Dr. Hospitalist

In this age of cost containment and fiscal frugality, how do you handle high-census periods without jeopardizing patient care?

–Michael P. Mason, Tulsa, Okla.

Dr. Hospitalist responds:

Your group must first define the term “high census,” because workload is based on many factors. Seeing 20 patients a day in a large inner-city hospital is much different from seeing 20 patients in a suburban hospital in an affluent part of town. Also, seeing 20 patients geographically located on the same floor is much easier than 20 patients spread all over the hospital. Mid-level or nurse case-management support also makes a difference.

Once defined, there are many different ways to handle the high census; each hospitalist group must decide what works for them.

Many groups rely on their compensation structure to entice their physicians to see higher numbers of patients. The pay structure may be production-based and entice many of the group members to see more patients. Typically, for the member that does not want to see the large volumes, there are usually colleagues who are more than happy to cover the excess patients.

Some groups employ a hybrid system, with their compensation based on production and salary. Generally, bonuses or incentives are applied after meeting a specific relative value unit (RVU) threshold. These thresholds vary and usually are raised periodically based on the percentage of staff able to collect. Again, some group members may volunteer to see the excess patients for higher compensation. It is up to the group to develop mechanisms to measure the quality of care of these high producers and monitor for burnout.

Then there are groups that have no volume incentives and everyone is paid a salary. Many groups that utilize any of these compensation models have group members “on call” to come in when needed and see the excess patients. Many pay the on-call person some nominal amount just for being on call, or a per-patient or hourly rate if they have to come in. Others make it a mandatory part of the schedule without any additional compensation.

Many groups have integrated advanced-practice providers (nurse practitioners and physician assistants) into their systems. They can help hospitalists improve efficiency by seeing patients that are less ill or awaiting placement, or by performing such labor-intensive tasks as admissions and discharges.

HM groups should collaborate with the hospital’s chief financial officer. Like clinicians, most administrators recognize it is very difficult to deliver high-quality and efficient care when the numbers get high. It is in their best interest to help devise strategies and models that deliver quality care and the metrics needed to sustain support.

HM has become such a large specialty that there is no-one-size-fits-all solution to high censuses. In the end, you have to be comfortable with the system created by your group, work to help improve it, or seek a better fit.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Hospitalist

In this age of cost containment and fiscal frugality, how do you handle high-census periods without jeopardizing patient care?

–Michael P. Mason, Tulsa, Okla.

Dr. Hospitalist responds:

Your group must first define the term “high census,” because workload is based on many factors. Seeing 20 patients a day in a large inner-city hospital is much different from seeing 20 patients in a suburban hospital in an affluent part of town. Also, seeing 20 patients geographically located on the same floor is much easier than 20 patients spread all over the hospital. Mid-level or nurse case-management support also makes a difference.

Once defined, there are many different ways to handle the high census; each hospitalist group must decide what works for them.

Many groups rely on their compensation structure to entice their physicians to see higher numbers of patients. The pay structure may be production-based and entice many of the group members to see more patients. Typically, for the member that does not want to see the large volumes, there are usually colleagues who are more than happy to cover the excess patients.

Some groups employ a hybrid system, with their compensation based on production and salary. Generally, bonuses or incentives are applied after meeting a specific relative value unit (RVU) threshold. These thresholds vary and usually are raised periodically based on the percentage of staff able to collect. Again, some group members may volunteer to see the excess patients for higher compensation. It is up to the group to develop mechanisms to measure the quality of care of these high producers and monitor for burnout.

Then there are groups that have no volume incentives and everyone is paid a salary. Many groups that utilize any of these compensation models have group members “on call” to come in when needed and see the excess patients. Many pay the on-call person some nominal amount just for being on call, or a per-patient or hourly rate if they have to come in. Others make it a mandatory part of the schedule without any additional compensation.

Many groups have integrated advanced-practice providers (nurse practitioners and physician assistants) into their systems. They can help hospitalists improve efficiency by seeing patients that are less ill or awaiting placement, or by performing such labor-intensive tasks as admissions and discharges.

HM groups should collaborate with the hospital’s chief financial officer. Like clinicians, most administrators recognize it is very difficult to deliver high-quality and efficient care when the numbers get high. It is in their best interest to help devise strategies and models that deliver quality care and the metrics needed to sustain support.

HM has become such a large specialty that there is no-one-size-fits-all solution to high censuses. In the end, you have to be comfortable with the system created by your group, work to help improve it, or seek a better fit.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Hospitalist

In this age of cost containment and fiscal frugality, how do you handle high-census periods without jeopardizing patient care?

–Michael P. Mason, Tulsa, Okla.

Dr. Hospitalist responds:

Your group must first define the term “high census,” because workload is based on many factors. Seeing 20 patients a day in a large inner-city hospital is much different from seeing 20 patients in a suburban hospital in an affluent part of town. Also, seeing 20 patients geographically located on the same floor is much easier than 20 patients spread all over the hospital. Mid-level or nurse case-management support also makes a difference.

Once defined, there are many different ways to handle the high census; each hospitalist group must decide what works for them.

Many groups rely on their compensation structure to entice their physicians to see higher numbers of patients. The pay structure may be production-based and entice many of the group members to see more patients. Typically, for the member that does not want to see the large volumes, there are usually colleagues who are more than happy to cover the excess patients.

Some groups employ a hybrid system, with their compensation based on production and salary. Generally, bonuses or incentives are applied after meeting a specific relative value unit (RVU) threshold. These thresholds vary and usually are raised periodically based on the percentage of staff able to collect. Again, some group members may volunteer to see the excess patients for higher compensation. It is up to the group to develop mechanisms to measure the quality of care of these high producers and monitor for burnout.

Then there are groups that have no volume incentives and everyone is paid a salary. Many groups that utilize any of these compensation models have group members “on call” to come in when needed and see the excess patients. Many pay the on-call person some nominal amount just for being on call, or a per-patient or hourly rate if they have to come in. Others make it a mandatory part of the schedule without any additional compensation.

Many groups have integrated advanced-practice providers (nurse practitioners and physician assistants) into their systems. They can help hospitalists improve efficiency by seeing patients that are less ill or awaiting placement, or by performing such labor-intensive tasks as admissions and discharges.

HM groups should collaborate with the hospital’s chief financial officer. Like clinicians, most administrators recognize it is very difficult to deliver high-quality and efficient care when the numbers get high. It is in their best interest to help devise strategies and models that deliver quality care and the metrics needed to sustain support.

HM has become such a large specialty that there is no-one-size-fits-all solution to high censuses. In the end, you have to be comfortable with the system created by your group, work to help improve it, or seek a better fit.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

SHM’s new Learning Portal (www.shmlearningportal.org) enables hospitalists to earn online continuing-medical-education (CME) credits online from anywhere. And it lets hospitalists track CME—earned from SHM or any other organization—in one easy location.

Best of all: It’s free for SHM members.

Access to the Learning Portal is an SHM member benefit, and many of the online CME courses are free as well. Others are provided at a reduced price.

Upon logging in, hospitalists can take advantage of the easy-to-use website with the most recent courses, maintenance-of-certification (MOC) courses, and recent user activity in a familiar “dashboard” format. Users can also take courses at their own pace, pausing educational activities and picking them up later. The transcript function within the Learning Portal is a one-stop destination for tracking CME and coursework at any time.

The new Learning Portal also lets hospitalists monitor their individual state’s licensure requirements, tracking total CME required against the start and end dates of licensure.

In addition to being the new home for SHM’s online CME for hospitalists, it’s also the new home for SHM’s popular Hospital Quality & Patient Safety (HQPS) Online Academy. New users can access the materials through the Learning Portal, and current users still retain all their HQPS credit on the new platform.

Brendon Shank is SHM’s associate vice president of communications.

SHM’s new Learning Portal (www.shmlearningportal.org) enables hospitalists to earn online continuing-medical-education (CME) credits online from anywhere. And it lets hospitalists track CME—earned from SHM or any other organization—in one easy location.

Best of all: It’s free for SHM members.

Access to the Learning Portal is an SHM member benefit, and many of the online CME courses are free as well. Others are provided at a reduced price.

Upon logging in, hospitalists can take advantage of the easy-to-use website with the most recent courses, maintenance-of-certification (MOC) courses, and recent user activity in a familiar “dashboard” format. Users can also take courses at their own pace, pausing educational activities and picking them up later. The transcript function within the Learning Portal is a one-stop destination for tracking CME and coursework at any time.

The new Learning Portal also lets hospitalists monitor their individual state’s licensure requirements, tracking total CME required against the start and end dates of licensure.

In addition to being the new home for SHM’s online CME for hospitalists, it’s also the new home for SHM’s popular Hospital Quality & Patient Safety (HQPS) Online Academy. New users can access the materials through the Learning Portal, and current users still retain all their HQPS credit on the new platform.

Brendon Shank is SHM’s associate vice president of communications.

SHM’s new Learning Portal (www.shmlearningportal.org) enables hospitalists to earn online continuing-medical-education (CME) credits online from anywhere. And it lets hospitalists track CME—earned from SHM or any other organization—in one easy location.

Best of all: It’s free for SHM members.

Access to the Learning Portal is an SHM member benefit, and many of the online CME courses are free as well. Others are provided at a reduced price.

Upon logging in, hospitalists can take advantage of the easy-to-use website with the most recent courses, maintenance-of-certification (MOC) courses, and recent user activity in a familiar “dashboard” format. Users can also take courses at their own pace, pausing educational activities and picking them up later. The transcript function within the Learning Portal is a one-stop destination for tracking CME and coursework at any time.

The new Learning Portal also lets hospitalists monitor their individual state’s licensure requirements, tracking total CME required against the start and end dates of licensure.

In addition to being the new home for SHM’s online CME for hospitalists, it’s also the new home for SHM’s popular Hospital Quality & Patient Safety (HQPS) Online Academy. New users can access the materials through the Learning Portal, and current users still retain all their HQPS credit on the new platform.

Brendon Shank is SHM’s associate vice president of communications.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Perioperative SSRI use associated with adverse surgical outcomes
2. Copper-surfaced rooms reduce health-care-acquired infections
3. Glucocorticoid therapy for five days not inferior to 14 days for COPD exacerbation
4. Patient preference for participation in medical decision-making may be associated with increased resource utilization
5. Early parenteral nutrition in critically ill adults does not significantly affect mortality or infection rates
6. Aggressive fluid and sodium restriction in acute decompensated heart failure did not improve outcomes
7. Lower rate of pacemaker, defibrillator device-pocket hematoma without anticoagulation interruption
8. Prophylactic penicillin decreased risk of recurrent leg cellulitis
9. Universal ICU decolonization reduced rates of mrsa clinical isolates and bloodstream infection
10. Intensive blood-pressure lowering in intracerebral hemorrhage did not reduce death or severe disability

Perioperative SSRI Use Associated with Adverse Surgical Outcomes

Clinical question: Does selective serotonin reuptake inhibitor (SSRI) use during hospitalization for surgery increase the risk of adverse perioperative outcomes?

Background: SSRIs commonly are prescribed but are associated with a small but higher risk for hemorrhage, arrhythmia, and sudden death. Single-site studies have described an association between SSRIs and adverse perioperative outcomes, but larger studies utilizing a broad range of surgical cases are lacking.

Study design: Retrospective cohort study.

Setting: Three hundred hospitals concentrated in the Southern U.S.

Synopsis: Using the “Perspective” database, this study examined 530,416 patients age >18 years undergoing major elective surgery, 72,540 (13.7%) of whom received an SSRI. Regression analysis showed patients receiving an SSRI had higher odds of mortality (OR 1.2, 95% CI [1.07-1.36]), higher odds of 30-day readmission (OR 1.22 [1.18-1.26]), and higher odds for bleeding (1.09 [1.04-1.15]). When the analysis was restricted to only patients with a diagnosis of depression, a higher risk of bleeding and readmission persisted.

This study reaffirms an association but does not establish a causal relationship between SSRI use and adverse perioperative outcomes. SSRI use may be a surrogate for other factors, including more severe mood disorders, poorer functional status, or chronic pain. Additionally, no information has been provided as to optimal duration of withholding SSRIs preoperatively. As such, it may be premature for hospitalists involved in perioperative care to modify recommendations based on this study.

Bottom line: Perioperative SSRI use is associated with an increased risk of bleeding and 30-day readmission.

Citation: Auerbach AD, Vittinghoff E, Maselli J, et al. Perioperative use of selective serotonin reuptake inhibitors and risks for adverse outcomes of surgery. JAMA Intern Med. 2013;173(12):1075-1081.

Copper-Surfaced Rooms Reduce Health-Care-Acquired Infections

Clinical question: Can copper alloy surfaces in ICU rooms lower rates of health-care-acquired infections (HAIs)?

Background: Environmental contamination is a potential source of HAIs. Copper has intrinsic broad-spectrum antimicrobial properties. This study tests the efficacy copper-surfaced items in hospital rooms have in preventing HAIs.

Study design: Randomized controlled trial.

