, physicians, and leadership. Over a third of respondents (36%) felt that <5% of all PICCs may be inappropriate in their facility, whereas 1 in 5 indicated that 10% to 24% of PICCs placed in their facilities may be inappropriate or could have been avoided. Almost all (98%) of the nurses stated they were not empowered to remove idle or clinically unnecessary PICCs without physician authorization. Although 51% of nurses described the support received from hospital leadership as excellent, very good, or good, 43% described leadership support as either fair or poor. Conversely, relationships with bedside nurses and physicians were rated as being very good or good by nearly two‐thirds of those surveyed (64% and 65%, respectively) (Table 3).
| Question | No. | % |
|---|---|---|
| ||
| Which of the following PICC‐related complications have you most frequently encountered in your practice? | ||
| Catheter occlusion | 81 | 57.9% |
| Catheter migration | 27 | 19.3% |
| PICC‐associated DVT | 6 | 4.3% |
| Catheter fracture or embolization | 3 | 2.1% |
| Exit site infection | 3 | 2.1% |
| Coiling or kinking after insertion | 2 | 1.4% |
| If you suspect a patient has catheter occlusion, which of the following best describes your approach to resolving this problem? | ||
| Begin with normal saline but use a tPA product if this fails to restore patency | 70 | 50.0% |
| Use a tPA product (eg, Cathflo, Activase, or Retavase) to restore patency | 44 | 31.4% |
| Begin with heparin‐based flushes but use a tPA product if this fails to restore | 7 | 5.0% |
| Use only normal saline flushes to restore patency | 3 | 2.1% |
| If you find a PICC that has migrated out or has been accidentally dislodged <5 cm in a patient without symptoms, and the device is still clinically needed, which of the following best describes your practice? | ||
| Obtain a chest x‐ray to verify tip position | 108 | 77.1% |
| Perform a complete catheter exchange over a guidewire if possible | 5 | 3.6% |
| Notify/discuss next steps with physician | 5 | 3.6% |
| Other | 6 | 4.3% |
| If you find a PICC that has migrated out or has been accidentally dislodged >5 cm in a patient without symptoms, and the device is still clinically needed, which of the following best describes your practice? | ||
| Obtain a chest x‐ray to verify tip position | 72 | 51.4% |
| Perform a catheter exchange over a guidewire if possible | 30 | 21.4% |
| Notify/discuss next steps with physician | 10 | 7.1% |
| Other | 12 | 8.6% |
| Which of the following best describes your first approach when you suspect a patient has PICC‐associated phlebitis? | ||
| Discuss best course of action with physician or nurse | 79 | 56.4% |
| Supportive measures (eg, warm compresses, analgesics, monitoring) | 25 | 17.9% |
| Remove the PICC | 15 | 10.7% |
| Other | 5 | 3.6% |
| Which of the following best describes your first approach when you suspect a patient has a PICC‐related DVT? | ||
| Notify caregivers to continue using PICC and consider tests such as ultrasound | 82 | 58.6% |
| Notify bedside nurse and physician not to continue use of the PICC and consider tests such as ultrasound | 42 | 30.0% |
| PICCs are often removed when physicians suspect, but have not yet confirmed, CLABSI. Considering your experiences, what percentage of PICCs may have been removed in this manner at your facility? | ||
| <5% | 11 | 7.9% |
| 59% | 16 | 11.4% |
| 1024% | 24 | 17.1% |
| 25% | 71 | 50.7% |
| Based on your experience, what percentage of PICCs do you think are inappropriate or could have been avoided at your facility? | ||
| <5% | 51 | 36.4% |
| 59% | 25 | 17.9% |
| 1024% | 28 | 20.0% |
| 2550% | 13 | 9.3% |
| >50% | 5 | 3.6% |
| Are vascular access nurses empowered to remove PICCs that are idle or clinically unnecessary without physician authorization? | ||
| Yes | 3 | 2.1% |
| No | 122 | 87.1% |
| How would you rank the overall support your vascular access service receives from hospital leadership? | ||
| Excellent | 5 | 3.6% |
| Very good | 32 | 22.9% |
| Good | 40 | 28.6% |
| Fair | 35 | 25.0% |
| Poor | 25 | 17.9% |
| How would you describe your relationship with physicians at your facility when it comes to communicating recommendations or management of PICCs? | ||
| Very good | 28 | 20.0% |
| Good | 63 | 45.0% |
| Fair | 35 | 25.0% |
| Poor | 7 | 5.0% |
| Very poor | 4 | 2.9% |
| How would you describe your relationship with bedside nurses at your facility when it comes to communicating recommendations or management of PICCs? | ||
| Very good | 32 | 22.9% |
| Good | 58 | 41.4% |
| Fair | 38 | 27.1% |
| Poor | 7 | 5.0% |
| Very poor | 2 | 1.4% |
Variation in Responses Based on Years in Practice or Certification
We initially hypothesized that responses regarding practice (ultrasound use, ECG guidance system use), management of complications, or perceptions regarding leadership might vary based on years of experience, number of PICCs placed, or certification status. However, no statistically significant associations with these factors and individual responses were identified.
DISCUSSION
In this survey of 140 vascular access nurses in hospitals across Michigan, new insights regarding the experience, practice, knowledge, and beliefs of this group of providers were obtained. We found that vascular access nurses varied with respect to years in practice, volume of PICCs placed, and certification status, reflecting heterogeneity in this provider group. Variation in insertion techniques, such as use of ultrasound to examine catheter‐to‐vein ratio (a key way to prevent thrombosis) or newer ECG technology to position the PICC, was also noted. Although indications for PICC insertion appeared consistent with published literature, the frequency with which these devices were placed in patients receiving dialysis (reportedly with nephrology approval) was surprising given national calls to avoid such use.[16] Opportunities to improve hospital practices, such as tracking PICC dwell times and PICC necessity, as well as the potential need to better educate physicians on when to remove PICCs for suspected CLABSI, were also identified. Collectively, these data are highly relevant to hospitalists and health systems as they help to identify areas for quality improvement and inform clinical practice regarding the use of PICCs in hospitalized patients. As hospitalists increasingly order PICCs and manage complications associated with these devices, they are well suited to use these data so as to improve patient safety and clinical outcomes.
Venous access is the most common medical procedure performed in hospitalized medical patients. Although a number of devices including peripheral intravenous catheters, central venous catheters, and PICCs are used for this purpose, the growing use of PICCs to secure venous access has been documented in several studies.[17] Such growth, in part, undoubtedly reflects increasing availability of vascular access nurses. Traditionally placed by interventional radiologists, the creation of dedicated vascular nursing teams has resulted in these subspecialists now serving in more of a backup or trouble‐shooting role rather than that of primary operator.[4, 14] This paradigm shift is well illustrated in a recent survey of infection preventionists, where over 60% of respondents reported that they had a vascular nursing team in their facility.[7] The growth of these nursing‐led vascular access teams has produced not only high rates of insertion success and low rates of complications, but also greater cost‐effectiveness when compared to interventional radiologybased insertion.[18]
Nonetheless, our survey also identified a number of important concerns regarding PICC practices and vascular nursing providers. First, we found variation in areas such as insertion practices and management of complications. Such variability highlights the importance of both growing and disseminating the evidence base for consistent practice in vascular nursing. Through their close clinical affiliation with vascular nurses and shared interests in obtaining safe and appropriate venous access for patients, hospitalists are ideally poised to lead this effort. Second, similarities between vascular nurse opinions regarding appropriateness of PICCs and those of hospitalists from a prior survey were noted.[19] Namely, a substantial proportion of both vascular nurses and hospitalists felt that some PICCs were inappropriate and could be avoided. Third, although relationships between vascular access nurses and leadership were reported as being variable, the survey responses suggested relatively good interprovider relationships with bedside nurses and physicians. Such relationships likely reflect the close clinical ties that emerge from being in the trenches of patient care and suggest that interventions to improve care in partnership with these providers are highly viable.
Our study has some limitations. First, despite a high response rate, our study used a survey design and reports findings from a convenience sample of vascular access nurses in a single state. Thus, nonrespondent and selection biases remain threats to our conclusions. Additionally, some respondents did not complete all responses, perhaps due to nonapplicability to practice or other unknown reasons. The pattern of missingness observed, however, suggested that such responses were missing at random. Second, we surveyed vascular nurses in hospitals that are actively engaged in improving PICC practices; our findings may therefore not be representative of vascular nursing professionals as a whole and may instead reflect those of a highly motivated group of individuals. Relatedly, the underlying reasons for adoption of specific practices or techniques cannot be discerned from our study. Third, although we did not find differences based on years in practice or certification status, our sample size was relatively small and likely underpowered for these comparisons. Finally, our study sample consists of vascular nurses who are clustered within hospitals in which they are employed. Therefore, overlap between reported practices and those required by the facility are possible.
Despite these limitations, our study has important strengths. First, this is among the most comprehensive of surveys examining vascular nursing experience, practice, knowledge, and beliefs. The growing presence of these providers across US hospitals, coupled with limited insight regarding their clinical practices, highlight the importance and utility of these data. Second, we noted important differences in experience, practices, and interprovider relationships between vascular providers in this field. Although we are unable to ascertain the drivers or significance of such variation, hospitals and health systems focused on improving patient safety should consider quantifying and exploring these factors. Third, findings from our survey within Michigan suggest the need for similar, larger studies across the country. Partnerships with nursing organizations or larger professional groups that represent vascular nursing specialists may be helpful in this regard.
In conclusion, we found important similarities and differences in vascular nursing experience, practice, knowledge, and beliefs in Michigan. These data are useful as they help provide context regarding the constitution of these teams, current practices, and opportunities for improving care. Hospitalists seeking to improve patient safety may use these data to better inform vascular access practice in hospitalized patients.
Acknowledgements
The authors thank Claire Rickard, PhD, RN, Britt Meyer, RN, Peter Carr, PhD, and David Dempsey, RN for their assistance in developing the survey instrument used in this study.
Disclosures: This project was funded through an Investigator Initiated Research Grant from the Blue Cross Blue Shield of Michigan (BCBSM) Foundation (grant number 2140.II). The funding source played no role in study design, data acquisition, analysis, or reporting of the data. Support for the Hospital Medicine Safety (HMS) Consortium is provided by BCBSM and the Blue Care Network as part of the BCBSM Value Partnerships program. Although BCBSM and HMS work collaboratively, the opinions, beliefs, and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees. This work was also supported with resources from the Veterans Affairs Ann Arbor Healthcare System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
- , , , et al. Peripherally inserted central venous catheters in the acute care setting: a safe alternative to high‐risk short‐term central venous catheters. Am J Infect Control. 2010;38(2):149–153.
- , , , , . Risk of venous thromboembolism in hospitalized patients with peripherally inserted central catheters. J Hosp Med. 2009;4(7):417–422.
- , , , , , . Central venous catheter placement by advanced practice nurses demonstrates low procedural complication and infection rates‐‐a report from 13 years of service. Crit Care Med. 2014;42(3):536–543.
- . Developing an alternative workflow model for peripherally inserted central catheter placement. J Infus Nurs. 2012;34(1):34–42.
- , . Facility wide benefits of radiology vascular access teams. Radiol Manage. 2010;32(1):28–32; quiz 33–34.
- , . Moving the needle forward: the imperative for collaboration in vascular access. J Infus Nurs. 2015;38(2):100–102.
- , , , . Use of designated PICC teams by U.S. hospitals: a survey‐based study [published online November 10, 2015]. J Patient Saf. doi: 10.1097/PTS.0000000000000246
- , , , , . The association between PICC use and venous thromboembolism in upper and lower extremities. American J Med. 2015;128(9):986–993.e1.
- , , , et al. Hospital performance for pharmacologic venous thromboembolism prophylaxis and rate of venous thromboembolism: a cohort study. JAMA Intern Med. 2014;174(10):1577–1584.
- , , , et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta‐analysis. Lancet. 2013;382(9889):311–325.
- Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2006;29(1 suppl):S1–S92.
- , , , et al. Guidelines for the prevention of intravascular catheter‐related infections. Am J Infect Control. 2011;39(4 suppl 1):S1–S34.
- , , , et al. International evidence‐based recommendations on ultrasound‐guided vascular access. Intensive Care Med. 2012;38(7):1105–1117.
- , , . A single institution experience of seven hundred consecutively placed peripherally inserted central venous catheters. J Vasc Access. 2014;15(6):498–502.
- , , . Central venous access devices site care practices: an international survey of 34 countries [published online September 3, 2015]. J Vasc Access. doi: 10.5301/jva.5000450
- American Society of Nephrology. World's Leading Kidney Society Joins Effort to Reduce Unnecessary Medical Tests and Procedures. Available at: https://www.asn‐online.org/policy/choosingwisely/PressReleaseChoosingWisely.pdf. Accessed September 4, 2015.
- , , , . A survey of the current use of peripherally inserted central venous catheter (PICC) in Swedish oncology departments. Acta Oncol. 2013;52(6):1241–1242.
- , . Nurse‐led PICC insertion: is it cost effective? Br J Nurs. 2013;22(19):S9–S15.
- , , , et al. Hospitalist experiences, practice, opinions, and knowledge regarding peripherally inserted central catheters: a Michigan survey. J Hosp Med. 2013;8(6):309–314.
Peripherally inserted central catheters (PICCs) are among the most prevalent of venous access devices in hospitalized patients.[1, 2] Although growing use of these devices reflects clinical advantages, such as a reduced risk of complications during insertion and durable venous access, use of PICCs is also likely related to the growth of vascular access nursing.[3, 4] A relatively new specialty, vascular access nurses obtain, maintain, and manage venous access in hospitalized patients.[4, 5] Depending on their scope of practice, these professionals are responsible not only for insertion of devices, such as peripheral intravenous catheters and PICCs, but also nontunneled central venous catheters and arterial catheters in some settings.[6]
Although a growing number of US hospitals have introduced vascular nursing teams,[7] little is known about the experience, practice, knowledge, and beliefs of vascular access nurses. This knowledge gap is relevant for hospitalists and hospital medicine as (1) vascular access nurses increasingly represent a key partner in the care of hospitalized patients; (2) the knowledge and practice of these individuals directly affects patient safety and clinical outcomes; and (3) understanding experience, practice, and beliefs of these specialists can help inform decision making and quality‐improvement efforts related to PICCs. As hospitalists increasingly order the placement of and care for patients with PICCs, they are also well suited to improve PICC practice.