Setting: Medical ICUs at Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center in Charleston, and the Memorial Sloan Kettering Cancer Center in New York City.

Synopsis: Six hundred fifty ICU patients were randomized to receive care either in rooms with copper surfacing on commonly handled patient care objects or in traditional rooms. Patients were screened for methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE) on admission. The proportion of patients that developed either an HAI and/or MRSA or VRE colonization was significantly lower among patients in rooms with the copper-surfaced items (0.071 vs. 0.128; P=0.02). The rate of HAIs alone was also lower in the rooms with the copper (0.034 vs. 0.081; P=0.013).

A potential limitation to this study is that the rooms with copper items appeared different than traditional rooms, and therefore might have changed the behavior of health-care workers. Further, it is unclear how much copper surfacing would be necessary on general wards, where patients are more mobile. Still, HAIs are associated with longer lengths of stay and higher 30-day readmission rates, so these encouraging results warrant additional investigation into antimicrobial copper-alloy surfaces.

Bottom line: Copper-surfaced objects reduce HAI rates in ICU patients.

Citation: Salgado CD, Sepkowitz, KA, John JF, et al. Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit. Infect Control Hosp Epidemiol. 2013;34(5):479-486.

Glucocorticoid Therapy for Five Days Not Inferior to 14 Days for COPD Exacerbation

Clinical question: Do short-course glucocorticoids work as well as conventional long courses for COPD exacerbation?

Background: International guidelines advocate a seven- to 14-day treatment course with glucocorticoids for COPD exacerbation, but the optimal duration of treatment is not known, and there are potential risks associated with glucocorticoid exposure.

Study design: Randomized, noninferiority, multicenter trial.

Setting: Five Swiss teaching hospitals.

Synopsis: Three hundred fourteen patients presenting to the ED with acute COPD exacerbation and without a history of asthma were randomized to receive treatment with 40 mg prednisone daily for either five or 14 days in a placebo-controlled, double-blinded fashion. There was no significant difference in the primary endpoint of re-exacerbation within six months. Patients in the five-day glucocorticoid group compared with the 14-day group were exposed to significantly less glucocorticoid.

Bottom line: Treatment for five days with glucocorticoids was not inferior to 14 days for acute COPD exacerbations with regard to re-exacerbations within six months and resulted in less glucocorticoid exposure overall.

Citation: Leuppi JF, Schuetz P, Bingisser R, et al. Short-term vs. conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE Randomized Clinical Trial. JAMA. 2013;390(21):2223-2231.

Patient Preference for Participation in Medical Decision-Making May Be Associated with Increased Resource Utilization

Clinical question: Do patient preferences for participation in medical decision-making affect health-care utilization?

Background: Patient participation in medical decision-making has been associated with improved patient satisfaction and health outcomes. There is little evidence to support theories that patient preferences might decrease or increase health-care utilization.

Study design: Survey study in academic research setting.

Setting: University of Chicago Medical Center.

Synopsis: More than 21,700 patients admitted to a general internal-medicine service completed a survey that included questions regarding preferences about receiving medical information and participation in medical decision-making. Survey data were linked with administrative data, including length of stay and total hospitalization costs.

Most patients (96.3%) expressed interest in receiving information about their illness and treatment options, but the majority of patients (71.1%) also expressed a preference to leave medical decision-making to their physician. Patients who preferred to participate in medical decision-making had significantly longer hospital LOS and higher total hospitalization cost.

Bottom line: Participation in medical decision-making significantly increased LOS and total costs.

Citation: Tak HJ, Ruhnke GW, Meltzer DO. Association of patient preferences for participation in decision making with length of stay and costs among hospitalized patients. JAMA Intern Med. 2013;173(13):1195-1205. doi: 10.1001/jamainternmed.2013.6048.

Early Parenteral Nutrition in Critically Ill Adults Does Not Significantly Affect Mortality or Infection Rates

Clinical question: Does providing early parenteral nutrition to critically ill adults with short-term relative contraindications to early enteral nutrition affect outcomes?

Background: The appropriate use of parenteral nutrition in critically ill adults is controversial. A systematic review found that critically ill patients randomized to receive early parenteral nutrition had significantly lower mortality but increased infection rates compared with standard care. A large-scale randomized trial was necessary to confirm the results.

Study design: Multicenter, randomized, single-blinded, controlled trial.

Setting: ICUs in 31 tertiary-care and community hospitals in Australia and New Zealand.

Synopsis: Researchers randomized 1,372 critically ill adults with relative contraindications to early enteral nutrition upon admission to the ICU to receive early parenteral nutrition or standard care. Early parenteral nutrition was started an average of 44 minutes after randomization. Clinicians defined standard care, with most patients remaining unfed for 2.8 days after randomization. Results were analyzed by intention-to-treat analysis, and loss to follow-up was 1%.

There was no significant difference in the primary outcome of 60-day mortality. Early parenteral nutrition patients received significantly fewer days of invasive ventilation, but did not have shorter ICU or hospital stays. Early parenteral nutrition patients experienced significantly less muscle-wasting and fat loss. There was no significant difference in new infection rates.

Bottom line: Early parenteral nutrition in critically ill adults resulted in significantly fewer days of invasive mechanical ventilation but did not cause a significant difference in length of stay, infection rates, or 60-day mortality.

Citation: Doig GS, Simpson F, Sweetman EA, et al. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition. JAMA. 2013;309(20): 2130-2138.

Aggressive Fluid and Sodium Restriction in Acute Decompensated Heart Failure Did Not Improve Outcomes

Clinical question: Does aggressive fluid and sodium restriction in acute decompensated heart failure (ADHF) result in increased weight loss, improved clinical stability, or decreased 30-day readmission rate?

Background: Fluid and sodium restriction are standard nonpharmacologic measures used in the management of ADHF in hospitalized patients, despite an absence of data to support their efficacy.

Study design: Randomized, controlled clinical trial with blinded outcome assessments.

Setting: A public teaching hospital in Brazil.

Synopsis: Seventy-five patients hospitalized with ADHF were randomized to receive aggressive fluid (800 mL/day) and sodium restriction (800 mg/day) or liberal intake (at least 2.5 L/day fluid, 3 to 5 g/day sodium). There were no significant between-group differences in diuretic administration. The primary outcomes of weight loss and clinical stability at three days were not significantly different between the groups. The heart-failure-specific readmission rate at 30 days was not significantly different between the groups. The aggressive restriction group had significantly worse thirst.

The study is limited by the small fraction of patients enrolled (9.2% of 813 screened) and homogenous population. Additional confirmatory trials likely are needed to change the standard of care, but this study demonstrated that aggressive fluid and sodium restriction does not benefit hospitalized patients with ADHF.

Bottom line: Aggressive fluid and sodium restriction in hospitalized patients with ADHF does not result in improved short-term weight loss, clinical stability, or decreased 30-day readmission rate, but it does cause significantly worse thirst.

Citation: Aliti GB, Rabelo ER, Clausell N, et al. Aggressive fluid and sodium restriction in acute decompensated heart failure. JAMA Intern Med. 2013;173(12):1058-1064.

Lower Rate of Pacemaker, Defibrillator Device-Pocket Hematoma without Anticoagulation Interruption

Clinical question: Is it safer to place a pacemaker or implantable cardioverter-defibrillator (ICD) while on therapeutic warfarin versus bridging with heparin/low-molecular-weight heparin (LMWH)?

Background: Current guidelines recommend bridging with heparin or LMWH for patients at high risk for thromboembolic events around the time of pacemaker or ICD placement, but it is associated with significant risk of device-pocket hematoma. Some centers place pacemakers and ICDs without interruption of warfarin. However, there are limited data to support the safety of this approach.

Study design: Multicenter, single-blinded, randomized, controlled trial.

Setting: Seventeen centers in Canada and one center in Brazil.

Synopsis: Patients with a predicted annual risk of 5% of thromboembolism were randomized to continue anticoagulation with warfarin (median INR 2.3) or to bridge therapy with heparin or LMWH; they then evaluated the incidence of clinically significant hematoma requiring prolonged hospitalization, interruption of anticoagulation therapy, or further surgical intervention. After reviewing the data on 668 patients, the Data and Safety Monitoring Board recommended termination of the study given a significantly lower rate of device-pocket hematoma in the warfarin group (3.5%) compared with the bridge group (16%) with RR 0.19 (95% CI 0.10-0.36, P<0.001). Otherwise, major surgical and thromboembolic complications were rare and not significantly different in both groups.

Bottom line: Continued warfarin therapy was associated with significantly reduced incidence of device-pocket hematoma compared with bridge with heparin or LMWH.

Citation: Birnie DH, Healey JS, Wells GA, et al. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med. 2013;368(22):2084-2093.

Prophylactic Penicillin Decreased Risk of Recurrent Leg Cellulitis

Clinical question: Does prophylactic, low-dose penicillin prevent recurrent cellulitis in patients with a history of two or more episodes of cellulitis?

Background: Some guidelines recommend prophylactic antibiotics for recurrent leg cellulitis, but there is no large randomized trial to support this practice, and clinical opinion is mixed.

Study design: Double-blinded, randomized, controlled trial.

Setting: Twenty-eight hospitals in the United Kingdom and Ireland.

Synopsis: Researchers randomized 274 patients with recurrent episodes of leg cellulitis (at least two episodes within the previous three years) to low-dose penicillin (250 mg) or placebo for 12 months and followed them for more than three years. During the prophylactic period, the penicillin group had a 45% reduction in the risk of a repeat cellulitis as compared to placebo (22% vs. 37%), equivalent to a number needed to treat to prevent a first recurrent cellulitis of five. The number of repeat episodes of cellulitis was lower overall in penicillin compared with the placebo group (119 vs. 164, P=0.02), although no significant difference was noted during the three-year follow-up period.

Factors associated with prophylaxis failure included three or more previous episodes of cellulitis, body mass index of 33 kg/m² or higher, and the presence of edema. No significant difference in adverse events was noted between the groups. Complete follow-up data was not available for participants during the follow-up period. Further study is needed to assess the long-term adverse effects and the duration of prophylaxis needed.

Bottom line: Prophylactic penicillin was effective in preventing recurrent leg cellulitis without increasing adverse effects, but its protective effect gradually declined once discontinued.

Citation: Thomas KS, Crook AM, Nunn AJ, et al. Penicillin to prevent recurrent leg cellulitis. N Engl J Med. 2013;368(18):1695-1703.

Universal ICU Decolonization Reduced Rates of MRSA Clinical Isolates and Bloodstream Infection

Clinical question: What is the most effective decolonization strategy for reducing methicillin-resistant Staphylococcus aureus (MRSA) and other pathogens in ICUs?

Background: Studies have shown that daily chlorhexidine bathing of all patients in ICUs reduced MRSA acquisition and bloodstream infection from all pathogens. However, this universal strategy has not been compared to MRSA screening and contact precautions alone, or to targeted decolonization of MRSA carriers.

Study design: Cluster-randomized comparative-effectiveness trial.

Setting: Adult ICUs in 43 Hospital Corporation of America (HCA) hospitals in 16 states.

Synopsis: All adult ICUs in a given hospital were randomized to one of three infection prevention strategies: Group 1 continued MRSA screening and isolation; Group 2 performed screening, isolation, and decolonization of MRSA carriers; and Group 3 implemented universal decolonization with intranasal mupirocin and daily bathing with chlorhexidine-impregnated cloths but no screening.

Forty-three hospitals, including 74 ICUs and 74,256 patients, underwent randomization. Significant reductions in the primary outcome of ICU-attributable MRSA clinical isolates (excluding MRSA screening tests) and the secondary outcome of bloodstream infection due to any pathogen were demonstrated across the three groups. One bloodstream infection was prevented for every 54 patients who underwent decolonization. Formal cost-effectiveness analysis was not performed.

Bottom line: In the ICU, universal decolonization was more effective than screening and isolation or targeted decolonization in the reduction of clinical MRSA isolates and bloodstream infection due to any pathogen, although monitoring for emerging resistance is necessary.

Citation: Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265.

Intensive Blood-Pressure Lowering in Intracerebral Hemorrhage Did Not Reduce Death or Severe Disability

Clinical question: What is the efficacy and safety of early intensive blood-pressure lowering in patients with acute intracerebral hemorrhage?

Background: After intracerebral hemorrhage, blood pressure often becomes elevated and is a predictor of outcome. It is not known whether rapid lowering of blood pressure would improve outcome.

Study design: International, multicenter, prospective, randomized, open-treatment, blinded end-point trial.

Setting: One hundred forty-four hospitals in 21 countries.

Synopsis: Researchers randomly assigned 2,839 patients with intracerebral hemorrhage in the previous six hours to intensive blood-pressure lowering with target systolic blood pressure of <140 mmHg within one hour, or guideline-recommended treatment with target systolic blood pressure of <180 mmHg. The mean systolic blood pressure achieved was 150 mmHg in the intensive-treatment group and 164 mmHg in the standard-treatment group.