Therefore, we conducted a survey of vascular access nurses employed by hospitals that participate in the Michigan Hospital Medicine Safety (HMS) Consortium, a Blue Cross Blue Shield of Michiganfunded collaborative quality initiative.[6] We aimed to understand experience, practice, knowledge, and beliefs related to PICC care and use.
METHODS
Study Setting and Participants
To quantify vascular nursing experience, practice, knowledge, and beliefs, we conducted a Web‐based survey of vascular nurses across 47 Michigan hospitals that participate in HMS. A statewide quality‐improvement initiative, HMS aims to prevent adverse events in hospitalized medical patients through the creation of a data registry and sharing of best practices. The setting and design of this multicenter initiative have been previously described.[8, 9] Although participation is voluntary, each hospital receives payment for participating in the consortium and for data collection. Because HMS has an ongoing initiative aimed at identifying and preventing PICC‐related complications, this study was particularly relevant for participating hospitals and nurses.
Each HMS site has a designated quality‐improvement lead, physician champion, and data abstractor. To coordinate distribution and dissemination of the survey, we contacted the quality‐improvement leads at each site and enquired whether their hospital employed vascular access nurses who placed PICCs. Because we were only interested in responses from vascular access nurses, HMS hospitals that did not have these providers or stated PICCs were placed by other specialists (eg, interventional radiology) were excluded. At eligible sites, we obtained the total number of vascular nurses employed so as to determine the number of eligible respondents. In this manner, a purposeful sample of vascular nurses at participating HMS hospitals was constituted.
Participation in the survey was solicited through hospital quality leads that either distributed an electronic survey link to vascular nurses at their facilities or sent us individual email addresses to contact them directly. A cover letter explaining the rationale and the purpose of the survey along with the survey link was then sent to respondents through either of these routes. The survey was administered at all HMS sites contemporaneously and kept open for a period of 5 weeks. During the 5‐week period, 2 e‐mail reminders were sent to encourage participation. As a token of appreciation, a $10 Amazon gift card was offered to those who took the survey.
Development and Validation of the Survey
We developed the survey instrument (which we call PICC1 as we hope to administer longitudinally to track changes over time) by first conducting a literature search to identify relevant evidence‐based guidelines and studies regarding vascular access nursing practices and experiences.[10, 11, 12, 13] In addition, we consulted and involved national and international leaders in vascular access nursing to ensure validity and representativeness of the questions posed. We were specifically interested in nursing background, hospital practices, types of PICCs used, use of various technologies, relationships with healthcare providers, and management of complications. To understand participant characteristics and quantify potential variation in responses, we collected basic participant data including demographics, years in practice, number of PICCs placed, leadership roles, and vascular access certification status. Based on clinical reasoning and existing studies,[14, 15] we hypothesized that responses regarding certain practices (ultrasound use, electrocardiography [ECG] guidance system use), management of complications, or perceptions regarding leadership might vary based on years of experience, number of PICCs placed, or certification status. We therefore examined these associations as prespecified subgroup analyses.
The initial survey instrument was pilot tested with vascular nurses outside of the sampling frame. Based on feedback from the pilot testers, the instrument was refined and edited to improve clarity of the questions. In addition, specific skip patterns and logic were programmed into the final survey to reduce respondent burden and allow participants to seamlessly bypass questions that were contingent on a prior response (eg, use of ECG to place PICCs would lead to a series of questions about ECG‐assisted placement only for those respondents who used the technology). This final version of the survey was tested by members of the study team (V.C., L.K., S.L.K.) and then posted to SurveyMonkey for dissemination.
Statistical Analysis
Descriptive statistics (percentage, n/N) were used to tabulate results. In accordance with our a priori hypothesis that variation to responses might be associated with respondent characteristics, responses to questions regarding insertion practice (eg, use of ultrasound, measurement of catheter:vein ratio, trimming of catheters) and approach to complications (eg, catheter occlusion, deep vein thrombosis [DVT] notification, and PICC removal in the setting of fever) were compared by respondent years in practice (dichotomized to <5 vs >5 years), volume of PICCs placed (<999 vs 1000), and certification status (yes/no). Bivariate comparisons were made using 2 or Fisher exact tests based on the number of responses in a cell as appropriate; 2‐sided with a P value <0.05 was considered statistically significant. All statistical analyses were conducted using SAS version 9.3 (SAS Institute, Cary, NC).
Ethical and Regulatory Oversight
Because our study sought to describe existing practice without collecting any individual or facility level identifiable information, the project received a Not Regulated status by the University of Michigan Medical School Institutional Review Board (HUM00088351).
RESULTS
Of 172 vascular nurses who received invitations, 140 completed the survey for a response rate of 81%. Respondents reported working in not‐for‐profit hospitals (36%), academic medical centers (29%), and for‐profit hospitals (21%). Although multiple providers (eg, interventional radiology staff and providers, physicians) placed PICCs, 95% of those surveyed reported that they placed the majority of the PICCs at their institutions. Although most respondents placed PICCs in adult patients (86%), a few also placed PICCs in pediatric populations (17%). Vascular nursing programs were largely housed in their own department, but some reported to general nursing or subspecialties such as interventional radiology, cardiology, and critical care. Most respondents indicated their facilities had written policies regarding standard insertion and care practices (87% and 95%, respectively), but only 30% had policies regarding the necessity or appropriateness of PICCs.
Experience among respondents was variable: approximately a third had placed PICCs for <5 years (28.6%), whereas 58% reported placing PICCs for 5 years Correspondingly, 26% reported having placed 100 to 500 PICCs, whereas 34% had placed 1000 or more PICCs. Only 23% of those surveyed held a dedicated vascular access certification, such as board certified in vascular access or certified registered nurse infusion, whereas 16% indicated that they served as the vascular access lead nurse for their facility. Following placement, 94% of respondents reported that their facilities tracked the number of PICCs inserted, but only 40% indicated that dwell times of devices were also recorded. Only 30% of nurses reported that their hospitals had a written policy to evaluate PICC necessity or appropriateness following placement (Table 1).
| No.* | % | |
|---|---|---|
| ||
| Participant characteristics | ||
| For how many years have you been inserting PICCs? | ||
| <5 years | 40 | 28.6% |
| 5 years | 81 | 57.9% |
| Missing | ||
| In which of the following populations do you insert PICCs? | ||
| Adult patients | 121 | 86.4% |
| Pediatric patients | 24 | 17.1% |
| Neonatal patients | 1 | 0.7% |
| In which of the following locations do you place PICCs? (Select all that apply.) | ||
| Adult medical ward | 115 | 82.1% |
| General adult surgical ward | 110 | 78.6% |
| General pediatric medical ward | 34 | 24.3% |
| General pediatric surgical ward | 24 | 17.1% |
| Adult intensive care unit | 114 | 81.4% |
| Pediatric intensive care unit | 19 | 13.6% |
| Neonatal intensive care unit | 3 | 2.1% |
| Other intensive care unit | 59 | 42.1% |
| Outpatient clinic or emergency department | 17 | 12.1% |
| Other | 10 | 7.1% |
| Approximately how many PICCs may you have placed in your career? | ||
| 099 | 15 | 10.7% |
| 100499 | 36 | 25.7% |
| 500999 | 23 | 16.4% |
| 1,000 | 47 | 33.6% |
| Are you the vascular access lead nurse for your facility or organization? | ||
| Yes | 22 | 15.7% |
| No | 98 | 70.0% |
| Do you currently hold a dedicated vascular access certification (BC‐VA, CRNI, etc.)? | ||
| Yes | 32 | 22.9% |
| No | 89 | 63.6% |
| Facility characteristics | ||
| Which of the following best describes your primary work location? | ||
| Academic medical center | 41 | 29.3% |
| For‐profit community‐based hospital or medical center | 30 | 21.4% |
| Not‐for‐profit community‐based hospital or medical center | 50 | 35.7% |
| Who inserts the most PICCs in your facility? | ||
| Vascular access nurses | 133 | 95.0% |
| Interventional radiology or other providers | 7 | 5.0% |
| In which department is vascular access nursing located? | ||
| Vascular nursing | 76 | 54.3% |
| General nursing | 38 | 27.1% |
| Interventional radiology | 15 | 10.7% |
| Other | 11 | 7.9% |
| Using your best guess, how many PICCs do you think your facility inserts each month? | ||
| <25 | 5 | 3.6% |
| 2549 | 13 | 9.3% |
| 50100 | 39 | 27.9% |
| >100 | 78 | 55.7% |
| Unknown | 2 | 1.4% |
| How many vascular access nurses are employed by your facility? | ||
| <4 | 14 | 10.0% |
| 46 | 33 | 23.6% |
| 79 | 15 | 10.7% |
| 1015 | 25 | 17.9% |
| >15 | 53 | 37.9% |
| Does your facility track the number of PICCs placed? | ||
| Yes | 132 | 94.3% |
| No | 5 | 3.6% |
| Unknown | 3 | 2.1% |
| Does your facility track the duration or dwell time of PICCs? | ||
| Yes | 56 | 40.0% |
| No | 60 | 42.9% |
| Unknown | 24 | 17.1% |
| Does your facility have a written policy regarding standard PICC insertion practices? | ||
| Yes | 122 | 87.1% |
| No | 8 | 5.7% |
| Unknown | 7 | 5.0% |
| Does your facility have a written policy regarding standard PICC care and maintenance? | ||
| Yes | 133 | 95.0% |
| No | 3 | 2.1% |
| Unknown | 1 | 0.7% |
| Does your facility have a written process to review the necessity or appropriateness of a PICC? | ||
| Yes | 42 | 30.0% |
| No | 63 | 45.0% |
| Unknown | 20 | 14.3% |
The most commonly reported indications for PICC placement included intravenous antibiotics at discharge, difficult venous access, and placement for chemotherapy in patients with cancer. Forty‐six percent of nurses indicated they had placed a PICC in a patient receiving some form of dialysis in the past several months; however, 91% of these respondents reported receiving approval from nephrology prior to placement in these patients. Although almost all nurses (91%) used ultrasound to find a suitable vein for PICC placement, a smaller percentage used ultrasound to estimate the catheter‐to‐vein ratio to prevent thrombosis (79%), and only a few (14%) documented this figure in the medical record. Three‐quarters of those surveyed (76%) indicated they used ECG‐based systems to position PICC tips at the cavoatrial junction to prevent thrombosis. Of those who used this technology, 36% still obtained chest x‐rays to verify the position of the PICC tip. According to 84% of respondents, flushing of PICCs was performed mainly by bedside nurses, whereas scheduled weekly dressing changes were most often performed by vascular access nurses (Table 2).
| Question | No. | % |
|---|---|---|
| ||
| Do you use ultrasound to find a suitable vein prior to PICC insertion? | ||
| Yes | 128 | 91.4% |
| No | 0 | 0.0% |
| Do you use ultrasound to estimate the catheter‐to‐vein ratio prior to PICC insertion? | ||
| Yes | 110 | 78.6% |
| No | 18 | 12.9% |
| When using ultrasound, do you document the catheter‐to‐vein ratio in the PICC insertion note? | ||
| Yes | 20 | 14.3% |
| No | 89 | 63.6% |
| Do you use ECG guidance‐assisted systems to place PICCs? | ||
| Yes | 106 | 75.7% |
| No | 21 | 15.0% |
| If using ECG guidance, do you still routinely obtain a chest x‐ray to verify PICC tip position after placing the PICC using ECG guidance? | ||
| Yes | 38 | 27.1% |
| No | 68 | 48.6% |
| Who is primarily responsible for administering and adhering to a flushing protocol after PICC insertion at your facility? | ||
| Bedside nurses | 118 | 83.6% |
| Patients | 1 | 0.7% |
| Vascular access nurses | 8 | 5.7% |
| Which of the following agents are most often used to flush PICCs? | ||
| Both heparin and normal saline flushes | 61 | 43.6% |
| Normal saline only | 63 | 45.0% |
| Heparin only | 3 | 2.1% |
| Who is responsible for scheduled weekly dressing changes for PICCs? | ||
| Vascular access nurses | 110 | 78.6% |
| Bedside nurses | 14 | 10.0% |
| Other (eg, IR staff, ICU staff) | 3 | 2.1% |
| In the past few months, have you placed a PICC in a patient who was receiving a form of dialysis (eg, peritoneal or hemodialysis)? | ||
| Yes | 65 | 46.4% |
| No | 64 | 45.7% |
| If you have placed PICCs in patients on dialysis, do you discuss PICC placement or receive approval from nephrology prior to inserting the PICC? | ||
| Yes | 59 | 90.8% |
| No | 6 | 9.2% |
With respect to complications, catheter occlusion, migration, and DVT were reported as the 3 most prevalent adverse events. Interestingly, respondents did not report central lineassociated bloodstream infection (CLABSI) as a common complication. Additionally, 51% of those surveyed indicated that physicians unnecessarily removed PICCs when CLABSI was suspected but not confirmed. When managing catheter occlusion, 50% of respondents began with normal saline flushes but used tissue‐plasminogen activator if saline failed to resolve occlusion. Management of catheter migration varied based on degree of device movement: when the PICC had migrated <5 cm, most respondents (77%) indicated they would first obtain a chest x‐ray to determine the position of the PICC tip, with few (4%) performing catheter exchange. However, if the PICC had migrated more than 5 cm, a significantly greater proportion of respondents (21%) indicated they would perform a catheter exchange. With regard to managing DVT, most vascular nurses reported they notified nurses and physicians to continue using the PICC but recommended tests to confirm the diagnosis.
To better understand the experiences of vascular nurses, we asked for their perceptions regarding appropriateness of PICC use and relationships with bedside nurses, physicians, and leadership. Over a third of respondents (36%) felt that <5% of all PICCs may be inappropriate in their facility, whereas 1 in 5 indicated that 10% to 24% of PICCs placed in their facilities may be inappropriate or could have been avoided. Almost all (98%) of the nurses stated they were not empowered to remove idle or clinically unnecessary PICCs without physician authorization. Although 51% of nurses described the support received from hospital leadership as excellent, very good, or good, 43% described leadership support as either fair or poor. Conversely, relationships with bedside nurses and physicians were rated as being very good or good by nearly two‐thirds of those surveyed (64% and 65%, respectively) (Table 3).
| Question | No. | % |
|---|---|---|
| ||
| Which of the following PICC‐related complications have you most frequently encountered in your practice? | ||
| Catheter occlusion | 81 | 57.9% |
| Catheter migration | 27 | 19.3% |
| PICC‐associated DVT | 6 | 4.3% |
| Catheter fracture or embolization | 3 | 2.1% |
| Exit site infection | 3 | 2.1% |
| Coiling or kinking after insertion | 2 | 1.4% |
| If you suspect a patient has catheter occlusion, which of the following best describes your approach to resolving this problem? | ||
| Begin with normal saline but use a tPA product if this fails to restore patency | 70 | 50.0% |
| Use a tPA product (eg, Cathflo, Activase, or Retavase) to restore patency | 44 | 31.4% |
| Begin with heparin‐based flushes but use a tPA product if this fails to restore | 7 | 5.0% |
| Use only normal saline flushes to restore patency | 3 | 2.1% |
| If you find a PICC that has migrated out or has been accidentally dislodged <5 cm in a patient without symptoms, and the device is still clinically needed, which of the following best describes your practice? | ||
| Obtain a chest x‐ray to verify tip position | 108 | 77.1% |
| Perform a complete catheter exchange over a guidewire if possible | 5 | 3.6% |
| Notify/discuss next steps with physician | 5 | 3.6% |
| Other | 6 | 4.3% |
| If you find a PICC that has migrated out or has been accidentally dislodged >5 cm in a patient without symptoms, and the device is still clinically needed, which of the following best describes your practice? | ||
| Obtain a chest x‐ray to verify tip position | 72 | 51.4% |
| Perform a catheter exchange over a guidewire if possible | 30 | 21.4% |
| Notify/discuss next steps with physician | 10 | 7.1% |
| Other | 12 | 8.6% |
| Which of the following best describes your first approach when you suspect a patient has PICC‐associated phlebitis? | ||
| Discuss best course of action with physician or nurse | 79 | 56.4% |
| Supportive measures (eg, warm compresses, analgesics, monitoring) | 25 | 17.9% |
| Remove the PICC | 15 | 10.7% |
| Other | 5 | 3.6% |
| Which of the following best describes your first approach when you suspect a patient has a PICC‐related DVT? | ||
| Notify caregivers to continue using PICC and consider tests such as ultrasound | 82 | 58.6% |
| Notify bedside nurse and physician not to continue use of the PICC and consider tests such as ultrasound | 42 | 30.0% |
| PICCs are often removed when physicians suspect, but have not yet confirmed, CLABSI. Considering your experiences, what percentage of PICCs may have been removed in this manner at your facility? | ||
| <5% | 11 | 7.9% |
| 59% | 16 | 11.4% |
| 1024% | 24 | 17.1% |
| 25% | 71 | 50.7% |
| Based on your experience, what percentage of PICCs do you think are inappropriate or could have been avoided at your facility? | ||
| <5% | 51 | 36.4% |
| 59% | 25 | 17.9% |
| 1024% | 28 | 20.0% |
| 2550% | 13 | 9.3% |
| >50% | 5 | 3.6% |
| Are vascular access nurses empowered to remove PICCs that are idle or clinically unnecessary without physician authorization? | ||
| Yes | 3 | 2.1% |
| No | 122 | 87.1% |
| How would you rank the overall support your vascular access service receives from hospital leadership? | ||
| Excellent | 5 | 3.6% |
| Very good | 32 | 22.9% |
| Good | 40 | 28.6% |
| Fair | 35 | 25.0% |
| Poor | 25 | 17.9% |
| How would you describe your relationship with physicians at your facility when it comes to communicating recommendations or management of PICCs? | ||
| Very good | 28 | 20.0% |
| Good | 63 | 45.0% |
| Fair | 35 | 25.0% |
| Poor | 7 | 5.0% |
| Very poor | 4 | 2.9% |
| How would you describe your relationship with bedside nurses at your facility when it comes to communicating recommendations or management of PICCs? | ||
| Very good | 32 | 22.9% |
| Good | 58 | 41.4% |
| Fair | 38 | 27.1% |
| Poor | 7 | 5.0% |
| Very poor | 2 | 1.4% |
Variation in Responses Based on Years in Practice or Certification
We initially hypothesized that responses regarding practice (ultrasound use, ECG guidance system use), management of complications, or perceptions regarding leadership might vary based on years of experience, number of PICCs placed, or certification status. However, no statistically significant associations with these factors and individual responses were identified.
DISCUSSION
In this survey of 140 vascular access nurses in hospitals across Michigan, new insights regarding the experience, practice, knowledge, and beliefs of this group of providers were obtained. We found that vascular access nurses varied with respect to years in practice, volume of PICCs placed, and certification status, reflecting heterogeneity in this provider group. Variation in insertion techniques, such as use of ultrasound to examine catheter‐to‐vein ratio (a key way to prevent thrombosis) or newer ECG technology to position the PICC, was also noted. Although indications for PICC insertion appeared consistent with published literature, the frequency with which these devices were placed in patients receiving dialysis (reportedly with nephrology approval) was surprising given national calls to avoid such use.[16] Opportunities to improve hospital practices, such as tracking PICC dwell times and PICC necessity, as well as the potential need to better educate physicians on when to remove PICCs for suspected CLABSI, were also identified. Collectively, these data are highly relevant to hospitalists and health systems as they help to identify areas for quality improvement and inform clinical practice regarding the use of PICCs in hospitalized patients. As hospitalists increasingly order PICCs and manage complications associated with these devices, they are well suited to use these data so as to improve patient safety and clinical outcomes.
Venous access is the most common medical procedure performed in hospitalized medical patients. Although a number of devices including peripheral intravenous catheters, central venous catheters, and PICCs are used for this purpose, the growing use of PICCs to secure venous access has been documented in several studies.[17] Such growth, in part, undoubtedly reflects increasing availability of vascular access nurses. Traditionally placed by interventional radiologists, the creation of dedicated vascular nursing teams has resulted in these subspecialists now serving in more of a backup or trouble‐shooting role rather than that of primary operator.[4, 14] This paradigm shift is well illustrated in a recent survey of infection preventionists, where over 60% of respondents reported that they had a vascular nursing team in their facility.[7] The growth of these nursing‐led vascular access teams has produced not only high rates of insertion success and low rates of complications, but also greater cost‐effectiveness when compared to interventional radiologybased insertion.[18]
Nonetheless, our survey also identified a number of important concerns regarding PICC practices and vascular nursing providers. First, we found variation in areas such as insertion practices and management of complications. Such variability highlights the importance of both growing and disseminating the evidence base for consistent practice in vascular nursing. Through their close clinical affiliation with vascular nurses and shared interests in obtaining safe and appropriate venous access for patients, hospitalists are ideally poised to lead this effort. Second, similarities between vascular nurse opinions regarding appropriateness of PICCs and those of hospitalists from a prior survey were noted.[19] Namely, a substantial proportion of both vascular nurses and hospitalists felt that some PICCs were inappropriate and could be avoided. Third, although relationships between vascular access nurses and leadership were reported as being variable, the survey responses suggested relatively good interprovider relationships with bedside nurses and physicians. Such relationships likely reflect the close clinical ties that emerge from being in the trenches of patient care and suggest that interventions to improve care in partnership with these providers are highly viable.
Our study has some limitations. First, despite a high response rate, our study used a survey design and reports findings from a convenience sample of vascular access nurses in a single state. Thus, nonrespondent and selection biases remain threats to our conclusions. Additionally, some respondents did not complete all responses, perhaps due to nonapplicability to practice or other unknown reasons. The pattern of missingness observed, however, suggested that such responses were missing at random. Second, we surveyed vascular nurses in hospitals that are actively engaged in improving PICC practices; our findings may therefore not be representative of vascular nursing professionals as a whole and may instead reflect those of a highly motivated group of individuals. Relatedly, the underlying reasons for adoption of specific practices or techniques cannot be discerned from our study. Third, although we did not find differences based on years in practice or certification status, our sample size was relatively small and likely underpowered for these comparisons. Finally, our study sample consists of vascular nurses who are clustered within hospitals in which they are employed. Therefore, overlap between reported practices and those required by the facility are possible.
Despite these limitations, our study has important strengths. First, this is among the most comprehensive of surveys examining vascular nursing experience, practice, knowledge, and beliefs. The growing presence of these providers across US hospitals, coupled with limited insight regarding their clinical practices, highlight the importance and utility of these data. Second, we noted important differences in experience, practices, and interprovider relationships between vascular providers in this field. Although we are unable to ascertain the drivers or significance of such variation, hospitals and health systems focused on improving patient safety should consider quantifying and exploring these factors. Third, findings from our survey within Michigan suggest the need for similar, larger studies across the country. Partnerships with nursing organizations or larger professional groups that represent vascular nursing specialists may be helpful in this regard.
In conclusion, we found important similarities and differences in vascular nursing experience, practice, knowledge, and beliefs in Michigan. These data are useful as they help provide context regarding the constitution of these teams, current practices, and opportunities for improving care. Hospitalists seeking to improve patient safety may use these data to better inform vascular access practice in hospitalized patients.
Acknowledgements
The authors thank Claire Rickard, PhD, RN, Britt Meyer, RN, Peter Carr, PhD, and David Dempsey, RN for their assistance in developing the survey instrument used in this study.
Disclosures: This project was funded through an Investigator Initiated Research Grant from the Blue Cross Blue Shield of Michigan (BCBSM) Foundation (grant number 2140.II). The funding source played no role in study design, data acquisition, analysis, or reporting of the data. Support for the Hospital Medicine Safety (HMS) Consortium is provided by BCBSM and the Blue Care Network as part of the BCBSM Value Partnerships program. Although BCBSM and HMS work collaboratively, the opinions, beliefs, and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees. This work was also supported with resources from the Veterans Affairs Ann Arbor Healthcare System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
Peripherally inserted central catheters (PICCs) are among the most prevalent of venous access devices in hospitalized patients.[1, 2] Although growing use of these devices reflects clinical advantages, such as a reduced risk of complications during insertion and durable venous access, use of PICCs is also likely related to the growth of vascular access nursing.[3, 4] A relatively new specialty, vascular access nurses obtain, maintain, and manage venous access in hospitalized patients.[4, 5] Depending on their scope of practice, these professionals are responsible not only for insertion of devices, such as peripheral intravenous catheters and PICCs, but also nontunneled central venous catheters and arterial catheters in some settings.[6]
Although a growing number of US hospitals have introduced vascular nursing teams,[7] little is known about the experience, practice, knowledge, and beliefs of vascular access nurses. This knowledge gap is relevant for hospitalists and hospital medicine as (1) vascular access nurses increasingly represent a key partner in the care of hospitalized patients; (2) the knowledge and practice of these individuals directly affects patient safety and clinical outcomes; and (3) understanding experience, practice, and beliefs of these specialists can help inform decision making and quality‐improvement efforts related to PICCs. As hospitalists increasingly order the placement of and care for patients with PICCs, they are also well suited to improve PICC practice.
Therefore, we conducted a survey of vascular access nurses employed by hospitals that participate in the Michigan Hospital Medicine Safety (HMS) Consortium, a Blue Cross Blue Shield of Michiganfunded collaborative quality initiative.[6] We aimed to understand experience, practice, knowledge, and beliefs related to PICC care and use.
METHODS
Study Setting and Participants
To quantify vascular nursing experience, practice, knowledge, and beliefs, we conducted a Web‐based survey of vascular nurses across 47 Michigan hospitals that participate in HMS. A statewide quality‐improvement initiative, HMS aims to prevent adverse events in hospitalized medical patients through the creation of a data registry and sharing of best practices. The setting and design of this multicenter initiative have been previously described.[8, 9] Although participation is voluntary, each hospital receives payment for participating in the consortium and for data collection. Because HMS has an ongoing initiative aimed at identifying and preventing PICC‐related complications, this study was particularly relevant for participating hospitals and nurses.
Each HMS site has a designated quality‐improvement lead, physician champion, and data abstractor. To coordinate distribution and dissemination of the survey, we contacted the quality‐improvement leads at each site and enquired whether their hospital employed vascular access nurses who placed PICCs. Because we were only interested in responses from vascular access nurses, HMS hospitals that did not have these providers or stated PICCs were placed by other specialists (eg, interventional radiology) were excluded. At eligible sites, we obtained the total number of vascular nurses employed so as to determine the number of eligible respondents. In this manner, a purposeful sample of vascular nurses at participating HMS hospitals was constituted.
Participation in the survey was solicited through hospital quality leads that either distributed an electronic survey link to vascular nurses at their facilities or sent us individual email addresses to contact them directly. A cover letter explaining the rationale and the purpose of the survey along with the survey link was then sent to respondents through either of these routes. The survey was administered at all HMS sites contemporaneously and kept open for a period of 5 weeks. During the 5‐week period, 2 e‐mail reminders were sent to encourage participation. As a token of appreciation, a $10 Amazon gift card was offered to those who took the survey.
Development and Validation of the Survey
We developed the survey instrument (which we call PICC1 as we hope to administer longitudinally to track changes over time) by first conducting a literature search to identify relevant evidence‐based guidelines and studies regarding vascular access nursing practices and experiences.[10, 11, 12, 13] In addition, we consulted and involved national and international leaders in vascular access nursing to ensure validity and representativeness of the questions posed. We were specifically interested in nursing background, hospital practices, types of PICCs used, use of various technologies, relationships with healthcare providers, and management of complications. To understand participant characteristics and quantify potential variation in responses, we collected basic participant data including demographics, years in practice, number of PICCs placed, leadership roles, and vascular access certification status. Based on clinical reasoning and existing studies,[14, 15] we hypothesized that responses regarding certain practices (ultrasound use, electrocardiography [ECG] guidance system use), management of complications, or perceptions regarding leadership might vary based on years of experience, number of PICCs placed, or certification status. We therefore examined these associations as prespecified subgroup analyses.