There was no significant difference between the two groups in the primary outcome of death or major disability. A pre-specified ordinal analysis of modified Rankin score (score of 0 indicates no symptoms; a score of 5 indicates severe disability) did show significantly lower modified Rankin scores with intensive treatment. There was no difference between the two groups in the rate of serious adverse events.

Bottom line: Early intensive blood-pressure lowering in patients with acute intracerebral hemorrhage did not reduce death or major disability, although there may be improved functional outcomes with intensive blood-pressure lowering.

Citation: Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-2365.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Perioperative SSRI use associated with adverse surgical outcomes
2. Copper-surfaced rooms reduce health-care-acquired infections
3. Glucocorticoid therapy for five days not inferior to 14 days for COPD exacerbation
4. Patient preference for participation in medical decision-making may be associated with increased resource utilization
5. Early parenteral nutrition in critically ill adults does not significantly affect mortality or infection rates
6. Aggressive fluid and sodium restriction in acute decompensated heart failure did not improve outcomes
7. Lower rate of pacemaker, defibrillator device-pocket hematoma without anticoagulation interruption
8. Prophylactic penicillin decreased risk of recurrent leg cellulitis
9. Universal ICU decolonization reduced rates of mrsa clinical isolates and bloodstream infection
10. Intensive blood-pressure lowering in intracerebral hemorrhage did not reduce death or severe disability

Perioperative SSRI Use Associated with Adverse Surgical Outcomes

Clinical question: Does selective serotonin reuptake inhibitor (SSRI) use during hospitalization for surgery increase the risk of adverse perioperative outcomes?

Background: SSRIs commonly are prescribed but are associated with a small but higher risk for hemorrhage, arrhythmia, and sudden death. Single-site studies have described an association between SSRIs and adverse perioperative outcomes, but larger studies utilizing a broad range of surgical cases are lacking.

Study design: Retrospective cohort study.

Setting: Three hundred hospitals concentrated in the Southern U.S.

Synopsis: Using the “Perspective” database, this study examined 530,416 patients age >18 years undergoing major elective surgery, 72,540 (13.7%) of whom received an SSRI. Regression analysis showed patients receiving an SSRI had higher odds of mortality (OR 1.2, 95% CI [1.07-1.36]), higher odds of 30-day readmission (OR 1.22 [1.18-1.26]), and higher odds for bleeding (1.09 [1.04-1.15]). When the analysis was restricted to only patients with a diagnosis of depression, a higher risk of bleeding and readmission persisted.

This study reaffirms an association but does not establish a causal relationship between SSRI use and adverse perioperative outcomes. SSRI use may be a surrogate for other factors, including more severe mood disorders, poorer functional status, or chronic pain. Additionally, no information has been provided as to optimal duration of withholding SSRIs preoperatively. As such, it may be premature for hospitalists involved in perioperative care to modify recommendations based on this study.

Bottom line: Perioperative SSRI use is associated with an increased risk of bleeding and 30-day readmission.

Citation: Auerbach AD, Vittinghoff E, Maselli J, et al. Perioperative use of selective serotonin reuptake inhibitors and risks for adverse outcomes of surgery. JAMA Intern Med. 2013;173(12):1075-1081.

Copper-Surfaced Rooms Reduce Health-Care-Acquired Infections

Clinical question: Can copper alloy surfaces in ICU rooms lower rates of health-care-acquired infections (HAIs)?

Background: Environmental contamination is a potential source of HAIs. Copper has intrinsic broad-spectrum antimicrobial properties. This study tests the efficacy copper-surfaced items in hospital rooms have in preventing HAIs.

Study design: Randomized controlled trial.

Setting: Medical ICUs at Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center in Charleston, and the Memorial Sloan Kettering Cancer Center in New York City.

Synopsis: Six hundred fifty ICU patients were randomized to receive care either in rooms with copper surfacing on commonly handled patient care objects or in traditional rooms. Patients were screened for methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE) on admission. The proportion of patients that developed either an HAI and/or MRSA or VRE colonization was significantly lower among patients in rooms with the copper-surfaced items (0.071 vs. 0.128; P=0.02). The rate of HAIs alone was also lower in the rooms with the copper (0.034 vs. 0.081; P=0.013).

A potential limitation to this study is that the rooms with copper items appeared different than traditional rooms, and therefore might have changed the behavior of health-care workers. Further, it is unclear how much copper surfacing would be necessary on general wards, where patients are more mobile. Still, HAIs are associated with longer lengths of stay and higher 30-day readmission rates, so these encouraging results warrant additional investigation into antimicrobial copper-alloy surfaces.

Bottom line: Copper-surfaced objects reduce HAI rates in ICU patients.

Citation: Salgado CD, Sepkowitz, KA, John JF, et al. Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit. Infect Control Hosp Epidemiol. 2013;34(5):479-486.

Glucocorticoid Therapy for Five Days Not Inferior to 14 Days for COPD Exacerbation

Clinical question: Do short-course glucocorticoids work as well as conventional long courses for COPD exacerbation?

Background: International guidelines advocate a seven- to 14-day treatment course with glucocorticoids for COPD exacerbation, but the optimal duration of treatment is not known, and there are potential risks associated with glucocorticoid exposure.

Study design: Randomized, noninferiority, multicenter trial.

Setting: Five Swiss teaching hospitals.

Synopsis: Three hundred fourteen patients presenting to the ED with acute COPD exacerbation and without a history of asthma were randomized to receive treatment with 40 mg prednisone daily for either five or 14 days in a placebo-controlled, double-blinded fashion. There was no significant difference in the primary endpoint of re-exacerbation within six months. Patients in the five-day glucocorticoid group compared with the 14-day group were exposed to significantly less glucocorticoid.

Bottom line: Treatment for five days with glucocorticoids was not inferior to 14 days for acute COPD exacerbations with regard to re-exacerbations within six months and resulted in less glucocorticoid exposure overall.

Citation: Leuppi JF, Schuetz P, Bingisser R, et al. Short-term vs. conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE Randomized Clinical Trial. JAMA. 2013;390(21):2223-2231.

Patient Preference for Participation in Medical Decision-Making May Be Associated with Increased Resource Utilization

Clinical question: Do patient preferences for participation in medical decision-making affect health-care utilization?

Background: Patient participation in medical decision-making has been associated with improved patient satisfaction and health outcomes. There is little evidence to support theories that patient preferences might decrease or increase health-care utilization.

Study design: Survey study in academic research setting.

Setting: University of Chicago Medical Center.

Synopsis: More than 21,700 patients admitted to a general internal-medicine service completed a survey that included questions regarding preferences about receiving medical information and participation in medical decision-making. Survey data were linked with administrative data, including length of stay and total hospitalization costs.

Most patients (96.3%) expressed interest in receiving information about their illness and treatment options, but the majority of patients (71.1%) also expressed a preference to leave medical decision-making to their physician. Patients who preferred to participate in medical decision-making had significantly longer hospital LOS and higher total hospitalization cost.

Bottom line: Participation in medical decision-making significantly increased LOS and total costs.

Citation: Tak HJ, Ruhnke GW, Meltzer DO. Association of patient preferences for participation in decision making with length of stay and costs among hospitalized patients. JAMA Intern Med. 2013;173(13):1195-1205. doi: 10.1001/jamainternmed.2013.6048.

Early Parenteral Nutrition in Critically Ill Adults Does Not Significantly Affect Mortality or Infection Rates

Clinical question: Does providing early parenteral nutrition to critically ill adults with short-term relative contraindications to early enteral nutrition affect outcomes?

Background: The appropriate use of parenteral nutrition in critically ill adults is controversial. A systematic review found that critically ill patients randomized to receive early parenteral nutrition had significantly lower mortality but increased infection rates compared with standard care. A large-scale randomized trial was necessary to confirm the results.

Study design: Multicenter, randomized, single-blinded, controlled trial.

Setting: ICUs in 31 tertiary-care and community hospitals in Australia and New Zealand.

Synopsis: Researchers randomized 1,372 critically ill adults with relative contraindications to early enteral nutrition upon admission to the ICU to receive early parenteral nutrition or standard care. Early parenteral nutrition was started an average of 44 minutes after randomization. Clinicians defined standard care, with most patients remaining unfed for 2.8 days after randomization. Results were analyzed by intention-to-treat analysis, and loss to follow-up was 1%.

There was no significant difference in the primary outcome of 60-day mortality. Early parenteral nutrition patients received significantly fewer days of invasive ventilation, but did not have shorter ICU or hospital stays. Early parenteral nutrition patients experienced significantly less muscle-wasting and fat loss. There was no significant difference in new infection rates.

Bottom line: Early parenteral nutrition in critically ill adults resulted in significantly fewer days of invasive mechanical ventilation but did not cause a significant difference in length of stay, infection rates, or 60-day mortality.

Citation: Doig GS, Simpson F, Sweetman EA, et al. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition. JAMA. 2013;309(20): 2130-2138.

Aggressive Fluid and Sodium Restriction in Acute Decompensated Heart Failure Did Not Improve Outcomes

Clinical question: Does aggressive fluid and sodium restriction in acute decompensated heart failure (ADHF) result in increased weight loss, improved clinical stability, or decreased 30-day readmission rate?

Background: Fluid and sodium restriction are standard nonpharmacologic measures used in the management of ADHF in hospitalized patients, despite an absence of data to support their efficacy.

Study design: Randomized, controlled clinical trial with blinded outcome assessments.

Setting: A public teaching hospital in Brazil.

Synopsis: Seventy-five patients hospitalized with ADHF were randomized to receive aggressive fluid (800 mL/day) and sodium restriction (800 mg/day) or liberal intake (at least 2.5 L/day fluid, 3 to 5 g/day sodium). There were no significant between-group differences in diuretic administration. The primary outcomes of weight loss and clinical stability at three days were not significantly different between the groups. The heart-failure-specific readmission rate at 30 days was not significantly different between the groups. The aggressive restriction group had significantly worse thirst.

The study is limited by the small fraction of patients enrolled (9.2% of 813 screened) and homogenous population. Additional confirmatory trials likely are needed to change the standard of care, but this study demonstrated that aggressive fluid and sodium restriction does not benefit hospitalized patients with ADHF.

Bottom line: Aggressive fluid and sodium restriction in hospitalized patients with ADHF does not result in improved short-term weight loss, clinical stability, or decreased 30-day readmission rate, but it does cause significantly worse thirst.

Citation: Aliti GB, Rabelo ER, Clausell N, et al. Aggressive fluid and sodium restriction in acute decompensated heart failure. JAMA Intern Med. 2013;173(12):1058-1064.

Lower Rate of Pacemaker, Defibrillator Device-Pocket Hematoma without Anticoagulation Interruption

Clinical question: Is it safer to place a pacemaker or implantable cardioverter-defibrillator (ICD) while on therapeutic warfarin versus bridging with heparin/low-molecular-weight heparin (LMWH)?

Background: Current guidelines recommend bridging with heparin or LMWH for patients at high risk for thromboembolic events around the time of pacemaker or ICD placement, but it is associated with significant risk of device-pocket hematoma. Some centers place pacemakers and ICDs without interruption of warfarin. However, there are limited data to support the safety of this approach.

Study design: Multicenter, single-blinded, randomized, controlled trial.

Setting: Seventeen centers in Canada and one center in Brazil.

Synopsis: Patients with a predicted annual risk of 5% of thromboembolism were randomized to continue anticoagulation with warfarin (median INR 2.3) or to bridge therapy with heparin or LMWH; they then evaluated the incidence of clinically significant hematoma requiring prolonged hospitalization, interruption of anticoagulation therapy, or further surgical intervention. After reviewing the data on 668 patients, the Data and Safety Monitoring Board recommended termination of the study given a significantly lower rate of device-pocket hematoma in the warfarin group (3.5%) compared with the bridge group (16%) with RR 0.19 (95% CI 0.10-0.36, P<0.001). Otherwise, major surgical and thromboembolic complications were rare and not significantly different in both groups.

Bottom line: Continued warfarin therapy was associated with significantly reduced incidence of device-pocket hematoma compared with bridge with heparin or LMWH.

Citation: Birnie DH, Healey JS, Wells GA, et al. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med. 2013;368(22):2084-2093.

Prophylactic Penicillin Decreased Risk of Recurrent Leg Cellulitis

Clinical question: Does prophylactic, low-dose penicillin prevent recurrent cellulitis in patients with a history of two or more episodes of cellulitis?

Background: Some guidelines recommend prophylactic antibiotics for recurrent leg cellulitis, but there is no large randomized trial to support this practice, and clinical opinion is mixed.

Study design: Double-blinded, randomized, controlled trial.

Setting: Twenty-eight hospitals in the United Kingdom and Ireland.

Synopsis: Researchers randomized 274 patients with recurrent episodes of leg cellulitis (at least two episodes within the previous three years) to low-dose penicillin (250 mg) or placebo for 12 months and followed them for more than three years. During the prophylactic period, the penicillin group had a 45% reduction in the risk of a repeat cellulitis as compared to placebo (22% vs. 37%), equivalent to a number needed to treat to prevent a first recurrent cellulitis of five. The number of repeat episodes of cellulitis was lower overall in penicillin compared with the placebo group (119 vs. 164, P=0.02), although no significant difference was noted during the three-year follow-up period.