The initial survey instrument was pilot tested with vascular nurses outside of the sampling frame. Based on feedback from the pilot testers, the instrument was refined and edited to improve clarity of the questions. In addition, specific skip patterns and logic were programmed into the final survey to reduce respondent burden and allow participants to seamlessly bypass questions that were contingent on a prior response (eg, use of ECG to place PICCs would lead to a series of questions about ECG‐assisted placement only for those respondents who used the technology). This final version of the survey was tested by members of the study team (V.C., L.K., S.L.K.) and then posted to SurveyMonkey for dissemination.
Statistical Analysis
Descriptive statistics (percentage, n/N) were used to tabulate results. In accordance with our a priori hypothesis that variation to responses might be associated with respondent characteristics, responses to questions regarding insertion practice (eg, use of ultrasound, measurement of catheter:vein ratio, trimming of catheters) and approach to complications (eg, catheter occlusion, deep vein thrombosis [DVT] notification, and PICC removal in the setting of fever) were compared by respondent years in practice (dichotomized to <5 vs >5 years), volume of PICCs placed (<999 vs 1000), and certification status (yes/no). Bivariate comparisons were made using 2 or Fisher exact tests based on the number of responses in a cell as appropriate; 2‐sided with a P value <0.05 was considered statistically significant. All statistical analyses were conducted using SAS version 9.3 (SAS Institute, Cary, NC).
Ethical and Regulatory Oversight
Because our study sought to describe existing practice without collecting any individual or facility level identifiable information, the project received a Not Regulated status by the University of Michigan Medical School Institutional Review Board (HUM00088351).
RESULTS
Of 172 vascular nurses who received invitations, 140 completed the survey for a response rate of 81%. Respondents reported working in not‐for‐profit hospitals (36%), academic medical centers (29%), and for‐profit hospitals (21%). Although multiple providers (eg, interventional radiology staff and providers, physicians) placed PICCs, 95% of those surveyed reported that they placed the majority of the PICCs at their institutions. Although most respondents placed PICCs in adult patients (86%), a few also placed PICCs in pediatric populations (17%). Vascular nursing programs were largely housed in their own department, but some reported to general nursing or subspecialties such as interventional radiology, cardiology, and critical care. Most respondents indicated their facilities had written policies regarding standard insertion and care practices (87% and 95%, respectively), but only 30% had policies regarding the necessity or appropriateness of PICCs.
Experience among respondents was variable: approximately a third had placed PICCs for <5 years (28.6%), whereas 58% reported placing PICCs for 5 years Correspondingly, 26% reported having placed 100 to 500 PICCs, whereas 34% had placed 1000 or more PICCs. Only 23% of those surveyed held a dedicated vascular access certification, such as board certified in vascular access or certified registered nurse infusion, whereas 16% indicated that they served as the vascular access lead nurse for their facility. Following placement, 94% of respondents reported that their facilities tracked the number of PICCs inserted, but only 40% indicated that dwell times of devices were also recorded. Only 30% of nurses reported that their hospitals had a written policy to evaluate PICC necessity or appropriateness following placement (Table 1).
| No.* | % | |
|---|---|---|
| ||
| Participant characteristics | ||
| For how many years have you been inserting PICCs? | ||
| <5 years | 40 | 28.6% |
| 5 years | 81 | 57.9% |
| Missing | ||
| In which of the following populations do you insert PICCs? | ||
| Adult patients | 121 | 86.4% |
| Pediatric patients | 24 | 17.1% |
| Neonatal patients | 1 | 0.7% |
| In which of the following locations do you place PICCs? (Select all that apply.) | ||
| Adult medical ward | 115 | 82.1% |
| General adult surgical ward | 110 | 78.6% |
| General pediatric medical ward | 34 | 24.3% |
| General pediatric surgical ward | 24 | 17.1% |
| Adult intensive care unit | 114 | 81.4% |
| Pediatric intensive care unit | 19 | 13.6% |
| Neonatal intensive care unit | 3 | 2.1% |
| Other intensive care unit | 59 | 42.1% |
| Outpatient clinic or emergency department | 17 | 12.1% |
| Other | 10 | 7.1% |
| Approximately how many PICCs may you have placed in your career? | ||
| 099 | 15 | 10.7% |
| 100499 | 36 | 25.7% |
| 500999 | 23 | 16.4% |
| 1,000 | 47 | 33.6% |
| Are you the vascular access lead nurse for your facility or organization? | ||
| Yes | 22 | 15.7% |
| No | 98 | 70.0% |
| Do you currently hold a dedicated vascular access certification (BC‐VA, CRNI, etc.)? | ||
| Yes | 32 | 22.9% |
| No | 89 | 63.6% |
| Facility characteristics | ||
| Which of the following best describes your primary work location? | ||
| Academic medical center | 41 | 29.3% |
| For‐profit community‐based hospital or medical center | 30 | 21.4% |
| Not‐for‐profit community‐based hospital or medical center | 50 | 35.7% |
| Who inserts the most PICCs in your facility? | ||
| Vascular access nurses | 133 | 95.0% |
| Interventional radiology or other providers | 7 | 5.0% |
| In which department is vascular access nursing located? | ||
| Vascular nursing | 76 | 54.3% |
| General nursing | 38 | 27.1% |
| Interventional radiology | 15 | 10.7% |
| Other | 11 | 7.9% |
| Using your best guess, how many PICCs do you think your facility inserts each month? | ||
| <25 | 5 | 3.6% |
| 2549 | 13 | 9.3% |
| 50100 | 39 | 27.9% |
| >100 | 78 | 55.7% |
| Unknown | 2 | 1.4% |
| How many vascular access nurses are employed by your facility? | ||
| <4 | 14 | 10.0% |
| 46 | 33 | 23.6% |
| 79 | 15 | 10.7% |
| 1015 | 25 | 17.9% |
| >15 | 53 | 37.9% |
| Does your facility track the number of PICCs placed? | ||
| Yes | 132 | 94.3% |
| No | 5 | 3.6% |
| Unknown | 3 | 2.1% |
| Does your facility track the duration or dwell time of PICCs? | ||
| Yes | 56 | 40.0% |
| No | 60 | 42.9% |
| Unknown | 24 | 17.1% |
| Does your facility have a written policy regarding standard PICC insertion practices? | ||
| Yes | 122 | 87.1% |
| No | 8 | 5.7% |
| Unknown | 7 | 5.0% |
| Does your facility have a written policy regarding standard PICC care and maintenance? | ||
| Yes | 133 | 95.0% |
| No | 3 | 2.1% |
| Unknown | 1 | 0.7% |
| Does your facility have a written process to review the necessity or appropriateness of a PICC? | ||
| Yes | 42 | 30.0% |
| No | 63 | 45.0% |
| Unknown | 20 | 14.3% |
The most commonly reported indications for PICC placement included intravenous antibiotics at discharge, difficult venous access, and placement for chemotherapy in patients with cancer. Forty‐six percent of nurses indicated they had placed a PICC in a patient receiving some form of dialysis in the past several months; however, 91% of these respondents reported receiving approval from nephrology prior to placement in these patients. Although almost all nurses (91%) used ultrasound to find a suitable vein for PICC placement, a smaller percentage used ultrasound to estimate the catheter‐to‐vein ratio to prevent thrombosis (79%), and only a few (14%) documented this figure in the medical record. Three‐quarters of those surveyed (76%) indicated they used ECG‐based systems to position PICC tips at the cavoatrial junction to prevent thrombosis. Of those who used this technology, 36% still obtained chest x‐rays to verify the position of the PICC tip. According to 84% of respondents, flushing of PICCs was performed mainly by bedside nurses, whereas scheduled weekly dressing changes were most often performed by vascular access nurses (Table 2).
| Question | No. | % |
|---|---|---|
| ||
| Do you use ultrasound to find a suitable vein prior to PICC insertion? | ||
| Yes | 128 | 91.4% |
| No | 0 | 0.0% |
| Do you use ultrasound to estimate the catheter‐to‐vein ratio prior to PICC insertion? | ||
| Yes | 110 | 78.6% |
| No | 18 | 12.9% |
| When using ultrasound, do you document the catheter‐to‐vein ratio in the PICC insertion note? | ||
| Yes | 20 | 14.3% |
| No | 89 | 63.6% |
| Do you use ECG guidance‐assisted systems to place PICCs? | ||
| Yes | 106 | 75.7% |
| No | 21 | 15.0% |
| If using ECG guidance, do you still routinely obtain a chest x‐ray to verify PICC tip position after placing the PICC using ECG guidance? | ||
| Yes | 38 | 27.1% |
| No | 68 | 48.6% |
| Who is primarily responsible for administering and adhering to a flushing protocol after PICC insertion at your facility? | ||
| Bedside nurses | 118 | 83.6% |
| Patients | 1 | 0.7% |
| Vascular access nurses | 8 | 5.7% |
| Which of the following agents are most often used to flush PICCs? | ||
| Both heparin and normal saline flushes | 61 | 43.6% |
| Normal saline only | 63 | 45.0% |
| Heparin only | 3 | 2.1% |
| Who is responsible for scheduled weekly dressing changes for PICCs? | ||
| Vascular access nurses | 110 | 78.6% |
| Bedside nurses | 14 | 10.0% |
| Other (eg, IR staff, ICU staff) | 3 | 2.1% |
| In the past few months, have you placed a PICC in a patient who was receiving a form of dialysis (eg, peritoneal or hemodialysis)? | ||
| Yes | 65 | 46.4% |
| No | 64 | 45.7% |
| If you have placed PICCs in patients on dialysis, do you discuss PICC placement or receive approval from nephrology prior to inserting the PICC? | ||
| Yes | 59 | 90.8% |
| No | 6 | 9.2% |
With respect to complications, catheter occlusion, migration, and DVT were reported as the 3 most prevalent adverse events. Interestingly, respondents did not report central lineassociated bloodstream infection (CLABSI) as a common complication. Additionally, 51% of those surveyed indicated that physicians unnecessarily removed PICCs when CLABSI was suspected but not confirmed. When managing catheter occlusion, 50% of respondents began with normal saline flushes but used tissue‐plasminogen activator if saline failed to resolve occlusion. Management of catheter migration varied based on degree of device movement: when the PICC had migrated <5 cm, most respondents (77%) indicated they would first obtain a chest x‐ray to determine the position of the PICC tip, with few (4%) performing catheter exchange. However, if the PICC had migrated more than 5 cm, a significantly greater proportion of respondents (21%) indicated they would perform a catheter exchange. With regard to managing DVT, most vascular nurses reported they notified nurses and physicians to continue using the PICC but recommended tests to confirm the diagnosis.
To better understand the experiences of vascular nurses, we asked for their perceptions regarding appropriateness of PICC use and relationships with bedside nurses, physicians, and leadership. Over a third of respondents (36%) felt that <5% of all PICCs may be inappropriate in their facility, whereas 1 in 5 indicated that 10% to 24% of PICCs placed in their facilities may be inappropriate or could have been avoided. Almost all (98%) of the nurses stated they were not empowered to remove idle or clinically unnecessary PICCs without physician authorization. Although 51% of nurses described the support received from hospital leadership as excellent, very good, or good, 43% described leadership support as either fair or poor. Conversely, relationships with bedside nurses and physicians were rated as being very good or good by nearly two‐thirds of those surveyed (64% and 65%, respectively) (Table 3).
| Question | No. | % |
|---|---|---|
| ||
| Which of the following PICC‐related complications have you most frequently encountered in your practice? | ||
| Catheter occlusion | 81 | 57.9% |
| Catheter migration | 27 | 19.3% |
| PICC‐associated DVT | 6 | 4.3% |
| Catheter fracture or embolization | 3 | 2.1% |
| Exit site infection | 3 | 2.1% |
| Coiling or kinking after insertion | 2 | 1.4% |
| If you suspect a patient has catheter occlusion, which of the following best describes your approach to resolving this problem? | ||
| Begin with normal saline but use a tPA product if this fails to restore patency | 70 | 50.0% |
| Use a tPA product (eg, Cathflo, Activase, or Retavase) to restore patency | 44 | 31.4% |
| Begin with heparin‐based flushes but use a tPA product if this fails to restore | 7 | 5.0% |
| Use only normal saline flushes to restore patency | 3 | 2.1% |
| If you find a PICC that has migrated out or has been accidentally dislodged <5 cm in a patient without symptoms, and the device is still clinically needed, which of the following best describes your practice? | ||
| Obtain a chest x‐ray to verify tip position | 108 | 77.1% |
| Perform a complete catheter exchange over a guidewire if possible | 5 | 3.6% |
| Notify/discuss next steps with physician | 5 | 3.6% |
| Other | 6 | 4.3% |
| If you find a PICC that has migrated out or has been accidentally dislodged >5 cm in a patient without symptoms, and the device is still clinically needed, which of the following best describes your practice? | ||
| Obtain a chest x‐ray to verify tip position | 72 | 51.4% |
| Perform a catheter exchange over a guidewire if possible | 30 | 21.4% |
| Notify/discuss next steps with physician | 10 | 7.1% |
| Other | 12 | 8.6% |
| Which of the following best describes your first approach when you suspect a patient has PICC‐associated phlebitis? | ||
| Discuss best course of action with physician or nurse | 79 | 56.4% |
| Supportive measures (eg, warm compresses, analgesics, monitoring) | 25 | 17.9% |
| Remove the PICC | 15 | 10.7% |
| Other | 5 | 3.6% |
| Which of the following best describes your first approach when you suspect a patient has a PICC‐related DVT? | ||
| Notify caregivers to continue using PICC and consider tests such as ultrasound | 82 | 58.6% |
| Notify bedside nurse and physician not to continue use of the PICC and consider tests such as ultrasound | 42 | 30.0% |
| PICCs are often removed when physicians suspect, but have not yet confirmed, CLABSI. Considering your experiences, what percentage of PICCs may have been removed in this manner at your facility? | ||
| <5% | 11 | 7.9% |
| 59% | 16 | 11.4% |
| 1024% | 24 | 17.1% |
| 25% | 71 | 50.7% |
| Based on your experience, what percentage of PICCs do you think are inappropriate or could have been avoided at your facility? | ||
| <5% | 51 | 36.4% |
| 59% | 25 | 17.9% |
| 1024% | 28 | 20.0% |
| 2550% | 13 | 9.3% |
| >50% | 5 | 3.6% |
| Are vascular access nurses empowered to remove PICCs that are idle or clinically unnecessary without physician authorization? | ||
| Yes | 3 | 2.1% |
| No | 122 | 87.1% |
| How would you rank the overall support your vascular access service receives from hospital leadership? | ||
| Excellent | 5 | 3.6% |
| Very good | 32 | 22.9% |
| Good | 40 | 28.6% |
| Fair | 35 | 25.0% |
| Poor | 25 | 17.9% |
| How would you describe your relationship with physicians at your facility when it comes to communicating recommendations or management of PICCs? | ||
| Very good | 28 | 20.0% |
| Good | 63 | 45.0% |
| Fair | 35 | 25.0% |
| Poor | 7 | 5.0% |
| Very poor | 4 | 2.9% |
| How would you describe your relationship with bedside nurses at your facility when it comes to communicating recommendations or management of PICCs? | ||
| Very good | 32 | 22.9% |
| Good | 58 | 41.4% |
| Fair | 38 | 27.1% |
| Poor | 7 | 5.0% |
| Very poor | 2 | 1.4% |
Variation in Responses Based on Years in Practice or Certification
We initially hypothesized that responses regarding practice (ultrasound use, ECG guidance system use), management of complications, or perceptions regarding leadership might vary based on years of experience, number of PICCs placed, or certification status. However, no statistically significant associations with these factors and individual responses were identified.