Factors associated with prophylaxis failure included three or more previous episodes of cellulitis, body mass index of 33 kg/m² or higher, and the presence of edema. No significant difference in adverse events was noted between the groups. Complete follow-up data was not available for participants during the follow-up period. Further study is needed to assess the long-term adverse effects and the duration of prophylaxis needed.

Bottom line: Prophylactic penicillin was effective in preventing recurrent leg cellulitis without increasing adverse effects, but its protective effect gradually declined once discontinued.

Citation: Thomas KS, Crook AM, Nunn AJ, et al. Penicillin to prevent recurrent leg cellulitis. N Engl J Med. 2013;368(18):1695-1703.

Universal ICU Decolonization Reduced Rates of MRSA Clinical Isolates and Bloodstream Infection

Clinical question: What is the most effective decolonization strategy for reducing methicillin-resistant Staphylococcus aureus (MRSA) and other pathogens in ICUs?

Background: Studies have shown that daily chlorhexidine bathing of all patients in ICUs reduced MRSA acquisition and bloodstream infection from all pathogens. However, this universal strategy has not been compared to MRSA screening and contact precautions alone, or to targeted decolonization of MRSA carriers.

Study design: Cluster-randomized comparative-effectiveness trial.

Setting: Adult ICUs in 43 Hospital Corporation of America (HCA) hospitals in 16 states.

Synopsis: All adult ICUs in a given hospital were randomized to one of three infection prevention strategies: Group 1 continued MRSA screening and isolation; Group 2 performed screening, isolation, and decolonization of MRSA carriers; and Group 3 implemented universal decolonization with intranasal mupirocin and daily bathing with chlorhexidine-impregnated cloths but no screening.

Forty-three hospitals, including 74 ICUs and 74,256 patients, underwent randomization. Significant reductions in the primary outcome of ICU-attributable MRSA clinical isolates (excluding MRSA screening tests) and the secondary outcome of bloodstream infection due to any pathogen were demonstrated across the three groups. One bloodstream infection was prevented for every 54 patients who underwent decolonization. Formal cost-effectiveness analysis was not performed.

Bottom line: In the ICU, universal decolonization was more effective than screening and isolation or targeted decolonization in the reduction of clinical MRSA isolates and bloodstream infection due to any pathogen, although monitoring for emerging resistance is necessary.

Citation: Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265.

Intensive Blood-Pressure Lowering in Intracerebral Hemorrhage Did Not Reduce Death or Severe Disability

Clinical question: What is the efficacy and safety of early intensive blood-pressure lowering in patients with acute intracerebral hemorrhage?

Background: After intracerebral hemorrhage, blood pressure often becomes elevated and is a predictor of outcome. It is not known whether rapid lowering of blood pressure would improve outcome.

Study design: International, multicenter, prospective, randomized, open-treatment, blinded end-point trial.

Setting: One hundred forty-four hospitals in 21 countries.

Synopsis: Researchers randomly assigned 2,839 patients with intracerebral hemorrhage in the previous six hours to intensive blood-pressure lowering with target systolic blood pressure of <140 mmHg within one hour, or guideline-recommended treatment with target systolic blood pressure of <180 mmHg. The mean systolic blood pressure achieved was 150 mmHg in the intensive-treatment group and 164 mmHg in the standard-treatment group.

There was no significant difference between the two groups in the primary outcome of death or major disability. A pre-specified ordinal analysis of modified Rankin score (score of 0 indicates no symptoms; a score of 5 indicates severe disability) did show significantly lower modified Rankin scores with intensive treatment. There was no difference between the two groups in the rate of serious adverse events.

Bottom line: Early intensive blood-pressure lowering in patients with acute intracerebral hemorrhage did not reduce death or major disability, although there may be improved functional outcomes with intensive blood-pressure lowering.

Citation: Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-2365.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Perioperative SSRI use associated with adverse surgical outcomes
2. Copper-surfaced rooms reduce health-care-acquired infections
3. Glucocorticoid therapy for five days not inferior to 14 days for COPD exacerbation
4. Patient preference for participation in medical decision-making may be associated with increased resource utilization
5. Early parenteral nutrition in critically ill adults does not significantly affect mortality or infection rates
6. Aggressive fluid and sodium restriction in acute decompensated heart failure did not improve outcomes
7. Lower rate of pacemaker, defibrillator device-pocket hematoma without anticoagulation interruption
8. Prophylactic penicillin decreased risk of recurrent leg cellulitis
9. Universal ICU decolonization reduced rates of mrsa clinical isolates and bloodstream infection
10. Intensive blood-pressure lowering in intracerebral hemorrhage did not reduce death or severe disability

Perioperative SSRI Use Associated with Adverse Surgical Outcomes

Clinical question: Does selective serotonin reuptake inhibitor (SSRI) use during hospitalization for surgery increase the risk of adverse perioperative outcomes?

Background: SSRIs commonly are prescribed but are associated with a small but higher risk for hemorrhage, arrhythmia, and sudden death. Single-site studies have described an association between SSRIs and adverse perioperative outcomes, but larger studies utilizing a broad range of surgical cases are lacking.

Study design: Retrospective cohort study.

Setting: Three hundred hospitals concentrated in the Southern U.S.

Synopsis: Using the “Perspective” database, this study examined 530,416 patients age >18 years undergoing major elective surgery, 72,540 (13.7%) of whom received an SSRI. Regression analysis showed patients receiving an SSRI had higher odds of mortality (OR 1.2, 95% CI [1.07-1.36]), higher odds of 30-day readmission (OR 1.22 [1.18-1.26]), and higher odds for bleeding (1.09 [1.04-1.15]). When the analysis was restricted to only patients with a diagnosis of depression, a higher risk of bleeding and readmission persisted.

This study reaffirms an association but does not establish a causal relationship between SSRI use and adverse perioperative outcomes. SSRI use may be a surrogate for other factors, including more severe mood disorders, poorer functional status, or chronic pain. Additionally, no information has been provided as to optimal duration of withholding SSRIs preoperatively. As such, it may be premature for hospitalists involved in perioperative care to modify recommendations based on this study.

Bottom line: Perioperative SSRI use is associated with an increased risk of bleeding and 30-day readmission.

Citation: Auerbach AD, Vittinghoff E, Maselli J, et al. Perioperative use of selective serotonin reuptake inhibitors and risks for adverse outcomes of surgery. JAMA Intern Med. 2013;173(12):1075-1081.

Copper-Surfaced Rooms Reduce Health-Care-Acquired Infections

Clinical question: Can copper alloy surfaces in ICU rooms lower rates of health-care-acquired infections (HAIs)?

Background: Environmental contamination is a potential source of HAIs. Copper has intrinsic broad-spectrum antimicrobial properties. This study tests the efficacy copper-surfaced items in hospital rooms have in preventing HAIs.

Study design: Randomized controlled trial.

Setting: Medical ICUs at Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center in Charleston, and the Memorial Sloan Kettering Cancer Center in New York City.

Synopsis: Six hundred fifty ICU patients were randomized to receive care either in rooms with copper surfacing on commonly handled patient care objects or in traditional rooms. Patients were screened for methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE) on admission. The proportion of patients that developed either an HAI and/or MRSA or VRE colonization was significantly lower among patients in rooms with the copper-surfaced items (0.071 vs. 0.128; P=0.02). The rate of HAIs alone was also lower in the rooms with the copper (0.034 vs. 0.081; P=0.013).

A potential limitation to this study is that the rooms with copper items appeared different than traditional rooms, and therefore might have changed the behavior of health-care workers. Further, it is unclear how much copper surfacing would be necessary on general wards, where patients are more mobile. Still, HAIs are associated with longer lengths of stay and higher 30-day readmission rates, so these encouraging results warrant additional investigation into antimicrobial copper-alloy surfaces.

Bottom line: Copper-surfaced objects reduce HAI rates in ICU patients.

Citation: Salgado CD, Sepkowitz, KA, John JF, et al. Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit. Infect Control Hosp Epidemiol. 2013;34(5):479-486.

Glucocorticoid Therapy for Five Days Not Inferior to 14 Days for COPD Exacerbation

Clinical question: Do short-course glucocorticoids work as well as conventional long courses for COPD exacerbation?

Background: International guidelines advocate a seven- to 14-day treatment course with glucocorticoids for COPD exacerbation, but the optimal duration of treatment is not known, and there are potential risks associated with glucocorticoid exposure.

Study design: Randomized, noninferiority, multicenter trial.

Setting: Five Swiss teaching hospitals.

Synopsis: Three hundred fourteen patients presenting to the ED with acute COPD exacerbation and without a history of asthma were randomized to receive treatment with 40 mg prednisone daily for either five or 14 days in a placebo-controlled, double-blinded fashion. There was no significant difference in the primary endpoint of re-exacerbation within six months. Patients in the five-day glucocorticoid group compared with the 14-day group were exposed to significantly less glucocorticoid.

Bottom line: Treatment for five days with glucocorticoids was not inferior to 14 days for acute COPD exacerbations with regard to re-exacerbations within six months and resulted in less glucocorticoid exposure overall.

Citation: Leuppi JF, Schuetz P, Bingisser R, et al. Short-term vs. conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE Randomized Clinical Trial. JAMA. 2013;390(21):2223-2231.

Patient Preference for Participation in Medical Decision-Making May Be Associated with Increased Resource Utilization

Clinical question: Do patient preferences for participation in medical decision-making affect health-care utilization?

Background: Patient participation in medical decision-making has been associated with improved patient satisfaction and health outcomes. There is little evidence to support theories that patient preferences might decrease or increase health-care utilization.

Study design: Survey study in academic research setting.

Setting: University of Chicago Medical Center.

Synopsis: More than 21,700 patients admitted to a general internal-medicine service completed a survey that included questions regarding preferences about receiving medical information and participation in medical decision-making. Survey data were linked with administrative data, including length of stay and total hospitalization costs.

Most patients (96.3%) expressed interest in receiving information about their illness and treatment options, but the majority of patients (71.1%) also expressed a preference to leave medical decision-making to their physician. Patients who preferred to participate in medical decision-making had significantly longer hospital LOS and higher total hospitalization cost.

Bottom line: Participation in medical decision-making significantly increased LOS and total costs.

Citation: Tak HJ, Ruhnke GW, Meltzer DO. Association of patient preferences for participation in decision making with length of stay and costs among hospitalized patients. JAMA Intern Med. 2013;173(13):1195-1205. doi: 10.1001/jamainternmed.2013.6048.

Early Parenteral Nutrition in Critically Ill Adults Does Not Significantly Affect Mortality or Infection Rates

Clinical question: Does providing early parenteral nutrition to critically ill adults with short-term relative contraindications to early enteral nutrition affect outcomes?

Background: The appropriate use of parenteral nutrition in critically ill adults is controversial. A systematic review found that critically ill patients randomized to receive early parenteral nutrition had significantly lower mortality but increased infection rates compared with standard care. A large-scale randomized trial was necessary to confirm the results.

Study design: Multicenter, randomized, single-blinded, controlled trial.

Setting: ICUs in 31 tertiary-care and community hospitals in Australia and New Zealand.

Synopsis: Researchers randomized 1,372 critically ill adults with relative contraindications to early enteral nutrition upon admission to the ICU to receive early parenteral nutrition or standard care. Early parenteral nutrition was started an average of 44 minutes after randomization. Clinicians defined standard care, with most patients remaining unfed for 2.8 days after randomization. Results were analyzed by intention-to-treat analysis, and loss to follow-up was 1%.

There was no significant difference in the primary outcome of 60-day mortality. Early parenteral nutrition patients received significantly fewer days of invasive ventilation, but did not have shorter ICU or hospital stays. Early parenteral nutrition patients experienced significantly less muscle-wasting and fat loss. There was no significant difference in new infection rates.

Bottom line: Early parenteral nutrition in critically ill adults resulted in significantly fewer days of invasive mechanical ventilation but did not cause a significant difference in length of stay, infection rates, or 60-day mortality.

Citation: Doig GS, Simpson F, Sweetman EA, et al. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition. JAMA. 2013;309(20): 2130-2138.

Aggressive Fluid and Sodium Restriction in Acute Decompensated Heart Failure Did Not Improve Outcomes

Clinical question: Does aggressive fluid and sodium restriction in acute decompensated heart failure (ADHF) result in increased weight loss, improved clinical stability, or decreased 30-day readmission rate?

Background: Fluid and sodium restriction are standard nonpharmacologic measures used in the management of ADHF in hospitalized patients, despite an absence of data to support their efficacy.

Study design: Randomized, controlled clinical trial with blinded outcome assessments.

Setting: A public teaching hospital in Brazil.