DISCUSSION
In this survey of 140 vascular access nurses in hospitals across Michigan, new insights regarding the experience, practice, knowledge, and beliefs of this group of providers were obtained. We found that vascular access nurses varied with respect to years in practice, volume of PICCs placed, and certification status, reflecting heterogeneity in this provider group. Variation in insertion techniques, such as use of ultrasound to examine catheter‐to‐vein ratio (a key way to prevent thrombosis) or newer ECG technology to position the PICC, was also noted. Although indications for PICC insertion appeared consistent with published literature, the frequency with which these devices were placed in patients receiving dialysis (reportedly with nephrology approval) was surprising given national calls to avoid such use.[16] Opportunities to improve hospital practices, such as tracking PICC dwell times and PICC necessity, as well as the potential need to better educate physicians on when to remove PICCs for suspected CLABSI, were also identified. Collectively, these data are highly relevant to hospitalists and health systems as they help to identify areas for quality improvement and inform clinical practice regarding the use of PICCs in hospitalized patients. As hospitalists increasingly order PICCs and manage complications associated with these devices, they are well suited to use these data so as to improve patient safety and clinical outcomes.
Venous access is the most common medical procedure performed in hospitalized medical patients. Although a number of devices including peripheral intravenous catheters, central venous catheters, and PICCs are used for this purpose, the growing use of PICCs to secure venous access has been documented in several studies.[17] Such growth, in part, undoubtedly reflects increasing availability of vascular access nurses. Traditionally placed by interventional radiologists, the creation of dedicated vascular nursing teams has resulted in these subspecialists now serving in more of a backup or trouble‐shooting role rather than that of primary operator.[4, 14] This paradigm shift is well illustrated in a recent survey of infection preventionists, where over 60% of respondents reported that they had a vascular nursing team in their facility.[7] The growth of these nursing‐led vascular access teams has produced not only high rates of insertion success and low rates of complications, but also greater cost‐effectiveness when compared to interventional radiologybased insertion.[18]
Nonetheless, our survey also identified a number of important concerns regarding PICC practices and vascular nursing providers. First, we found variation in areas such as insertion practices and management of complications. Such variability highlights the importance of both growing and disseminating the evidence base for consistent practice in vascular nursing. Through their close clinical affiliation with vascular nurses and shared interests in obtaining safe and appropriate venous access for patients, hospitalists are ideally poised to lead this effort. Second, similarities between vascular nurse opinions regarding appropriateness of PICCs and those of hospitalists from a prior survey were noted.[19] Namely, a substantial proportion of both vascular nurses and hospitalists felt that some PICCs were inappropriate and could be avoided. Third, although relationships between vascular access nurses and leadership were reported as being variable, the survey responses suggested relatively good interprovider relationships with bedside nurses and physicians. Such relationships likely reflect the close clinical ties that emerge from being in the trenches of patient care and suggest that interventions to improve care in partnership with these providers are highly viable.
Our study has some limitations. First, despite a high response rate, our study used a survey design and reports findings from a convenience sample of vascular access nurses in a single state. Thus, nonrespondent and selection biases remain threats to our conclusions. Additionally, some respondents did not complete all responses, perhaps due to nonapplicability to practice or other unknown reasons. The pattern of missingness observed, however, suggested that such responses were missing at random. Second, we surveyed vascular nurses in hospitals that are actively engaged in improving PICC practices; our findings may therefore not be representative of vascular nursing professionals as a whole and may instead reflect those of a highly motivated group of individuals. Relatedly, the underlying reasons for adoption of specific practices or techniques cannot be discerned from our study. Third, although we did not find differences based on years in practice or certification status, our sample size was relatively small and likely underpowered for these comparisons. Finally, our study sample consists of vascular nurses who are clustered within hospitals in which they are employed. Therefore, overlap between reported practices and those required by the facility are possible.
Despite these limitations, our study has important strengths. First, this is among the most comprehensive of surveys examining vascular nursing experience, practice, knowledge, and beliefs. The growing presence of these providers across US hospitals, coupled with limited insight regarding their clinical practices, highlight the importance and utility of these data. Second, we noted important differences in experience, practices, and interprovider relationships between vascular providers in this field. Although we are unable to ascertain the drivers or significance of such variation, hospitals and health systems focused on improving patient safety should consider quantifying and exploring these factors. Third, findings from our survey within Michigan suggest the need for similar, larger studies across the country. Partnerships with nursing organizations or larger professional groups that represent vascular nursing specialists may be helpful in this regard.
In conclusion, we found important similarities and differences in vascular nursing experience, practice, knowledge, and beliefs in Michigan. These data are useful as they help provide context regarding the constitution of these teams, current practices, and opportunities for improving care. Hospitalists seeking to improve patient safety may use these data to better inform vascular access practice in hospitalized patients.
Acknowledgements
The authors thank Claire Rickard, PhD, RN, Britt Meyer, RN, Peter Carr, PhD, and David Dempsey, RN for their assistance in developing the survey instrument used in this study.
Disclosures: This project was funded through an Investigator Initiated Research Grant from the Blue Cross Blue Shield of Michigan (BCBSM) Foundation (grant number 2140.II). The funding source played no role in study design, data acquisition, analysis, or reporting of the data. Support for the Hospital Medicine Safety (HMS) Consortium is provided by BCBSM and the Blue Care Network as part of the BCBSM Value Partnerships program. Although BCBSM and HMS work collaboratively, the opinions, beliefs, and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees. This work was also supported with resources from the Veterans Affairs Ann Arbor Healthcare System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
- , , , et al. Peripherally inserted central venous catheters in the acute care setting: a safe alternative to high‐risk short‐term central venous catheters. Am J Infect Control. 2010;38(2):149–153.
- , , , , . Risk of venous thromboembolism in hospitalized patients with peripherally inserted central catheters. J Hosp Med. 2009;4(7):417–422.
- , , , , , . Central venous catheter placement by advanced practice nurses demonstrates low procedural complication and infection rates‐‐a report from 13 years of service. Crit Care Med. 2014;42(3):536–543.
- . Developing an alternative workflow model for peripherally inserted central catheter placement. J Infus Nurs. 2012;34(1):34–42.
- , . Facility wide benefits of radiology vascular access teams. Radiol Manage. 2010;32(1):28–32; quiz 33–34.
- , . Moving the needle forward: the imperative for collaboration in vascular access. J Infus Nurs. 2015;38(2):100–102.
- , , , . Use of designated PICC teams by U.S. hospitals: a survey‐based study [published online November 10, 2015]. J Patient Saf. doi: 10.1097/PTS.0000000000000246
- , , , , . The association between PICC use and venous thromboembolism in upper and lower extremities. American J Med. 2015;128(9):986–993.e1.
- , , , et al. Hospital performance for pharmacologic venous thromboembolism prophylaxis and rate of venous thromboembolism: a cohort study. JAMA Intern Med. 2014;174(10):1577–1584.
- , , , et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta‐analysis. Lancet. 2013;382(9889):311–325.
- Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2006;29(1 suppl):S1–S92.
- , , , et al. Guidelines for the prevention of intravascular catheter‐related infections. Am J Infect Control. 2011;39(4 suppl 1):S1–S34.
- , , , et al. International evidence‐based recommendations on ultrasound‐guided vascular access. Intensive Care Med. 2012;38(7):1105–1117.
- , , . A single institution experience of seven hundred consecutively placed peripherally inserted central venous catheters. J Vasc Access. 2014;15(6):498–502.
- , , . Central venous access devices site care practices: an international survey of 34 countries [published online September 3, 2015]. J Vasc Access. doi: 10.5301/jva.5000450
- American Society of Nephrology. World's Leading Kidney Society Joins Effort to Reduce Unnecessary Medical Tests and Procedures. Available at: https://www.asn‐online.org/policy/choosingwisely/PressReleaseChoosingWisely.pdf. Accessed September 4, 2015.
- , , , . A survey of the current use of peripherally inserted central venous catheter (PICC) in Swedish oncology departments. Acta Oncol. 2013;52(6):1241–1242.
- , . Nurse‐led PICC insertion: is it cost effective? Br J Nurs. 2013;22(19):S9–S15.
- , , , et al. Hospitalist experiences, practice, opinions, and knowledge regarding peripherally inserted central catheters: a Michigan survey. J Hosp Med. 2013;8(6):309–314.
- , , , et al. Peripherally inserted central venous catheters in the acute care setting: a safe alternative to high‐risk short‐term central venous catheters. Am J Infect Control. 2010;38(2):149–153.
- , , , , . Risk of venous thromboembolism in hospitalized patients with peripherally inserted central catheters. J Hosp Med. 2009;4(7):417–422.
- , , , , , . Central venous catheter placement by advanced practice nurses demonstrates low procedural complication and infection rates‐‐a report from 13 years of service. Crit Care Med. 2014;42(3):536–543.
- . Developing an alternative workflow model for peripherally inserted central catheter placement. J Infus Nurs. 2012;34(1):34–42.
- , . Facility wide benefits of radiology vascular access teams. Radiol Manage. 2010;32(1):28–32; quiz 33–34.
- , . Moving the needle forward: the imperative for collaboration in vascular access. J Infus Nurs. 2015;38(2):100–102.
- , , , . Use of designated PICC teams by U.S. hospitals: a survey‐based study [published online November 10, 2015]. J Patient Saf. doi: 10.1097/PTS.0000000000000246
- , , , , . The association between PICC use and venous thromboembolism in upper and lower extremities. American J Med. 2015;128(9):986–993.e1.
- , , , et al. Hospital performance for pharmacologic venous thromboembolism prophylaxis and rate of venous thromboembolism: a cohort study. JAMA Intern Med. 2014;174(10):1577–1584.
- , , , et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta‐analysis. Lancet. 2013;382(9889):311–325.
- Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2006;29(1 suppl):S1–S92.
- , , , et al. Guidelines for the prevention of intravascular catheter‐related infections. Am J Infect Control. 2011;39(4 suppl 1):S1–S34.
- , , , et al. International evidence‐based recommendations on ultrasound‐guided vascular access. Intensive Care Med. 2012;38(7):1105–1117.
- , , . A single institution experience of seven hundred consecutively placed peripherally inserted central venous catheters. J Vasc Access. 2014;15(6):498–502.
- , , . Central venous access devices site care practices: an international survey of 34 countries [published online September 3, 2015]. J Vasc Access. doi: 10.5301/jva.5000450
- American Society of Nephrology. World's Leading Kidney Society Joins Effort to Reduce Unnecessary Medical Tests and Procedures. Available at: https://www.asn‐online.org/policy/choosingwisely/PressReleaseChoosingWisely.pdf. Accessed September 4, 2015.
- , , , . A survey of the current use of peripherally inserted central venous catheter (PICC) in Swedish oncology departments. Acta Oncol. 2013;52(6):1241–1242.
- , . Nurse‐led PICC insertion: is it cost effective? Br J Nurs. 2013;22(19):S9–S15.
- , , , et al. Hospitalist experiences, practice, opinions, and knowledge regarding peripherally inserted central catheters: a Michigan survey. J Hosp Med. 2013;8(6):309–314.
© 2015 Society of Hospital Medicine
USPSTF urges extra step before treating hypertension
Screening for and treating high blood pressure (HBP) to prevent cardiovascular and renal disease is a tried-and-true preventive intervention that is supported by strong evidence. And not surprisingly, when the US Preventive Services Task Force (USPSTF) recently updated its 2007 recommendation for blood pressure screening for adults, it once again gave an A recommendation for those ages 18 years and older. What is noteworthy, however, is that this update concentrates on the accuracy of blood pressure measurement methods and optimal frequency of screening.1
The most significant modification of past recommendations is that HBP found with office measurement of blood pressure (OMBP) should be confirmed with either ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) before starting treatment. (For its recommendation, the USPSTF used the HBP definition from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [TABLE 1].2,3)
Ensuring accurate blood-pressure measurements. More than 30% of adults in the United States have HBP, with prevalence increasing with age (TABLE 2).2 Only about half of this population has HBP under control.4 This modifiable condition contributes to more than 360,000 deaths annually.2 However, while treatment of true HBP results in substantial benefits, it is important not to over-diagnose HBP and over-treat it.
Studies have shown that 15% to 30% of individuals diagnosed with HBP in a clinical setting will have blood pressure in the normal range when measurements are taken outside of the doctor’s office.1 This discrepancy can be due to measurement error, regression to the mean, recent caffeine ingestion by the patient, or isolated clinical hypertension wherein the stress and anxiety caused by clinic visits elevates blood pressure transiently.