Synopsis: Seventy-five patients hospitalized with ADHF were randomized to receive aggressive fluid (800 mL/day) and sodium restriction (800 mg/day) or liberal intake (at least 2.5 L/day fluid, 3 to 5 g/day sodium). There were no significant between-group differences in diuretic administration. The primary outcomes of weight loss and clinical stability at three days were not significantly different between the groups. The heart-failure-specific readmission rate at 30 days was not significantly different between the groups. The aggressive restriction group had significantly worse thirst.

The study is limited by the small fraction of patients enrolled (9.2% of 813 screened) and homogenous population. Additional confirmatory trials likely are needed to change the standard of care, but this study demonstrated that aggressive fluid and sodium restriction does not benefit hospitalized patients with ADHF.

Bottom line: Aggressive fluid and sodium restriction in hospitalized patients with ADHF does not result in improved short-term weight loss, clinical stability, or decreased 30-day readmission rate, but it does cause significantly worse thirst.

Citation: Aliti GB, Rabelo ER, Clausell N, et al. Aggressive fluid and sodium restriction in acute decompensated heart failure. JAMA Intern Med. 2013;173(12):1058-1064.

Lower Rate of Pacemaker, Defibrillator Device-Pocket Hematoma without Anticoagulation Interruption

Clinical question: Is it safer to place a pacemaker or implantable cardioverter-defibrillator (ICD) while on therapeutic warfarin versus bridging with heparin/low-molecular-weight heparin (LMWH)?

Background: Current guidelines recommend bridging with heparin or LMWH for patients at high risk for thromboembolic events around the time of pacemaker or ICD placement, but it is associated with significant risk of device-pocket hematoma. Some centers place pacemakers and ICDs without interruption of warfarin. However, there are limited data to support the safety of this approach.

Study design: Multicenter, single-blinded, randomized, controlled trial.

Setting: Seventeen centers in Canada and one center in Brazil.

Synopsis: Patients with a predicted annual risk of 5% of thromboembolism were randomized to continue anticoagulation with warfarin (median INR 2.3) or to bridge therapy with heparin or LMWH; they then evaluated the incidence of clinically significant hematoma requiring prolonged hospitalization, interruption of anticoagulation therapy, or further surgical intervention. After reviewing the data on 668 patients, the Data and Safety Monitoring Board recommended termination of the study given a significantly lower rate of device-pocket hematoma in the warfarin group (3.5%) compared with the bridge group (16%) with RR 0.19 (95% CI 0.10-0.36, P<0.001). Otherwise, major surgical and thromboembolic complications were rare and not significantly different in both groups.

Bottom line: Continued warfarin therapy was associated with significantly reduced incidence of device-pocket hematoma compared with bridge with heparin or LMWH.

Citation: Birnie DH, Healey JS, Wells GA, et al. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med. 2013;368(22):2084-2093.

Prophylactic Penicillin Decreased Risk of Recurrent Leg Cellulitis

Clinical question: Does prophylactic, low-dose penicillin prevent recurrent cellulitis in patients with a history of two or more episodes of cellulitis?

Background: Some guidelines recommend prophylactic antibiotics for recurrent leg cellulitis, but there is no large randomized trial to support this practice, and clinical opinion is mixed.

Study design: Double-blinded, randomized, controlled trial.

Setting: Twenty-eight hospitals in the United Kingdom and Ireland.

Synopsis: Researchers randomized 274 patients with recurrent episodes of leg cellulitis (at least two episodes within the previous three years) to low-dose penicillin (250 mg) or placebo for 12 months and followed them for more than three years. During the prophylactic period, the penicillin group had a 45% reduction in the risk of a repeat cellulitis as compared to placebo (22% vs. 37%), equivalent to a number needed to treat to prevent a first recurrent cellulitis of five. The number of repeat episodes of cellulitis was lower overall in penicillin compared with the placebo group (119 vs. 164, P=0.02), although no significant difference was noted during the three-year follow-up period.

Factors associated with prophylaxis failure included three or more previous episodes of cellulitis, body mass index of 33 kg/m² or higher, and the presence of edema. No significant difference in adverse events was noted between the groups. Complete follow-up data was not available for participants during the follow-up period. Further study is needed to assess the long-term adverse effects and the duration of prophylaxis needed.

Bottom line: Prophylactic penicillin was effective in preventing recurrent leg cellulitis without increasing adverse effects, but its protective effect gradually declined once discontinued.

Citation: Thomas KS, Crook AM, Nunn AJ, et al. Penicillin to prevent recurrent leg cellulitis. N Engl J Med. 2013;368(18):1695-1703.

Universal ICU Decolonization Reduced Rates of MRSA Clinical Isolates and Bloodstream Infection

Clinical question: What is the most effective decolonization strategy for reducing methicillin-resistant Staphylococcus aureus (MRSA) and other pathogens in ICUs?

Background: Studies have shown that daily chlorhexidine bathing of all patients in ICUs reduced MRSA acquisition and bloodstream infection from all pathogens. However, this universal strategy has not been compared to MRSA screening and contact precautions alone, or to targeted decolonization of MRSA carriers.

Study design: Cluster-randomized comparative-effectiveness trial.

Setting: Adult ICUs in 43 Hospital Corporation of America (HCA) hospitals in 16 states.

Synopsis: All adult ICUs in a given hospital were randomized to one of three infection prevention strategies: Group 1 continued MRSA screening and isolation; Group 2 performed screening, isolation, and decolonization of MRSA carriers; and Group 3 implemented universal decolonization with intranasal mupirocin and daily bathing with chlorhexidine-impregnated cloths but no screening.

Forty-three hospitals, including 74 ICUs and 74,256 patients, underwent randomization. Significant reductions in the primary outcome of ICU-attributable MRSA clinical isolates (excluding MRSA screening tests) and the secondary outcome of bloodstream infection due to any pathogen were demonstrated across the three groups. One bloodstream infection was prevented for every 54 patients who underwent decolonization. Formal cost-effectiveness analysis was not performed.

Bottom line: In the ICU, universal decolonization was more effective than screening and isolation or targeted decolonization in the reduction of clinical MRSA isolates and bloodstream infection due to any pathogen, although monitoring for emerging resistance is necessary.

Citation: Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265.

Intensive Blood-Pressure Lowering in Intracerebral Hemorrhage Did Not Reduce Death or Severe Disability

Clinical question: What is the efficacy and safety of early intensive blood-pressure lowering in patients with acute intracerebral hemorrhage?

Background: After intracerebral hemorrhage, blood pressure often becomes elevated and is a predictor of outcome. It is not known whether rapid lowering of blood pressure would improve outcome.

Study design: International, multicenter, prospective, randomized, open-treatment, blinded end-point trial.

Setting: One hundred forty-four hospitals in 21 countries.

Synopsis: Researchers randomly assigned 2,839 patients with intracerebral hemorrhage in the previous six hours to intensive blood-pressure lowering with target systolic blood pressure of <140 mmHg within one hour, or guideline-recommended treatment with target systolic blood pressure of <180 mmHg. The mean systolic blood pressure achieved was 150 mmHg in the intensive-treatment group and 164 mmHg in the standard-treatment group.

There was no significant difference between the two groups in the primary outcome of death or major disability. A pre-specified ordinal analysis of modified Rankin score (score of 0 indicates no symptoms; a score of 5 indicates severe disability) did show significantly lower modified Rankin scores with intensive treatment. There was no difference between the two groups in the rate of serious adverse events.

Bottom line: Early intensive blood-pressure lowering in patients with acute intracerebral hemorrhage did not reduce death or major disability, although there may be improved functional outcomes with intensive blood-pressure lowering.

Citation: Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-2365.

Percentage of practicing physicians who would not recommend a medical career to a young person, according to Filling The Void: 2013 Physician Outlook Practice Trends, a national physician practice survey conducted by health-care staffing firm Jackson Healthcare.⁶ “Physician discontent appears to be creating a void in the health-care field,” with dissatisfaction and burnout leading to early retirement, the report stated. Discontent is driven by decreased autonomy, decreased reimbursement, administrative and regulatory distractions, corporatization of medicine, and fear of litigation, according to the report. Thirty-six percent of the respondents reported a generally negative outlook about their career, compared with only 16% who had a generally favorable outlook.

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Percentage of practicing physicians who would not recommend a medical career to a young person, according to Filling The Void: 2013 Physician Outlook Practice Trends, a national physician practice survey conducted by health-care staffing firm Jackson Healthcare.⁶ “Physician discontent appears to be creating a void in the health-care field,” with dissatisfaction and burnout leading to early retirement, the report stated. Discontent is driven by decreased autonomy, decreased reimbursement, administrative and regulatory distractions, corporatization of medicine, and fear of litigation, according to the report. Thirty-six percent of the respondents reported a generally negative outlook about their career, compared with only 16% who had a generally favorable outlook.

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Percentage of practicing physicians who would not recommend a medical career to a young person, according to Filling The Void: 2013 Physician Outlook Practice Trends, a national physician practice survey conducted by health-care staffing firm Jackson Healthcare.⁶ “Physician discontent appears to be creating a void in the health-care field,” with dissatisfaction and burnout leading to early retirement, the report stated. Discontent is driven by decreased autonomy, decreased reimbursement, administrative and regulatory distractions, corporatization of medicine, and fear of litigation, according to the report. Thirty-six percent of the respondents reported a generally negative outlook about their career, compared with only 16% who had a generally favorable outlook.

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Hospital readmission rate for sickle cell anemia, the diagnosis that is most likely to land a patient back in the hospital within 30 days, according to a report by the federal Healthcare Cost and Utilization Project.⁵ The authors list the top 10 diagnoses for readmissions, with gangrene as No. 2 at 31.6%, followed by hepatitis (30.9%), diseases of white blood cells (30.6%), and chronic renal failure (27.4%).

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Hospital readmission rate for sickle cell anemia, the diagnosis that is most likely to land a patient back in the hospital within 30 days, according to a report by the federal Healthcare Cost and Utilization Project.⁵ The authors list the top 10 diagnoses for readmissions, with gangrene as No. 2 at 31.6%, followed by hepatitis (30.9%), diseases of white blood cells (30.6%), and chronic renal failure (27.4%).

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Hospital readmission rate for sickle cell anemia, the diagnosis that is most likely to land a patient back in the hospital within 30 days, according to a report by the federal Healthcare Cost and Utilization Project.⁵ The authors list the top 10 diagnoses for readmissions, with gangrene as No. 2 at 31.6%, followed by hepatitis (30.9%), diseases of white blood cells (30.6%), and chronic renal failure (27.4%).

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

click for large version

Case

A 65-year-old man with a history of coronary artery disease (CAD) presents to the ED after a mechanical fall. He was found to have a hip fracture, admitted to orthopedic service, and underwent an uneventful hip repair. His post-operative course was uncomplicated, except for his hemoglobin level of 7.5 g/dL, which had decreased from his pre-operative hemoglobin of 11.2 g/dL. The patient was without cardiac symptoms, was ambulating with assistance, had normal vital signs, and was otherwise having an unremarkable recovery. The orthopedic surgeon, who recently heard that you do not have to transfuse patients unless their hemoglobin is less than 7 g/dL, consulted the hospitalist to help make the decision. What would your recommendation be?

Overview

Blood transfusions are a common medical procedure routinely given in the hospital.¹ An estimated 15 million red blood cell (RBC) units are transfused each year in the United States.² Despite its common use, the clinical indications for transfusion continue to be the subject of considerable debate. Most clinicians would agree that treating a patient with a low hemoglobin level and symptoms of anemia is reasonable.^1,3 However, in the absence of overt symptoms, there is debate about when transfusions are appropriate.^2,3

Because tissue oxygen delivery is dependent on hemoglobin and cardiac output, past medical practice has supported the use of the “golden 10/30 rule,” by which patients are transfused to a hemoglobin concentration of 10 g/dL or a hematocrit of 30%, regardless of symptoms. The rationale for this approach is based on physiologic evidence that cardiac output increases when hemoglobin falls below 7 g/dl. In patients with cardiac disease, the ability to increase cardiac output is compromised. Therefore, in order to reduce strain on the heart, hemoglobin levels historically have been kept higher than this threshold.

However, several studies have forced us to re-evaluate this old paradigm, including increasing concern for the infectious and noninfectious complications associated with blood transfusions and the need for cost containment (see Table 1).^1,2,4 Due to improved blood screening, infectious complications from transfusions have been greatly reduced; noninfectious complications are 1,000 times more likely than infectious ones.

click for large version

Review of Data

Although a number of studies have been performed on the indications for blood transfusions, many of the trials conducted in the past were too small to substantiate a certain practice. However, three trials with a large number of participants have allowed for a more evidence-based approach to blood transfusions. The studies address different patient populations to help broaden the restrictive transfusion approach to a larger range of patients.

TRICC trial: critically ill patients⁵. The TRICC trial was the first major study that compared a liberal transfusion strategy (transfuse when Hb <10 g/dL) to a more conservative approach (transfuse when Hb <7 g/dL). In this multicenter, randomized controlled trial, Hébert et al enrolled 418 critically ill patients and found that there was no significant difference in 30-day all-cause mortality between the restrictive-strategy group (18.7%) and the liberal-strategy group (23.3%).

However, in the pre-determined subgroup analysis, patients who were less severely ill (APACHE II scores of <20) had 30-day all-cause mortality of 8.7%, compared with 16.1% in the liberal-strategy group. Interestingly, there were more cardiac complications (pulmonary edema, angina, MI, and cardiac arrest) in the liberal-strategy group (21%) compared with the restrictive-strategy group (13%). Despite this finding, 30-day mortality was not significantly different in patients with clinically significant cardiac disease (primary or secondary diagnosis of cardiac disease [20.5% restrictive versus 22.9% liberal]).

An average of 2.6 units of RBCs per patient were given in the restrictive group, while 5.6 units were given to patients in the liberal group. This reflects a 54% decrease in the number of transfusions used in the conservative group. All the patients in the liberal group received transfusions, while 33% of the restrictive group’s patients received no blood at all.

The results of this trial suggested that there is no clinical advantage in transfusing ICU patients to Hb values above 9 g/dL, even if they have a history of cardiac disease. In fact, it may be harmful to practice a liberal transfusion strategy in critically ill younger patients (<55 years old) and those who are less severely ill (APACHE II <20).⁵

FOCUS trial: hip surgery and history of cardiac disease⁶. The FOCUS trial is a recent study that looked at the optimal hemoglobin level at which an RBC transfusion is beneficial for patients undergoing hip surgery. This study enrolled patients aged 50 or older who had a history or risk factors for cardiovascular disease (clinical evidence of cardiovascular disease: h/o ischemic heart disease, EKG evidence of previous MI, h/o CHF/PVD, h/o stroke/TIA, h/o HTN, DM, hyperlipidemia (TC >200/LDL >130), current tobacco use, or Cr>2.0), who were undergoing primary surgical repair of a hip fracture, and who had Hb <10g/dL within three days after surgery.

More than 2,000 patients were assigned randomly to a liberal-strategy group (transfuse to maintain a Hb >10g/dL) or a restrictive strategy group (transfuse to maintain Hg >8g/dl or for symptoms or signs of anemia). These signs/symptoms included chest pain that was possibly cardiac-related, congestive heart failure, tachycardia, and unresponsive hypotension. The primary outcomes were mortality or inability to walk 10 feet without assistance at 60-day follow-up.

The FOCUS trial found no statistically significant difference in mortality rate (7.6% in the liberal group versus 6.6% in the restrictive group) or in the ability to walk at 60 days (35.2% in the liberal group versus 34.7% in the restrictive group). There were no significant differences in the rates of in-hospital acute MI, unstable angina, or death between the two groups.

Patients in the restrictive-strategy group received 65% fewer units of blood than the liberal group, with 59% receiving no blood after surgery compared with 3% of the liberal group. Overall, the liberal group received 1,866 units of blood, compared with 652 units in the restrictive group.

This trial helps support the findings in previous trials, such as TRICC, by showing that a restrictive transfusion strategy using a trigger point of 8 g/dl does not increase mortality or cardiovascular complications and does not decrease functional ability after orthopedic surgery.

TRAC trial: patients after cardiac surgery⁷. The TRAC trial was a prospective randomized trial in 502 patients undergoing cardiac surgery that assigned 253 patients to the liberal-transfusion-strategy group (Hb >10g/dl) and 249 to the restrictive-strategy group (Hb >8 g/dl). In this study, the primary endpoint of all-cause 30-day mortality occurred in 10% of the liberal group and 11% of the restrictive group. This difference was not significant.

Subanalysis showed that blood transfusion in both groups was an independent risk factor for the occurrence of respiratory, cardiac, renal, and infectious complications, in addition to the composite end point of 30-day mortality—again highlighting the risk involved in of blood transfusions.

These results support the other trial conclusions that a restrictive transfusion strategy of maintaining a hematocrit of 24% (Hb 8 g/dL) is as safe as a more liberal strategy with a hematocrit of 30% (Hb 10 g/dL). It also offers further evidence of the risks of blood transfusions and supports the view that blood transfusions should never be given simply to correct low hemoglobin levels.

Cochrane Review. A recent Cochrane Review that comprised 19 trials with a combined total of 6,264 patients also supported a restrictive-strategy approach.⁸ In this review, no difference in mortality was established between the restrictive and liberal transfusion groups, with a trend toward decreased hospital mortality in the restrictive-transfusion group. The authors of the study felt that for most patients, blood transfusion is not necessary until hemoglobin levels drop below 7-8 g/dL but emphasized that this criteria should not be generalized to patients with an acute cardiac issue.

click for large version

Back to the Case

In this case, the patient is doing well post-operatively and has no cardiac symptoms or hypotension. However, based on the new available data from the FOCUS trial, given the patient’s history of CAD, and the threshold of 8 g/dL used in the study, it was recommended that the patient be transfused.

Bottom Line

Current practice guidelines clearly support clinical judgment as the primary determinant in the decision to transfuse.² However, current evidence is growing that our threshold for blood transfusions should be a hemoglobin level of 7-8 g/dl.

Dr. Chang is a hospitalist and assistant professor at Mount Sinai Medical Center in New York City, and is co-director of the medicine-geriatrics clerkship at the Icahn School of Medicine at Mount Sinai. Dr. Torgalkar is a hospitalist and assistant professor at Mount Sinai Medical Center.

References

1. Sharma S, Sharma P, Tyler L. Transfusion of blood and blood products: indications and complications. Am Fam Physician. 2011;83:719-724.
2. Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2012;157:49-58.
3. Valeri CR, Crowley JP, Loscalzo J. The red cell transfusion trigger: has a sin of commission now become a sin of omission? Transfusion. 1998;38:602-610.
4. Klein HG, Spahn DR, Carson JL. Red blood cell transfusion in clinical practice. Lancet. 2007;370(9585):415-426.
5. Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med. 1999;340:409-17.
6. Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011;365:2453-2462.
7. Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA. 2010;304:1559-1567.
8. Carson JL, Carless PA, Hébert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2012; 4:CD002042.

click for large version

Case

A 65-year-old man with a history of coronary artery disease (CAD) presents to the ED after a mechanical fall. He was found to have a hip fracture, admitted to orthopedic service, and underwent an uneventful hip repair. His post-operative course was uncomplicated, except for his hemoglobin level of 7.5 g/dL, which had decreased from his pre-operative hemoglobin of 11.2 g/dL. The patient was without cardiac symptoms, was ambulating with assistance, had normal vital signs, and was otherwise having an unremarkable recovery. The orthopedic surgeon, who recently heard that you do not have to transfuse patients unless their hemoglobin is less than 7 g/dL, consulted the hospitalist to help make the decision. What would your recommendation be?

Overview

Blood transfusions are a common medical procedure routinely given in the hospital.¹ An estimated 15 million red blood cell (RBC) units are transfused each year in the United States.² Despite its common use, the clinical indications for transfusion continue to be the subject of considerable debate. Most clinicians would agree that treating a patient with a low hemoglobin level and symptoms of anemia is reasonable.^1,3 However, in the absence of overt symptoms, there is debate about when transfusions are appropriate.^2,3

Because tissue oxygen delivery is dependent on hemoglobin and cardiac output, past medical practice has supported the use of the “golden 10/30 rule,” by which patients are transfused to a hemoglobin concentration of 10 g/dL or a hematocrit of 30%, regardless of symptoms. The rationale for this approach is based on physiologic evidence that cardiac output increases when hemoglobin falls below 7 g/dl. In patients with cardiac disease, the ability to increase cardiac output is compromised. Therefore, in order to reduce strain on the heart, hemoglobin levels historically have been kept higher than this threshold.

However, several studies have forced us to re-evaluate this old paradigm, including increasing concern for the infectious and noninfectious complications associated with blood transfusions and the need for cost containment (see Table 1).^1,2,4 Due to improved blood screening, infectious complications from transfusions have been greatly reduced; noninfectious complications are 1,000 times more likely than infectious ones.

click for large version

Review of Data

Although a number of studies have been performed on the indications for blood transfusions, many of the trials conducted in the past were too small to substantiate a certain practice. However, three trials with a large number of participants have allowed for a more evidence-based approach to blood transfusions. The studies address different patient populations to help broaden the restrictive transfusion approach to a larger range of patients.

TRICC trial: critically ill patients⁵. The TRICC trial was the first major study that compared a liberal transfusion strategy (transfuse when Hb <10 g/dL) to a more conservative approach (transfuse when Hb <7 g/dL). In this multicenter, randomized controlled trial, Hébert et al enrolled 418 critically ill patients and found that there was no significant difference in 30-day all-cause mortality between the restrictive-strategy group (18.7%) and the liberal-strategy group (23.3%).

However, in the pre-determined subgroup analysis, patients who were less severely ill (APACHE II scores of <20) had 30-day all-cause mortality of 8.7%, compared with 16.1% in the liberal-strategy group. Interestingly, there were more cardiac complications (pulmonary edema, angina, MI, and cardiac arrest) in the liberal-strategy group (21%) compared with the restrictive-strategy group (13%). Despite this finding, 30-day mortality was not significantly different in patients with clinically significant cardiac disease (primary or secondary diagnosis of cardiac disease [20.5% restrictive versus 22.9% liberal]).

An average of 2.6 units of RBCs per patient were given in the restrictive group, while 5.6 units were given to patients in the liberal group. This reflects a 54% decrease in the number of transfusions used in the conservative group. All the patients in the liberal group received transfusions, while 33% of the restrictive group’s patients received no blood at all.

The results of this trial suggested that there is no clinical advantage in transfusing ICU patients to Hb values above 9 g/dL, even if they have a history of cardiac disease. In fact, it may be harmful to practice a liberal transfusion strategy in critically ill younger patients (<55 years old) and those who are less severely ill (APACHE II <20).⁵

FOCUS trial: hip surgery and history of cardiac disease⁶. The FOCUS trial is a recent study that looked at the optimal hemoglobin level at which an RBC transfusion is beneficial for patients undergoing hip surgery. This study enrolled patients aged 50 or older who had a history or risk factors for cardiovascular disease (clinical evidence of cardiovascular disease: h/o ischemic heart disease, EKG evidence of previous MI, h/o CHF/PVD, h/o stroke/TIA, h/o HTN, DM, hyperlipidemia (TC >200/LDL >130), current tobacco use, or Cr>2.0), who were undergoing primary surgical repair of a hip fracture, and who had Hb <10g/dL within three days after surgery.

More than 2,000 patients were assigned randomly to a liberal-strategy group (transfuse to maintain a Hb >10g/dL) or a restrictive strategy group (transfuse to maintain Hg >8g/dl or for symptoms or signs of anemia). These signs/symptoms included chest pain that was possibly cardiac-related, congestive heart failure, tachycardia, and unresponsive hypotension. The primary outcomes were mortality or inability to walk 10 feet without assistance at 60-day follow-up.

The FOCUS trial found no statistically significant difference in mortality rate (7.6% in the liberal group versus 6.6% in the restrictive group) or in the ability to walk at 60 days (35.2% in the liberal group versus 34.7% in the restrictive group). There were no significant differences in the rates of in-hospital acute MI, unstable angina, or death between the two groups.

Patients in the restrictive-strategy group received 65% fewer units of blood than the liberal group, with 59% receiving no blood after surgery compared with 3% of the liberal group. Overall, the liberal group received 1,866 units of blood, compared with 652 units in the restrictive group.

This trial helps support the findings in previous trials, such as TRICC, by showing that a restrictive transfusion strategy using a trigger point of 8 g/dl does not increase mortality or cardiovascular complications and does not decrease functional ability after orthopedic surgery.

TRAC trial: patients after cardiac surgery⁷. The TRAC trial was a prospective randomized trial in 502 patients undergoing cardiac surgery that assigned 253 patients to the liberal-transfusion-strategy group (Hb >10g/dl) and 249 to the restrictive-strategy group (Hb >8 g/dl). In this study, the primary endpoint of all-cause 30-day mortality occurred in 10% of the liberal group and 11% of the restrictive group. This difference was not significant.

Subanalysis showed that blood transfusion in both groups was an independent risk factor for the occurrence of respiratory, cardiac, renal, and infectious complications, in addition to the composite end point of 30-day mortality—again highlighting the risk involved in of blood transfusions.

These results support the other trial conclusions that a restrictive transfusion strategy of maintaining a hematocrit of 24% (Hb 8 g/dL) is as safe as a more liberal strategy with a hematocrit of 30% (Hb 10 g/dL). It also offers further evidence of the risks of blood transfusions and supports the view that blood transfusions should never be given simply to correct low hemoglobin levels.