With this in mind, the USPSTF recommends that OMBP-detected HBP be confirmed with either ABPM or HBPM. Of these 2 follow-up methods, ABPM is supported by stronger evidence and is preferred. The USPSTF includes HBPM as an alternative because ABPM equipment may not always be available—or affordable—and using the equipment may present logistical challenges.
Starting off on the right foot
Screening for HBP in a clinical setting is more accurate if conducted according to recommended procedures: use an appropriately sized cuff; take the measurement at least 5 minutes after the patient’s arrival while he or she is seated with legs uncrossed and the cuffed arm is at the level of the heart; and record the mean of 2 separate measurements. There appears to be no real difference in the accuracy of automated vs manual sphygmomanometers.
Optimal frequency of screening varies. While the USPSTF found little evidence to support any particular overall screening frequency, it recommends annual screening for those who are 40 years of age or older and those ages 18 to 39 who are obese or overweight, are African American, or who have high-normal blood pressure (TABLE 3).1 Screening every 3 to 5 years is recommended for individuals not in these categories.
Initial steps in treating HBP. The Task Force also commented on which medications to use when initiating HBP treatment (after lifestyle and dietary interventions). Non-African Americans should receive a thiazide diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin-receptor blocker. African Americans should begin treatment with a thiazide diuretic or calcium channel blocker. These recommendations appear to have been adopted from the Eighth Joint National Committee, since the accompanying evidence report for the USPSTF’s update did not address this issue.5
Don't forget patient support
Patient support is key. As of June 2015, the Community Preventive Services Task Force (CPSTF) recommends self-measured blood pressure monitoring combined with additional support as a means of improving blood pressure control in those with HBP.4
Supportive measures include things such as patient counseling on medications and health behavior changes (eg, diet and exercise); education on HBP and blood pressure self-management; and use of secure electronic or Web-based tools such as text or e-mail reminders to measure blood pressure, show up for appointments, or communicate blood pressure readings to healthcare providers. Patients who participate in home self-measurement of blood pressure with additional support lower their systolic blood pressure, on average, 1.4 mm Hg more than those who do not.4
Remaining questions
The new USPSTF recommendation leaves several issues unaddressed. For one thing, the Affordable Care Act mandates that commercial health insurance plans provide services with an A or B Task Force recommendation to patients with no copayments. So does the new HBP recommendation mean payers have to make ABPM and HBPM available to patients at no charge?
There are other questions, too. If HBP detected by OMBP is not confirmed when ABPM is performed, should ABPM be repeated, and if so, at what interval? What is the role of emerging technologies that use devices other than arm cuffs to measure blood pressure?
Despite these uncertainties, the new USPSTF and CPSTF recommendations refine the longstanding in-office–only approach to diagnosing and monitoring HBP and advocate newer technologies that could help improve diagnostic accuracy, avoid over-diagnosis and over-treatment, and improve patient adherence to treatment goals.
1. US Preventive Services Task Force. High blood pressure in adults: screening. Available at: http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/high-blood-pressure-in-adults-screening. Accessed November 24, 2015.
2. Piper MA, Evans CV, Burda BU, et al. Screening for high blood pressure in adults: a systematic evidence review for the U.S. Preventive Services Task Force. Available at: http://www.ncbi.nlm.nih.gov/books/NBK269495/. Accessed November 24, 2015.
3. US Department of Health and Human Services. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Available at: http://www.nhlbi.nih.gov/files/docs/guidelines/jnc7full.pdf. Accessed November 24, 2015.
4. Community Preventive Services Task Force. Cardiovascular disease prevention and control: self-measured blood pressure monitoring interventions for improved blood pressure control — when combined with additional support. Available at: http://www.thecommunityguide.org/cvd/SMBP-additional.html. Accessed November 24, 2015.
5. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC8). JAMA. 2014;311:507-520.
Screening for and treating high blood pressure (HBP) to prevent cardiovascular and renal disease is a tried-and-true preventive intervention that is supported by strong evidence. And not surprisingly, when the US Preventive Services Task Force (USPSTF) recently updated its 2007 recommendation for blood pressure screening for adults, it once again gave an A recommendation for those ages 18 years and older. What is noteworthy, however, is that this update concentrates on the accuracy of blood pressure measurement methods and optimal frequency of screening.1
The most significant modification of past recommendations is that HBP found with office measurement of blood pressure (OMBP) should be confirmed with either ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) before starting treatment. (For its recommendation, the USPSTF used the HBP definition from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [TABLE 1].2,3)
Ensuring accurate blood-pressure measurements. More than 30% of adults in the United States have HBP, with prevalence increasing with age (TABLE 2).2 Only about half of this population has HBP under control.4 This modifiable condition contributes to more than 360,000 deaths annually.2 However, while treatment of true HBP results in substantial benefits, it is important not to over-diagnose HBP and over-treat it.
Studies have shown that 15% to 30% of individuals diagnosed with HBP in a clinical setting will have blood pressure in the normal range when measurements are taken outside of the doctor’s office.1 This discrepancy can be due to measurement error, regression to the mean, recent caffeine ingestion by the patient, or isolated clinical hypertension wherein the stress and anxiety caused by clinic visits elevates blood pressure transiently.
With this in mind, the USPSTF recommends that OMBP-detected HBP be confirmed with either ABPM or HBPM. Of these 2 follow-up methods, ABPM is supported by stronger evidence and is preferred. The USPSTF includes HBPM as an alternative because ABPM equipment may not always be available—or affordable—and using the equipment may present logistical challenges.
Starting off on the right foot
Screening for HBP in a clinical setting is more accurate if conducted according to recommended procedures: use an appropriately sized cuff; take the measurement at least 5 minutes after the patient’s arrival while he or she is seated with legs uncrossed and the cuffed arm is at the level of the heart; and record the mean of 2 separate measurements. There appears to be no real difference in the accuracy of automated vs manual sphygmomanometers.
Optimal frequency of screening varies. While the USPSTF found little evidence to support any particular overall screening frequency, it recommends annual screening for those who are 40 years of age or older and those ages 18 to 39 who are obese or overweight, are African American, or who have high-normal blood pressure (TABLE 3).1 Screening every 3 to 5 years is recommended for individuals not in these categories.
Initial steps in treating HBP. The Task Force also commented on which medications to use when initiating HBP treatment (after lifestyle and dietary interventions). Non-African Americans should receive a thiazide diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin-receptor blocker. African Americans should begin treatment with a thiazide diuretic or calcium channel blocker. These recommendations appear to have been adopted from the Eighth Joint National Committee, since the accompanying evidence report for the USPSTF’s update did not address this issue.5
Don't forget patient support
Patient support is key. As of June 2015, the Community Preventive Services Task Force (CPSTF) recommends self-measured blood pressure monitoring combined with additional support as a means of improving blood pressure control in those with HBP.4
Supportive measures include things such as patient counseling on medications and health behavior changes (eg, diet and exercise); education on HBP and blood pressure self-management; and use of secure electronic or Web-based tools such as text or e-mail reminders to measure blood pressure, show up for appointments, or communicate blood pressure readings to healthcare providers. Patients who participate in home self-measurement of blood pressure with additional support lower their systolic blood pressure, on average, 1.4 mm Hg more than those who do not.4
Remaining questions
The new USPSTF recommendation leaves several issues unaddressed. For one thing, the Affordable Care Act mandates that commercial health insurance plans provide services with an A or B Task Force recommendation to patients with no copayments. So does the new HBP recommendation mean payers have to make ABPM and HBPM available to patients at no charge?
There are other questions, too. If HBP detected by OMBP is not confirmed when ABPM is performed, should ABPM be repeated, and if so, at what interval? What is the role of emerging technologies that use devices other than arm cuffs to measure blood pressure?
Despite these uncertainties, the new USPSTF and CPSTF recommendations refine the longstanding in-office–only approach to diagnosing and monitoring HBP and advocate newer technologies that could help improve diagnostic accuracy, avoid over-diagnosis and over-treatment, and improve patient adherence to treatment goals.
Screening for and treating high blood pressure (HBP) to prevent cardiovascular and renal disease is a tried-and-true preventive intervention that is supported by strong evidence. And not surprisingly, when the US Preventive Services Task Force (USPSTF) recently updated its 2007 recommendation for blood pressure screening for adults, it once again gave an A recommendation for those ages 18 years and older. What is noteworthy, however, is that this update concentrates on the accuracy of blood pressure measurement methods and optimal frequency of screening.1
The most significant modification of past recommendations is that HBP found with office measurement of blood pressure (OMBP) should be confirmed with either ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) before starting treatment. (For its recommendation, the USPSTF used the HBP definition from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [TABLE 1].2,3)
Ensuring accurate blood-pressure measurements. More than 30% of adults in the United States have HBP, with prevalence increasing with age (TABLE 2).2 Only about half of this population has HBP under control.4 This modifiable condition contributes to more than 360,000 deaths annually.2 However, while treatment of true HBP results in substantial benefits, it is important not to over-diagnose HBP and over-treat it.
Studies have shown that 15% to 30% of individuals diagnosed with HBP in a clinical setting will have blood pressure in the normal range when measurements are taken outside of the doctor’s office.1 This discrepancy can be due to measurement error, regression to the mean, recent caffeine ingestion by the patient, or isolated clinical hypertension wherein the stress and anxiety caused by clinic visits elevates blood pressure transiently.
With this in mind, the USPSTF recommends that OMBP-detected HBP be confirmed with either ABPM or HBPM. Of these 2 follow-up methods, ABPM is supported by stronger evidence and is preferred. The USPSTF includes HBPM as an alternative because ABPM equipment may not always be available—or affordable—and using the equipment may present logistical challenges.
Starting off on the right foot
Screening for HBP in a clinical setting is more accurate if conducted according to recommended procedures: use an appropriately sized cuff; take the measurement at least 5 minutes after the patient’s arrival while he or she is seated with legs uncrossed and the cuffed arm is at the level of the heart; and record the mean of 2 separate measurements. There appears to be no real difference in the accuracy of automated vs manual sphygmomanometers.
Optimal frequency of screening varies. While the USPSTF found little evidence to support any particular overall screening frequency, it recommends annual screening for those who are 40 years of age or older and those ages 18 to 39 who are obese or overweight, are African American, or who have high-normal blood pressure (TABLE 3).1 Screening every 3 to 5 years is recommended for individuals not in these categories.
Initial steps in treating HBP. The Task Force also commented on which medications to use when initiating HBP treatment (after lifestyle and dietary interventions). Non-African Americans should receive a thiazide diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin-receptor blocker. African Americans should begin treatment with a thiazide diuretic or calcium channel blocker. These recommendations appear to have been adopted from the Eighth Joint National Committee, since the accompanying evidence report for the USPSTF’s update did not address this issue.5
Don't forget patient support
Patient support is key. As of June 2015, the Community Preventive Services Task Force (CPSTF) recommends self-measured blood pressure monitoring combined with additional support as a means of improving blood pressure control in those with HBP.4
Supportive measures include things such as patient counseling on medications and health behavior changes (eg, diet and exercise); education on HBP and blood pressure self-management; and use of secure electronic or Web-based tools such as text or e-mail reminders to measure blood pressure, show up for appointments, or communicate blood pressure readings to healthcare providers. Patients who participate in home self-measurement of blood pressure with additional support lower their systolic blood pressure, on average, 1.4 mm Hg more than those who do not.4
Remaining questions
The new USPSTF recommendation leaves several issues unaddressed. For one thing, the Affordable Care Act mandates that commercial health insurance plans provide services with an A or B Task Force recommendation to patients with no copayments. So does the new HBP recommendation mean payers have to make ABPM and HBPM available to patients at no charge?
There are other questions, too. If HBP detected by OMBP is not confirmed when ABPM is performed, should ABPM be repeated, and if so, at what interval? What is the role of emerging technologies that use devices other than arm cuffs to measure blood pressure?
Despite these uncertainties, the new USPSTF and CPSTF recommendations refine the longstanding in-office–only approach to diagnosing and monitoring HBP and advocate newer technologies that could help improve diagnostic accuracy, avoid over-diagnosis and over-treatment, and improve patient adherence to treatment goals.
1. US Preventive Services Task Force. High blood pressure in adults: screening. Available at: http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/high-blood-pressure-in-adults-screening. Accessed November 24, 2015.
2. Piper MA, Evans CV, Burda BU, et al. Screening for high blood pressure in adults: a systematic evidence review for the U.S. Preventive Services Task Force. Available at: http://www.ncbi.nlm.nih.gov/books/NBK269495/. Accessed November 24, 2015.
3. US Department of Health and Human Services. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Available at: http://www.nhlbi.nih.gov/files/docs/guidelines/jnc7full.pdf. Accessed November 24, 2015.
4. Community Preventive Services Task Force. Cardiovascular disease prevention and control: self-measured blood pressure monitoring interventions for improved blood pressure control — when combined with additional support. Available at: http://www.thecommunityguide.org/cvd/SMBP-additional.html. Accessed November 24, 2015.
5. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC8). JAMA. 2014;311:507-520.
1. US Preventive Services Task Force. High blood pressure in adults: screening. Available at: http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/high-blood-pressure-in-adults-screening. Accessed November 24, 2015.
2. Piper MA, Evans CV, Burda BU, et al. Screening for high blood pressure in adults: a systematic evidence review for the U.S. Preventive Services Task Force. Available at: http://www.ncbi.nlm.nih.gov/books/NBK269495/. Accessed November 24, 2015.
3. US Department of Health and Human Services. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Available at: http://www.nhlbi.nih.gov/files/docs/guidelines/jnc7full.pdf. Accessed November 24, 2015.
4. Community Preventive Services Task Force. Cardiovascular disease prevention and control: self-measured blood pressure monitoring interventions for improved blood pressure control — when combined with additional support. Available at: http://www.thecommunityguide.org/cvd/SMBP-additional.html. Accessed November 24, 2015.
5. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC8). JAMA. 2014;311:507-520.
What Should Hospitalists Know about Surgical Tubes and Drains?
Case
A 45-year-old woman was admitted with choledocholithiasis. Two days prior, following endoscopic retrograde cholangiopancreatography (ERCP), she had gone to the OR for cholecystectomy. The procedure was completed laparoscopically, though the surgeon reported a difficult dissection. The surgeon left a Blake drain in the gallbladder fossa, which initially contained punch-colored fluid. Today, there is bilious fluid in the drain.