Cochrane Review. A recent Cochrane Review that comprised 19 trials with a combined total of 6,264 patients also supported a restrictive-strategy approach.⁸ In this review, no difference in mortality was established between the restrictive and liberal transfusion groups, with a trend toward decreased hospital mortality in the restrictive-transfusion group. The authors of the study felt that for most patients, blood transfusion is not necessary until hemoglobin levels drop below 7-8 g/dL but emphasized that this criteria should not be generalized to patients with an acute cardiac issue.

click for large version

Back to the Case

In this case, the patient is doing well post-operatively and has no cardiac symptoms or hypotension. However, based on the new available data from the FOCUS trial, given the patient’s history of CAD, and the threshold of 8 g/dL used in the study, it was recommended that the patient be transfused.

Bottom Line

Current practice guidelines clearly support clinical judgment as the primary determinant in the decision to transfuse.² However, current evidence is growing that our threshold for blood transfusions should be a hemoglobin level of 7-8 g/dl.

Dr. Chang is a hospitalist and assistant professor at Mount Sinai Medical Center in New York City, and is co-director of the medicine-geriatrics clerkship at the Icahn School of Medicine at Mount Sinai. Dr. Torgalkar is a hospitalist and assistant professor at Mount Sinai Medical Center.

References

1. Sharma S, Sharma P, Tyler L. Transfusion of blood and blood products: indications and complications. Am Fam Physician. 2011;83:719-724.
2. Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2012;157:49-58.
3. Valeri CR, Crowley JP, Loscalzo J. The red cell transfusion trigger: has a sin of commission now become a sin of omission? Transfusion. 1998;38:602-610.
4. Klein HG, Spahn DR, Carson JL. Red blood cell transfusion in clinical practice. Lancet. 2007;370(9585):415-426.
5. Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med. 1999;340:409-17.
6. Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011;365:2453-2462.
7. Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA. 2010;304:1559-1567.
8. Carson JL, Carless PA, Hébert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2012; 4:CD002042.

click for large version

Case

A 65-year-old man with a history of coronary artery disease (CAD) presents to the ED after a mechanical fall. He was found to have a hip fracture, admitted to orthopedic service, and underwent an uneventful hip repair. His post-operative course was uncomplicated, except for his hemoglobin level of 7.5 g/dL, which had decreased from his pre-operative hemoglobin of 11.2 g/dL. The patient was without cardiac symptoms, was ambulating with assistance, had normal vital signs, and was otherwise having an unremarkable recovery. The orthopedic surgeon, who recently heard that you do not have to transfuse patients unless their hemoglobin is less than 7 g/dL, consulted the hospitalist to help make the decision. What would your recommendation be?

Overview

Blood transfusions are a common medical procedure routinely given in the hospital.¹ An estimated 15 million red blood cell (RBC) units are transfused each year in the United States.² Despite its common use, the clinical indications for transfusion continue to be the subject of considerable debate. Most clinicians would agree that treating a patient with a low hemoglobin level and symptoms of anemia is reasonable.^1,3 However, in the absence of overt symptoms, there is debate about when transfusions are appropriate.^2,3

Because tissue oxygen delivery is dependent on hemoglobin and cardiac output, past medical practice has supported the use of the “golden 10/30 rule,” by which patients are transfused to a hemoglobin concentration of 10 g/dL or a hematocrit of 30%, regardless of symptoms. The rationale for this approach is based on physiologic evidence that cardiac output increases when hemoglobin falls below 7 g/dl. In patients with cardiac disease, the ability to increase cardiac output is compromised. Therefore, in order to reduce strain on the heart, hemoglobin levels historically have been kept higher than this threshold.

However, several studies have forced us to re-evaluate this old paradigm, including increasing concern for the infectious and noninfectious complications associated with blood transfusions and the need for cost containment (see Table 1).^1,2,4 Due to improved blood screening, infectious complications from transfusions have been greatly reduced; noninfectious complications are 1,000 times more likely than infectious ones.

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Review of Data

Although a number of studies have been performed on the indications for blood transfusions, many of the trials conducted in the past were too small to substantiate a certain practice. However, three trials with a large number of participants have allowed for a more evidence-based approach to blood transfusions. The studies address different patient populations to help broaden the restrictive transfusion approach to a larger range of patients.

TRICC trial: critically ill patients⁵. The TRICC trial was the first major study that compared a liberal transfusion strategy (transfuse when Hb <10 g/dL) to a more conservative approach (transfuse when Hb <7 g/dL). In this multicenter, randomized controlled trial, Hébert et al enrolled 418 critically ill patients and found that there was no significant difference in 30-day all-cause mortality between the restrictive-strategy group (18.7%) and the liberal-strategy group (23.3%).

However, in the pre-determined subgroup analysis, patients who were less severely ill (APACHE II scores of <20) had 30-day all-cause mortality of 8.7%, compared with 16.1% in the liberal-strategy group. Interestingly, there were more cardiac complications (pulmonary edema, angina, MI, and cardiac arrest) in the liberal-strategy group (21%) compared with the restrictive-strategy group (13%). Despite this finding, 30-day mortality was not significantly different in patients with clinically significant cardiac disease (primary or secondary diagnosis of cardiac disease [20.5% restrictive versus 22.9% liberal]).

An average of 2.6 units of RBCs per patient were given in the restrictive group, while 5.6 units were given to patients in the liberal group. This reflects a 54% decrease in the number of transfusions used in the conservative group. All the patients in the liberal group received transfusions, while 33% of the restrictive group’s patients received no blood at all.

The results of this trial suggested that there is no clinical advantage in transfusing ICU patients to Hb values above 9 g/dL, even if they have a history of cardiac disease. In fact, it may be harmful to practice a liberal transfusion strategy in critically ill younger patients (<55 years old) and those who are less severely ill (APACHE II <20).⁵

FOCUS trial: hip surgery and history of cardiac disease⁶. The FOCUS trial is a recent study that looked at the optimal hemoglobin level at which an RBC transfusion is beneficial for patients undergoing hip surgery. This study enrolled patients aged 50 or older who had a history or risk factors for cardiovascular disease (clinical evidence of cardiovascular disease: h/o ischemic heart disease, EKG evidence of previous MI, h/o CHF/PVD, h/o stroke/TIA, h/o HTN, DM, hyperlipidemia (TC >200/LDL >130), current tobacco use, or Cr>2.0), who were undergoing primary surgical repair of a hip fracture, and who had Hb <10g/dL within three days after surgery.

More than 2,000 patients were assigned randomly to a liberal-strategy group (transfuse to maintain a Hb >10g/dL) or a restrictive strategy group (transfuse to maintain Hg >8g/dl or for symptoms or signs of anemia). These signs/symptoms included chest pain that was possibly cardiac-related, congestive heart failure, tachycardia, and unresponsive hypotension. The primary outcomes were mortality or inability to walk 10 feet without assistance at 60-day follow-up.

The FOCUS trial found no statistically significant difference in mortality rate (7.6% in the liberal group versus 6.6% in the restrictive group) or in the ability to walk at 60 days (35.2% in the liberal group versus 34.7% in the restrictive group). There were no significant differences in the rates of in-hospital acute MI, unstable angina, or death between the two groups.

Patients in the restrictive-strategy group received 65% fewer units of blood than the liberal group, with 59% receiving no blood after surgery compared with 3% of the liberal group. Overall, the liberal group received 1,866 units of blood, compared with 652 units in the restrictive group.

This trial helps support the findings in previous trials, such as TRICC, by showing that a restrictive transfusion strategy using a trigger point of 8 g/dl does not increase mortality or cardiovascular complications and does not decrease functional ability after orthopedic surgery.

TRAC trial: patients after cardiac surgery⁷. The TRAC trial was a prospective randomized trial in 502 patients undergoing cardiac surgery that assigned 253 patients to the liberal-transfusion-strategy group (Hb >10g/dl) and 249 to the restrictive-strategy group (Hb >8 g/dl). In this study, the primary endpoint of all-cause 30-day mortality occurred in 10% of the liberal group and 11% of the restrictive group. This difference was not significant.

Subanalysis showed that blood transfusion in both groups was an independent risk factor for the occurrence of respiratory, cardiac, renal, and infectious complications, in addition to the composite end point of 30-day mortality—again highlighting the risk involved in of blood transfusions.

These results support the other trial conclusions that a restrictive transfusion strategy of maintaining a hematocrit of 24% (Hb 8 g/dL) is as safe as a more liberal strategy with a hematocrit of 30% (Hb 10 g/dL). It also offers further evidence of the risks of blood transfusions and supports the view that blood transfusions should never be given simply to correct low hemoglobin levels.

Cochrane Review. A recent Cochrane Review that comprised 19 trials with a combined total of 6,264 patients also supported a restrictive-strategy approach.⁸ In this review, no difference in mortality was established between the restrictive and liberal transfusion groups, with a trend toward decreased hospital mortality in the restrictive-transfusion group. The authors of the study felt that for most patients, blood transfusion is not necessary until hemoglobin levels drop below 7-8 g/dL but emphasized that this criteria should not be generalized to patients with an acute cardiac issue.

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Back to the Case

In this case, the patient is doing well post-operatively and has no cardiac symptoms or hypotension. However, based on the new available data from the FOCUS trial, given the patient’s history of CAD, and the threshold of 8 g/dL used in the study, it was recommended that the patient be transfused.

Bottom Line

Current practice guidelines clearly support clinical judgment as the primary determinant in the decision to transfuse.² However, current evidence is growing that our threshold for blood transfusions should be a hemoglobin level of 7-8 g/dl.

Dr. Chang is a hospitalist and assistant professor at Mount Sinai Medical Center in New York City, and is co-director of the medicine-geriatrics clerkship at the Icahn School of Medicine at Mount Sinai. Dr. Torgalkar is a hospitalist and assistant professor at Mount Sinai Medical Center.

References

1. Sharma S, Sharma P, Tyler L. Transfusion of blood and blood products: indications and complications. Am Fam Physician. 2011;83:719-724.
2. Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2012;157:49-58.
3. Valeri CR, Crowley JP, Loscalzo J. The red cell transfusion trigger: has a sin of commission now become a sin of omission? Transfusion. 1998;38:602-610.
4. Klein HG, Spahn DR, Carson JL. Red blood cell transfusion in clinical practice. Lancet. 2007;370(9585):415-426.
5. Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med. 1999;340:409-17.
6. Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011;365:2453-2462.
7. Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA. 2010;304:1559-1567.
8. Carson JL, Carless PA, Hébert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2012; 4:CD002042.

Given the encouraging results published in Infection Control and Hospital Epidemiology regarding the effectiveness of copper-alloy surfaces in killing bacteria, one institution has decided to go full steam ahead with installing copper components.¹

The Ronald McDonald House of Charleston, S.C. (RMHC), a home for families of critically ill children who are being treated at the Medical University of South Carolina (MUSC), was the first nonprofit, temporary-residence facility in the U.S. to undertake an antimicrobial copper retrofit.

“We were the ideal public building site to test copper’s antimicrobial efficacy outside of ICUs,” says Robin Willis, RMHC’s antimicrobial project manager.

South Carolina Research Authority, which managed the study, approached RMHC about being the “guinea pig.”

“The families would get the benefits for a long time, and we would have additional data outside of a closed ICU,” Willis says. “Additionally, it gave vendors a testing ground for copper components.”

Surfaces that were identified in the study as having the highest bacteria counts (stair railings, sinks, faucets, tables, locksets, cabinet pulls, and chair arms) were replaced with solid, copper-based metals such as bronze and brass that are registered by the Environmental Protection Agency. The Copper Development Association donated the bulk of funds for the project. Copper manufacturers and installers donated their time and materials.

Initial discussions about the project began in 2010; copper installations started in November 2011. The facility remained open and fully functional throughout the project, which was completed in April 2012.

MUSC measured the amount of bacteria on touch surfaces prior to the copper retrofit, then compared the amount of bacteria on the new copper surfaces against their predecessors.

“Bacteria levels dropped more than 90 percent, around the clock, without cleaning agents,” Willis says.

The study’s lead investigator, Michael Schmidt, PhD, professor and vice chair of the department of microbiology and immunology at MUSC, says the practical application of antimicrobial copper “provides a strong, real-world example of the public-health benefits of copper materials, not only in a health-care setting, but also in hotels, restaurants, and other public gathering places.” TH

Karen Appold is a freelance writer in Pennsylvania.

Reference

1. Salgado CD, Sepkowitz KA, John JF, et al. Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit. Infect Control Hosp Epidemiol. 2013;34(5):479-486.

Given the encouraging results published in Infection Control and Hospital Epidemiology regarding the effectiveness of copper-alloy surfaces in killing bacteria, one institution has decided to go full steam ahead with installing copper components.¹

The Ronald McDonald House of Charleston, S.C. (RMHC), a home for families of critically ill children who are being treated at the Medical University of South Carolina (MUSC), was the first nonprofit, temporary-residence facility in the U.S. to undertake an antimicrobial copper retrofit.

“We were the ideal public building site to test copper’s antimicrobial efficacy outside of ICUs,” says Robin Willis, RMHC’s antimicrobial project manager.

South Carolina Research Authority, which managed the study, approached RMHC about being the “guinea pig.”

“The families would get the benefits for a long time, and we would have additional data outside of a closed ICU,” Willis says. “Additionally, it gave vendors a testing ground for copper components.”