Overview
Surgical drains are used to monitor for postoperative leaks or abscesses, to collect normal physiologic fluid, or to minimize dead space. A hospitalist caring for surgical patients may be the first provider to note when something changes in the color or volume of surgical drains. Table 1 lists various types of drains with their indications for use.
Surgical Tubes and Drains
Chest tubes. Chest tubes are placed in the pleural space to evacuate air or fluid. They can be as thin as 20 French or as thick as 40 French (for adults). Chest tubes are typically placed between the fourth and fifth intercostal spaces in the anterior axillary or mid-axillary line; however, the location may vary according to the indication for placement. The tubes can be straight or angled.
The tubes are connected to a collecting system with a three-way chamber. The water chamber holds a column of water, which prevents air from being sucked into the pleural space with inhalation. The suction chamber can be attached to continuous wall suction to remove air or fluid, or it can be placed on “water seal” with no active suction mechanism. The third chamber is the collection chamber for fluid drainage.
Indications for a chest tube include pneumothorax, hemothorax, or a persistent or large pleural effusion. Pneumothorax and hemothorax usually require immediate chest tube placement. Chest tubes are also commonly placed at the end of thoracic surgeries to allow for appropriate re-expansion of the lung tissue.
A chest X-ray should be obtained after any chest tube insertion to ensure appropriate placement. Chest tubes are equipped with a radiopaque line along the longitudinal axis, which should be visible on X-ray. Respiratory variation in the fluid in the collecting tube, called “tidling,” should also be seen in a correctly placed chest tube, and should be monitored at the bedside to reassure continued appropriate location. The interventional radiologist or surgeon who placed the tube should determine the subsequent frequency of serial chest X-rays required to monitor the location of the chest tube.
If the patient has a pneumothorax, air bubbles will be visible in the water chamber; called an air leak, these are often more apparent when the patient coughs. The chest tube should initially be set to continuous suction at -20 mmHg to evacuate the air. Once the air leak has stopped, the chest tube should be placed on water seal to confirm resolution of the pneumothorax (water seal mimics normal physiology). If, after the transition from suction to water seal, resumption of the air leak is noted, it may indicate recurrence of the patient’s pneumothorax. A stat chest X-ray should be obtained, and the chest tube should be placed back on continuous suction. In general, a chest X-ray should be obtained any time the chest tube is changed from suction to water seal or vice versa.
If the patient experiences ongoing or worsening pain, fever, or inadequate drainage, a chest computed tomographic (CT) scan may be warranted to identify inappropriate positioning or other complications, such as occlusion or effusion of the tube. Blood or other debris might clog chest tubes; the surgical team may be able to evacuate the tube with suction tubing at the bedside. If unsuccessful, the tube may need to be removed and reinserted.
The team that placed the tube should help the hospitalist determine the timing of the chest tube removal. If the patient has a pleural effusion, the chest tube can usually be removed when the output is less than 100-200 mL per day and the lung is expanded. The tube should usually be taken off suction and placed on water seal to rule out pneumothorax prior to tube removal.
Penrose drains. Penrose drains are often used to drain fluid or to keep a space open for drainage. Surgeons may use sutures to anchor Penrose drains to skin. Common indications include:
- Ventral hernia repair;
- Debridement of infected pancreatitis; and
- Drainage of superficial abscess cavities.
Penrose drains are simple, flexible tubes that are open at both ends; in contrast to closed drains, they permit ingress as well as egress, facilitating colonization.
Closed suction drains. Closed suction drains with a plastic bulb attachment (i.e., Jackson-Pratt, Blake, Hemovac) are used to collect fluid from a postoperative cavity. Common indications include:
- Post-mastectomy to drain subcutaneous fluid;
- Abdominal surgery;
- Plastic surgery to prevent seroma formation and promote tissue apposition;
- Cholecystectomy if there is concern for damage to ducts of Luschka or other source of bile leak;
- Inadvertent postoperative leakage following a difficult rectal anastomosis; and
- Post-pancreatic surgery.
The quality and quantity of fluid drained should always be carefully noted and recorded. Changes in the fluid can imply development of bleed, leak, or other complications. The surgical team should be contacted immediately if changes are noted.
Typically, closed suction drains will be left in place until the drainage is less than 20 mL per day. These drains can be left in for weeks if necessary and will often be removed during the patient’s scheduled surgical follow-up. Rare complications include erosion into surrounding tissues and inadvertent suturing of the drain in place, such that reexploration is required to remove it. If a closed suction drain becomes occluded, contact the team that placed the drain for further recommendations on adjustment, replacement, or removal.
Nasogastric and duodenal tubes. Nasogastric tubes (NGTs) are often used in the nonoperative management of small bowel obstruction or ileus. They should be placed in the most dependent portion of the gastric lumen and confirmed by chest or abdominal X-ray. NGTs are sump pumps and have a double lumen, which includes an air port to assure flow. The air port should be patent for optimal functioning. The tube may be connected to continuous wall suction or intermittent suction, set to low (less than 60 mmHg) to avoid mucosal avulsion.
NGT output should decrease during the resolution of obstruction or ileus, and symptoms of nausea, vomiting, and abdominal distention should concomitantly improve. Persistently high output in a patient with other indicators of bowel function (flatus, for example) may suggest postpyloric placement (and placement should be checked by X-ray). The timing of NGT removal depends on resumption of bowel function.
Gastrostomy and jejunostomy tubes. Gastrostomy tubes are most commonly used for feeding but may also be used for decompression of functional or anatomic gastric outlet obstruction. They are indicated when patients need prolonged enteral access, such as those with prolonged mechanical ventilation or head and neck pathology that prohibits oral feeding. They are also rarely used for gastropexy to tack an atonic or patulous stomach to the abdominal wall or to prevent recurrence of paraesophageal hernias. These tubes can be placed percutaneously by interventional radiologists, endoscopically by surgeons and gastroenterologists, or laparoscopically or laparotomally by surgeons. This last option is often reserved for patients with difficult anatomy or those who are having laparotomy for another reason.
Because of the stomach’s generous lumen, gastrostomy tubes rarely clog. In the event that they do get clogged, carbonated liquids, meat tenderizer, or enzymes can help dissolve the obstruction. If a gastrostomy tube is left to drain, the patient may experience significant fluid and electrolyte losses, so these need to be carefully monitored.
Jejunostomy tubes are used exclusively for feeding and are usually placed 10-20 cm distal to the ligament of Treitz. These tubes are indicated in patients who require distal feedings due to gastric dysfunction or in those who have undergone a surgery in which a proximal anastomosis requires time to heal. These tubes are more apt to clog and can be more difficult to manage because the lumen of the small bowel is smaller than the stomach. Some prefer not to put pills down the tube to mitigate this risk. Routine flushes with water or saline (30 mL every four to six hours) are also helpful in mitigating the risk of clogging. In the event that they do get clogged, they may be treated like gastrostomy tubes, using carbonated liquids, meat tenderizer, or enzymes to help dissolve the obstruction.
Percutaneous tube sites should be examined frequently for signs of infection. Though gastrostomy and jejunostomy tubes are typically well secured intraabdominally, they can become dislodged. If a gastrostomy or jejunostomy tube has been in place for more than two weeks, it can easily be replaced at the bedside with a tube of comparable caliber by a member of the surgical team or by an experienced hospitalist. If the tube has been in place less than two weeks, it requires replacement with radiographic guidance, as the risk of creating a false lumen is high. Over time, tubes can become loose and fall out. If they need replacement, the preceding guidelines apply.
Back to the Case
A potential major complication of cholecystectomy is severance of the common bile duct, which necessitates significant further surgery. Less severe complications include injuries to the cholecystohepatic ducts (otherwise known as the ducts of Luschka), which can result in leakage of bile into the peritoneal cavity. A bile leak can lead to abscess and systemic infection if left undrained.
Surgeons who are concerned for such a complication intraoperatively may opt to leave a closed suction drain in the gallbladder fossa, such as a Blake drain, for monitoring and subsequent drainage. The drain will remain in place at least until the patient’s diet has been advanced fully, because digestion promotes the secretion of bile and may elucidate a leak. Bilious fluid in the Blake drain is suspicious for a leak.
The surgeon should be notified, and imaging should be obtained to find the nature of the injury to the biliary tree (CT scan with IV contrast, hepatobiliary iminodiacetic acid scan, or endoscopic retrograde cholangiopancreatography). If injury to major biliary structures (the cystic duct stump, the hepatic ducts, or the common bile duct) is diagnosed, a stent may be placed in order to restore ductile continuity.
Minor leaks, with damage to the cystic duct stump, hepatic ducts, and common bile duct ruled out, more often resolve on their own over time, and thus the patient’s closed suction drain will be left in place until biliary drainage ceases, without further initial intervention.
Bottom Line
Surgical tubes and drains have several placement indications. Alterations in quality and quantity of output can indicate changes in clinical status, and hospitalists should be able to handle initial troubleshooting. TH
Dr. Columbus is a general surgery resident at Brigham and Women’s Hospital in Boston. Dr. Havens is an instructor for the department of surgery at Brigham and Women’s Hospital. Dr. Peetz is an instructor for the department of surgery at University Hospital Case Medical Center in Cleveland.
Case
A 45-year-old woman was admitted with choledocholithiasis. Two days prior, following endoscopic retrograde cholangiopancreatography (ERCP), she had gone to the OR for cholecystectomy. The procedure was completed laparoscopically, though the surgeon reported a difficult dissection. The surgeon left a Blake drain in the gallbladder fossa, which initially contained punch-colored fluid. Today, there is bilious fluid in the drain.
Overview
Surgical drains are used to monitor for postoperative leaks or abscesses, to collect normal physiologic fluid, or to minimize dead space. A hospitalist caring for surgical patients may be the first provider to note when something changes in the color or volume of surgical drains. Table 1 lists various types of drains with their indications for use.
Surgical Tubes and Drains
Chest tubes. Chest tubes are placed in the pleural space to evacuate air or fluid. They can be as thin as 20 French or as thick as 40 French (for adults). Chest tubes are typically placed between the fourth and fifth intercostal spaces in the anterior axillary or mid-axillary line; however, the location may vary according to the indication for placement. The tubes can be straight or angled.
The tubes are connected to a collecting system with a three-way chamber. The water chamber holds a column of water, which prevents air from being sucked into the pleural space with inhalation. The suction chamber can be attached to continuous wall suction to remove air or fluid, or it can be placed on “water seal” with no active suction mechanism. The third chamber is the collection chamber for fluid drainage.
Indications for a chest tube include pneumothorax, hemothorax, or a persistent or large pleural effusion. Pneumothorax and hemothorax usually require immediate chest tube placement. Chest tubes are also commonly placed at the end of thoracic surgeries to allow for appropriate re-expansion of the lung tissue.
A chest X-ray should be obtained after any chest tube insertion to ensure appropriate placement. Chest tubes are equipped with a radiopaque line along the longitudinal axis, which should be visible on X-ray. Respiratory variation in the fluid in the collecting tube, called “tidling,” should also be seen in a correctly placed chest tube, and should be monitored at the bedside to reassure continued appropriate location. The interventional radiologist or surgeon who placed the tube should determine the subsequent frequency of serial chest X-rays required to monitor the location of the chest tube.
If the patient has a pneumothorax, air bubbles will be visible in the water chamber; called an air leak, these are often more apparent when the patient coughs. The chest tube should initially be set to continuous suction at -20 mmHg to evacuate the air. Once the air leak has stopped, the chest tube should be placed on water seal to confirm resolution of the pneumothorax (water seal mimics normal physiology). If, after the transition from suction to water seal, resumption of the air leak is noted, it may indicate recurrence of the patient’s pneumothorax. A stat chest X-ray should be obtained, and the chest tube should be placed back on continuous suction. In general, a chest X-ray should be obtained any time the chest tube is changed from suction to water seal or vice versa.
If the patient experiences ongoing or worsening pain, fever, or inadequate drainage, a chest computed tomographic (CT) scan may be warranted to identify inappropriate positioning or other complications, such as occlusion or effusion of the tube. Blood or other debris might clog chest tubes; the surgical team may be able to evacuate the tube with suction tubing at the bedside. If unsuccessful, the tube may need to be removed and reinserted.
The team that placed the tube should help the hospitalist determine the timing of the chest tube removal. If the patient has a pleural effusion, the chest tube can usually be removed when the output is less than 100-200 mL per day and the lung is expanded. The tube should usually be taken off suction and placed on water seal to rule out pneumothorax prior to tube removal.
Penrose drains. Penrose drains are often used to drain fluid or to keep a space open for drainage. Surgeons may use sutures to anchor Penrose drains to skin. Common indications include:
- Ventral hernia repair;
- Debridement of infected pancreatitis; and
- Drainage of superficial abscess cavities.
Penrose drains are simple, flexible tubes that are open at both ends; in contrast to closed drains, they permit ingress as well as egress, facilitating colonization.
Closed suction drains. Closed suction drains with a plastic bulb attachment (i.e., Jackson-Pratt, Blake, Hemovac) are used to collect fluid from a postoperative cavity. Common indications include:
- Post-mastectomy to drain subcutaneous fluid;
- Abdominal surgery;
- Plastic surgery to prevent seroma formation and promote tissue apposition;
- Cholecystectomy if there is concern for damage to ducts of Luschka or other source of bile leak;
- Inadvertent postoperative leakage following a difficult rectal anastomosis; and
- Post-pancreatic surgery.
The quality and quantity of fluid drained should always be carefully noted and recorded. Changes in the fluid can imply development of bleed, leak, or other complications. The surgical team should be contacted immediately if changes are noted.
Typically, closed suction drains will be left in place until the drainage is less than 20 mL per day. These drains can be left in for weeks if necessary and will often be removed during the patient’s scheduled surgical follow-up. Rare complications include erosion into surrounding tissues and inadvertent suturing of the drain in place, such that reexploration is required to remove it. If a closed suction drain becomes occluded, contact the team that placed the drain for further recommendations on adjustment, replacement, or removal.
Nasogastric and duodenal tubes. Nasogastric tubes (NGTs) are often used in the nonoperative management of small bowel obstruction or ileus. They should be placed in the most dependent portion of the gastric lumen and confirmed by chest or abdominal X-ray. NGTs are sump pumps and have a double lumen, which includes an air port to assure flow. The air port should be patent for optimal functioning. The tube may be connected to continuous wall suction or intermittent suction, set to low (less than 60 mmHg) to avoid mucosal avulsion.
NGT output should decrease during the resolution of obstruction or ileus, and symptoms of nausea, vomiting, and abdominal distention should concomitantly improve. Persistently high output in a patient with other indicators of bowel function (flatus, for example) may suggest postpyloric placement (and placement should be checked by X-ray). The timing of NGT removal depends on resumption of bowel function.
Gastrostomy and jejunostomy tubes. Gastrostomy tubes are most commonly used for feeding but may also be used for decompression of functional or anatomic gastric outlet obstruction. They are indicated when patients need prolonged enteral access, such as those with prolonged mechanical ventilation or head and neck pathology that prohibits oral feeding. They are also rarely used for gastropexy to tack an atonic or patulous stomach to the abdominal wall or to prevent recurrence of paraesophageal hernias. These tubes can be placed percutaneously by interventional radiologists, endoscopically by surgeons and gastroenterologists, or laparoscopically or laparotomally by surgeons. This last option is often reserved for patients with difficult anatomy or those who are having laparotomy for another reason.
Because of the stomach’s generous lumen, gastrostomy tubes rarely clog. In the event that they do get clogged, carbonated liquids, meat tenderizer, or enzymes can help dissolve the obstruction. If a gastrostomy tube is left to drain, the patient may experience significant fluid and electrolyte losses, so these need to be carefully monitored.
Jejunostomy tubes are used exclusively for feeding and are usually placed 10-20 cm distal to the ligament of Treitz. These tubes are indicated in patients who require distal feedings due to gastric dysfunction or in those who have undergone a surgery in which a proximal anastomosis requires time to heal. These tubes are more apt to clog and can be more difficult to manage because the lumen of the small bowel is smaller than the stomach. Some prefer not to put pills down the tube to mitigate this risk. Routine flushes with water or saline (30 mL every four to six hours) are also helpful in mitigating the risk of clogging. In the event that they do get clogged, they may be treated like gastrostomy tubes, using carbonated liquids, meat tenderizer, or enzymes to help dissolve the obstruction.
Percutaneous tube sites should be examined frequently for signs of infection. Though gastrostomy and jejunostomy tubes are typically well secured intraabdominally, they can become dislodged. If a gastrostomy or jejunostomy tube has been in place for more than two weeks, it can easily be replaced at the bedside with a tube of comparable caliber by a member of the surgical team or by an experienced hospitalist. If the tube has been in place less than two weeks, it requires replacement with radiographic guidance, as the risk of creating a false lumen is high. Over time, tubes can become loose and fall out. If they need replacement, the preceding guidelines apply.
Back to the Case
A potential major complication of cholecystectomy is severance of the common bile duct, which necessitates significant further surgery. Less severe complications include injuries to the cholecystohepatic ducts (otherwise known as the ducts of Luschka), which can result in leakage of bile into the peritoneal cavity. A bile leak can lead to abscess and systemic infection if left undrained.
Surgeons who are concerned for such a complication intraoperatively may opt to leave a closed suction drain in the gallbladder fossa, such as a Blake drain, for monitoring and subsequent drainage. The drain will remain in place at least until the patient’s diet has been advanced fully, because digestion promotes the secretion of bile and may elucidate a leak. Bilious fluid in the Blake drain is suspicious for a leak.
The surgeon should be notified, and imaging should be obtained to find the nature of the injury to the biliary tree (CT scan with IV contrast, hepatobiliary iminodiacetic acid scan, or endoscopic retrograde cholangiopancreatography). If injury to major biliary structures (the cystic duct stump, the hepatic ducts, or the common bile duct) is diagnosed, a stent may be placed in order to restore ductile continuity.
Minor leaks, with damage to the cystic duct stump, hepatic ducts, and common bile duct ruled out, more often resolve on their own over time, and thus the patient’s closed suction drain will be left in place until biliary drainage ceases, without further initial intervention.
Bottom Line
Surgical tubes and drains have several placement indications. Alterations in quality and quantity of output can indicate changes in clinical status, and hospitalists should be able to handle initial troubleshooting. TH
Dr. Columbus is a general surgery resident at Brigham and Women’s Hospital in Boston. Dr. Havens is an instructor for the department of surgery at Brigham and Women’s Hospital. Dr. Peetz is an instructor for the department of surgery at University Hospital Case Medical Center in Cleveland.
Case
A 45-year-old woman was admitted with choledocholithiasis. Two days prior, following endoscopic retrograde cholangiopancreatography (ERCP), she had gone to the OR for cholecystectomy. The procedure was completed laparoscopically, though the surgeon reported a difficult dissection. The surgeon left a Blake drain in the gallbladder fossa, which initially contained punch-colored fluid. Today, there is bilious fluid in the drain.
Overview
Surgical drains are used to monitor for postoperative leaks or abscesses, to collect normal physiologic fluid, or to minimize dead space. A hospitalist caring for surgical patients may be the first provider to note when something changes in the color or volume of surgical drains. Table 1 lists various types of drains with their indications for use.
Surgical Tubes and Drains
Chest tubes. Chest tubes are placed in the pleural space to evacuate air or fluid. They can be as thin as 20 French or as thick as 40 French (for adults). Chest tubes are typically placed between the fourth and fifth intercostal spaces in the anterior axillary or mid-axillary line; however, the location may vary according to the indication for placement. The tubes can be straight or angled.
The tubes are connected to a collecting system with a three-way chamber. The water chamber holds a column of water, which prevents air from being sucked into the pleural space with inhalation. The suction chamber can be attached to continuous wall suction to remove air or fluid, or it can be placed on “water seal” with no active suction mechanism. The third chamber is the collection chamber for fluid drainage.
Indications for a chest tube include pneumothorax, hemothorax, or a persistent or large pleural effusion. Pneumothorax and hemothorax usually require immediate chest tube placement. Chest tubes are also commonly placed at the end of thoracic surgeries to allow for appropriate re-expansion of the lung tissue.
A chest X-ray should be obtained after any chest tube insertion to ensure appropriate placement. Chest tubes are equipped with a radiopaque line along the longitudinal axis, which should be visible on X-ray. Respiratory variation in the fluid in the collecting tube, called “tidling,” should also be seen in a correctly placed chest tube, and should be monitored at the bedside to reassure continued appropriate location. The interventional radiologist or surgeon who placed the tube should determine the subsequent frequency of serial chest X-rays required to monitor the location of the chest tube.
If the patient has a pneumothorax, air bubbles will be visible in the water chamber; called an air leak, these are often more apparent when the patient coughs. The chest tube should initially be set to continuous suction at -20 mmHg to evacuate the air. Once the air leak has stopped, the chest tube should be placed on water seal to confirm resolution of the pneumothorax (water seal mimics normal physiology). If, after the transition from suction to water seal, resumption of the air leak is noted, it may indicate recurrence of the patient’s pneumothorax. A stat chest X-ray should be obtained, and the chest tube should be placed back on continuous suction. In general, a chest X-ray should be obtained any time the chest tube is changed from suction to water seal or vice versa.
If the patient experiences ongoing or worsening pain, fever, or inadequate drainage, a chest computed tomographic (CT) scan may be warranted to identify inappropriate positioning or other complications, such as occlusion or effusion of the tube. Blood or other debris might clog chest tubes; the surgical team may be able to evacuate the tube with suction tubing at the bedside. If unsuccessful, the tube may need to be removed and reinserted.
The team that placed the tube should help the hospitalist determine the timing of the chest tube removal. If the patient has a pleural effusion, the chest tube can usually be removed when the output is less than 100-200 mL per day and the lung is expanded. The tube should usually be taken off suction and placed on water seal to rule out pneumothorax prior to tube removal.
Penrose drains. Penrose drains are often used to drain fluid or to keep a space open for drainage. Surgeons may use sutures to anchor Penrose drains to skin. Common indications include:
- Ventral hernia repair;
- Debridement of infected pancreatitis; and
- Drainage of superficial abscess cavities.
Penrose drains are simple, flexible tubes that are open at both ends; in contrast to closed drains, they permit ingress as well as egress, facilitating colonization.
Closed suction drains. Closed suction drains with a plastic bulb attachment (i.e., Jackson-Pratt, Blake, Hemovac) are used to collect fluid from a postoperative cavity. Common indications include:
- Post-mastectomy to drain subcutaneous fluid;
- Abdominal surgery;
- Plastic surgery to prevent seroma formation and promote tissue apposition;
- Cholecystectomy if there is concern for damage to ducts of Luschka or other source of bile leak;
- Inadvertent postoperative leakage following a difficult rectal anastomosis; and
- Post-pancreatic surgery.
The quality and quantity of fluid drained should always be carefully noted and recorded. Changes in the fluid can imply development of bleed, leak, or other complications. The surgical team should be contacted immediately if changes are noted.
Typically, closed suction drains will be left in place until the drainage is less than 20 mL per day. These drains can be left in for weeks if necessary and will often be removed during the patient’s scheduled surgical follow-up. Rare complications include erosion into surrounding tissues and inadvertent suturing of the drain in place, such that reexploration is required to remove it. If a closed suction drain becomes occluded, contact the team that placed the drain for further recommendations on adjustment, replacement, or removal.
Nasogastric and duodenal tubes. Nasogastric tubes (NGTs) are often used in the nonoperative management of small bowel obstruction or ileus. They should be placed in the most dependent portion of the gastric lumen and confirmed by chest or abdominal X-ray. NGTs are sump pumps and have a double lumen, which includes an air port to assure flow. The air port should be patent for optimal functioning. The tube may be connected to continuous wall suction or intermittent suction, set to low (less than 60 mmHg) to avoid mucosal avulsion.
NGT output should decrease during the resolution of obstruction or ileus, and symptoms of nausea, vomiting, and abdominal distention should concomitantly improve. Persistently high output in a patient with other indicators of bowel function (flatus, for example) may suggest postpyloric placement (and placement should be checked by X-ray). The timing of NGT removal depends on resumption of bowel function.
Gastrostomy and jejunostomy tubes. Gastrostomy tubes are most commonly used for feeding but may also be used for decompression of functional or anatomic gastric outlet obstruction. They are indicated when patients need prolonged enteral access, such as those with prolonged mechanical ventilation or head and neck pathology that prohibits oral feeding. They are also rarely used for gastropexy to tack an atonic or patulous stomach to the abdominal wall or to prevent recurrence of paraesophageal hernias. These tubes can be placed percutaneously by interventional radiologists, endoscopically by surgeons and gastroenterologists, or laparoscopically or laparotomally by surgeons. This last option is often reserved for patients with difficult anatomy or those who are having laparotomy for another reason.
Because of the stomach’s generous lumen, gastrostomy tubes rarely clog. In the event that they do get clogged, carbonated liquids, meat tenderizer, or enzymes can help dissolve the obstruction. If a gastrostomy tube is left to drain, the patient may experience significant fluid and electrolyte losses, so these need to be carefully monitored.
Jejunostomy tubes are used exclusively for feeding and are usually placed 10-20 cm distal to the ligament of Treitz. These tubes are indicated in patients who require distal feedings due to gastric dysfunction or in those who have undergone a surgery in which a proximal anastomosis requires time to heal. These tubes are more apt to clog and can be more difficult to manage because the lumen of the small bowel is smaller than the stomach. Some prefer not to put pills down the tube to mitigate this risk. Routine flushes with water or saline (30 mL every four to six hours) are also helpful in mitigating the risk of clogging. In the event that they do get clogged, they may be treated like gastrostomy tubes, using carbonated liquids, meat tenderizer, or enzymes to help dissolve the obstruction.
Percutaneous tube sites should be examined frequently for signs of infection. Though gastrostomy and jejunostomy tubes are typically well secured intraabdominally, they can become dislodged. If a gastrostomy or jejunostomy tube has been in place for more than two weeks, it can easily be replaced at the bedside with a tube of comparable caliber by a member of the surgical team or by an experienced hospitalist. If the tube has been in place less than two weeks, it requires replacement with radiographic guidance, as the risk of creating a false lumen is high. Over time, tubes can become loose and fall out. If they need replacement, the preceding guidelines apply.
Back to the Case
A potential major complication of cholecystectomy is severance of the common bile duct, which necessitates significant further surgery. Less severe complications include injuries to the cholecystohepatic ducts (otherwise known as the ducts of Luschka), which can result in leakage of bile into the peritoneal cavity. A bile leak can lead to abscess and systemic infection if left undrained.
Surgeons who are concerned for such a complication intraoperatively may opt to leave a closed suction drain in the gallbladder fossa, such as a Blake drain, for monitoring and subsequent drainage. The drain will remain in place at least until the patient’s diet has been advanced fully, because digestion promotes the secretion of bile and may elucidate a leak. Bilious fluid in the Blake drain is suspicious for a leak.
The surgeon should be notified, and imaging should be obtained to find the nature of the injury to the biliary tree (CT scan with IV contrast, hepatobiliary iminodiacetic acid scan, or endoscopic retrograde cholangiopancreatography). If injury to major biliary structures (the cystic duct stump, the hepatic ducts, or the common bile duct) is diagnosed, a stent may be placed in order to restore ductile continuity.
Minor leaks, with damage to the cystic duct stump, hepatic ducts, and common bile duct ruled out, more often resolve on their own over time, and thus the patient’s closed suction drain will be left in place until biliary drainage ceases, without further initial intervention.
Bottom Line
Surgical tubes and drains have several placement indications. Alterations in quality and quantity of output can indicate changes in clinical status, and hospitalists should be able to handle initial troubleshooting. TH
Dr. Columbus is a general surgery resident at Brigham and Women’s Hospital in Boston. Dr. Havens is an instructor for the department of surgery at Brigham and Women’s Hospital. Dr. Peetz is an instructor for the department of surgery at University Hospital Case Medical Center in Cleveland.