Surfaces that were identified in the study as having the highest bacteria counts (stair railings, sinks, faucets, tables, locksets, cabinet pulls, and chair arms) were replaced with solid, copper-based metals such as bronze and brass that are registered by the Environmental Protection Agency. The Copper Development Association donated the bulk of funds for the project. Copper manufacturers and installers donated their time and materials.

Initial discussions about the project began in 2010; copper installations started in November 2011. The facility remained open and fully functional throughout the project, which was completed in April 2012.

MUSC measured the amount of bacteria on touch surfaces prior to the copper retrofit, then compared the amount of bacteria on the new copper surfaces against their predecessors.

“Bacteria levels dropped more than 90 percent, around the clock, without cleaning agents,” Willis says.

The study’s lead investigator, Michael Schmidt, PhD, professor and vice chair of the department of microbiology and immunology at MUSC, says the practical application of antimicrobial copper “provides a strong, real-world example of the public-health benefits of copper materials, not only in a health-care setting, but also in hotels, restaurants, and other public gathering places.” TH

Karen Appold is a freelance writer in Pennsylvania.

Reference

1. Salgado CD, Sepkowitz KA, John JF, et al. Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit. Infect Control Hosp Epidemiol. 2013;34(5):479-486.

Given the encouraging results published in Infection Control and Hospital Epidemiology regarding the effectiveness of copper-alloy surfaces in killing bacteria, one institution has decided to go full steam ahead with installing copper components.¹

The Ronald McDonald House of Charleston, S.C. (RMHC), a home for families of critically ill children who are being treated at the Medical University of South Carolina (MUSC), was the first nonprofit, temporary-residence facility in the U.S. to undertake an antimicrobial copper retrofit.

“We were the ideal public building site to test copper’s antimicrobial efficacy outside of ICUs,” says Robin Willis, RMHC’s antimicrobial project manager.

South Carolina Research Authority, which managed the study, approached RMHC about being the “guinea pig.”

“The families would get the benefits for a long time, and we would have additional data outside of a closed ICU,” Willis says. “Additionally, it gave vendors a testing ground for copper components.”

Surfaces that were identified in the study as having the highest bacteria counts (stair railings, sinks, faucets, tables, locksets, cabinet pulls, and chair arms) were replaced with solid, copper-based metals such as bronze and brass that are registered by the Environmental Protection Agency. The Copper Development Association donated the bulk of funds for the project. Copper manufacturers and installers donated their time and materials.

Initial discussions about the project began in 2010; copper installations started in November 2011. The facility remained open and fully functional throughout the project, which was completed in April 2012.

MUSC measured the amount of bacteria on touch surfaces prior to the copper retrofit, then compared the amount of bacteria on the new copper surfaces against their predecessors.

“Bacteria levels dropped more than 90 percent, around the clock, without cleaning agents,” Willis says.

The study’s lead investigator, Michael Schmidt, PhD, professor and vice chair of the department of microbiology and immunology at MUSC, says the practical application of antimicrobial copper “provides a strong, real-world example of the public-health benefits of copper materials, not only in a health-care setting, but also in hotels, restaurants, and other public gathering places.” TH

Karen Appold is a freelance writer in Pennsylvania.

Reference

1. Salgado CD, Sepkowitz KA, John JF, et al. Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit. Infect Control Hosp Epidemiol. 2013;34(5):479-486.

Click here to listen to more of our interview with Dr. Arora

Click here to listen to more of our interview with Dr. Grant

Click here to listen to more of our interview with Dr. Maynard

Click here to listen to more of our interview with Dr. Wise

Click here to listen to more of our interview with Dr. Arora

Click here to listen to more of our interview with Dr. Grant

Click here to listen to more of our interview with Dr. Maynard

Click here to listen to more of our interview with Dr. Wise

Click here to listen to more of our interview with Dr. Arora

Click here to listen to more of our interview with Dr. Grant

Click here to listen to more of our interview with Dr. Maynard

Click here to listen to more of our interview with Dr. Wise

Click here to listen to more of our interview with Dr. Schmidt

Click here to listen to more of our interview with Dr. Schmidt

Click here to listen to more of our interview with Dr. Schmidt

Sorting out whether a hospitalist’s bonus and other compensation elements are in line with survey data often leads to confusion. The 2013 MGMA Physician Compensation and Production Survey report, based on 2012 data, shows median compensation of $240,352 for internal-medicine hospitalists (I’ll round it to $240,000 for the rest of this piece). So is your compensation in line with survey medians if your base pay is $230,000 and you have a performance bonus of up to $20,000?

The problem is that you can’t know in advance how much of the $20,000 performance bonus you will earn. And isn’t a bonus supposed to be on top of typical compensation? To be in line with the survey, shouldn’t your base pay equal the $240,000 median, with any available bonus dollars on top of that? (Base pay means all forms of compensation other than a performance bonus; it could be productivity-based compensation, pay connected to numbers of shifts or hours worked, or a fixed annual salary, etc.)

The short answer is no, and to demonstrate why, I’ll first review some facts about the survey itself, then apply that knowledge to the hospitalist marketplace.

I want to emphasize that in this article, I’m not taking a position on the right amount of workload, compensation, or bonus for any hospitalist practice. And I’m using survey medians just to simplify the discussion, not because they’re optimal for any particular practice.

Survey Data

The most important thing to know about the survey data is that the $240,000 figure takes into account all forms of pay, including extra shift pay and any bonuses that might have been paid to each provider in the data set. Such benefits as health insurance and retirement-plan contribution are not included in this figure.

There are several ways a hospitalist might have earned compensation that matches the survey median. He or she might have a fixed annual salary equal to the median with no bonus available or had a meaningful bonus (e.g. $10,000 to $20,000) available and failed to earn any of it. Or the base might have come to $230,000, and he or she earned half of the available $20,000 performance bonus. Many other permutations of bonus and other salary elements could occur to arrive at the same $240,000 figure.

The important thing to remember is that whatever bonus dollars were paid, they are included in the salary figure from the survey—not added on top of that figure. So if all bonus dollars earned were subtracted from the survey, the total “nonbonus” compensation would be lower than $240,000.

How much lower?

Typical Hospitalist Bonus Amounts

The MGMA survey doesn’t report the portion of compensation tied to a bonus, but SHM’s does. SHM’s 2012 State of Hospital Medicine Report, based on 2011 data (www.hospitalmedicine.org/survey), is based on the most recent data available, and it showed (on page 60) that an average of 7% of pay was tied to performance for nonacademic hospitalist groups serving adults only. This included any payments for good individual or group performance on quality, efficiency, service, satisfaction, and/or other nonproduction measures. In conversation, this often is referred to as a “bonus” rather than “performance compensation.”

One way to estimate the nonbonus compensation would be to reduce the total pay by 7%, which comes to $223,200. Keep in mind that there are all kinds of mathematical and methodological problems in manipulating the reported survey numbers from two separate surveys to derive additional benchmarks. But this seems like a reasonable guess.

An increasing portion of hospitalist groups have some pay tied to performance, and the portion of total pay tied to performance seems to be going up at least a little. It was 5% of pay in 2010 and 4% in 2011, compared with 7% in the 2012 survey.

Keep in mind two things. First, this 7% reflects the performance or bonus dollars actually paid out, not the total amount available. In other words, even if the median total bonus dollars available were 20% of compensation, hospitalists earned less than that. Some hospitalists earned all dollars available, and some earned only a portion of what was available. And second, some hospitalists fail to earn any bonus or don’t have one available at all. So the survey would show for them zero compensation tied to bonus.

Making Sense of the Numbers

If you follow the reasoning above, then you probably agree that if your goal is to match mean compensation from the MGMA survey (I’m not suggesting that is the best goal, merely using it for simplicity), then you would set nonbonus compensation 7% below median—as long as you’re likely to get the same portion of a bonus as the median practice.

In some practices, performance thresholds are set at a level that is very easy to achieve, meaning the hospitalists are almost guaranteed to get all of the bonus compensation available. To be consistent with survey medians, it would be appropriate for them to set nonbonus compensation by subtracting all bonus dollars from the survey median. For example, if a $20,000 bonus is available and all of it is likely to be earned by the hospitalists, then total nonbonus compensation would be $220,000.

However, what if the bonus requires significant improvements in performance by the doctors (which seems most appropriate to me; why have a bonus otherwise?) and it is likely they will earn only 25% of all bonus dollars available? If the total available bonus is $20,000, then something like 25%, or $5,000, should be subtracted from the median to yield a total nonbonus compensation of $235,000.

Simple Thinking

I think it makes most sense to set total nonbonus compensation below the targeted total compensation. Failure to achieve any performance thresholds means no bonus and compensation will be below target that year. Meeting some thresholds (some improvement in performance) should result in matching the target compensation, and truly terrific performance that meets or exceeds all thresholds should result in the doctor being paid above the target.

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

Sorting out whether a hospitalist’s bonus and other compensation elements are in line with survey data often leads to confusion. The 2013 MGMA Physician Compensation and Production Survey report, based on 2012 data, shows median compensation of $240,352 for internal-medicine hospitalists (I’ll round it to $240,000 for the rest of this piece). So is your compensation in line with survey medians if your base pay is $230,000 and you have a performance bonus of up to $20,000?

The problem is that you can’t know in advance how much of the $20,000 performance bonus you will earn. And isn’t a bonus supposed to be on top of typical compensation? To be in line with the survey, shouldn’t your base pay equal the $240,000 median, with any available bonus dollars on top of that? (Base pay means all forms of compensation other than a performance bonus; it could be productivity-based compensation, pay connected to numbers of shifts or hours worked, or a fixed annual salary, etc.)

The short answer is no, and to demonstrate why, I’ll first review some facts about the survey itself, then apply that knowledge to the hospitalist marketplace.

I want to emphasize that in this article, I’m not taking a position on the right amount of workload, compensation, or bonus for any hospitalist practice. And I’m using survey medians just to simplify the discussion, not because they’re optimal for any particular practice.

Survey Data

The most important thing to know about the survey data is that the $240,000 figure takes into account all forms of pay, including extra shift pay and any bonuses that might have been paid to each provider in the data set. Such benefits as health insurance and retirement-plan contribution are not included in this figure.

There are several ways a hospitalist might have earned compensation that matches the survey median. He or she might have a fixed annual salary equal to the median with no bonus available or had a meaningful bonus (e.g. $10,000 to $20,000) available and failed to earn any of it. Or the base might have come to $230,000, and he or she earned half of the available $20,000 performance bonus. Many other permutations of bonus and other salary elements could occur to arrive at the same $240,000 figure.

The important thing to remember is that whatever bonus dollars were paid, they are included in the salary figure from the survey—not added on top of that figure. So if all bonus dollars earned were subtracted from the survey, the total “nonbonus” compensation would be lower than $240,000.

How much lower?

Typical Hospitalist Bonus Amounts

The MGMA survey doesn’t report the portion of compensation tied to a bonus, but SHM’s does. SHM’s 2012 State of Hospital Medicine Report, based on 2011 data (www.hospitalmedicine.org/survey), is based on the most recent data available, and it showed (on page 60) that an average of 7% of pay was tied to performance for nonacademic hospitalist groups serving adults only. This included any payments for good individual or group performance on quality, efficiency, service, satisfaction, and/or other nonproduction measures. In conversation, this often is referred to as a “bonus” rather than “performance compensation.”

One way to estimate the nonbonus compensation would be to reduce the total pay by 7%, which comes to $223,200. Keep in mind that there are all kinds of mathematical and methodological problems in manipulating the reported survey numbers from two separate surveys to derive additional benchmarks. But this seems like a reasonable guess.

An increasing portion of hospitalist groups have some pay tied to performance, and the portion of total pay tied to performance seems to be going up at least a little. It was 5% of pay in 2010 and 4% in 2011, compared with 7% in the 2012 survey.

Keep in mind two things. First, this 7% reflects the performance or bonus dollars actually paid out, not the total amount available. In other words, even if the median total bonus dollars available were 20% of compensation, hospitalists earned less than that. Some hospitalists earned all dollars available, and some earned only a portion of what was available. And second, some hospitalists fail to earn any bonus or don’t have one available at all. So the survey would show for them zero compensation tied to bonus.

Making Sense of the Numbers

If you follow the reasoning above, then you probably agree that if your goal is to match mean compensation from the MGMA survey (I’m not suggesting that is the best goal, merely using it for simplicity), then you would set nonbonus compensation 7% below median—as long as you’re likely to get the same portion of a bonus as the median practice.

In some practices, performance thresholds are set at a level that is very easy to achieve, meaning the hospitalists are almost guaranteed to get all of the bonus compensation available. To be consistent with survey medians, it would be appropriate for them to set nonbonus compensation by subtracting all bonus dollars from the survey median. For example, if a $20,000 bonus is available and all of it is likely to be earned by the hospitalists, then total nonbonus compensation would be $220,000.

However, what if the bonus requires significant improvements in performance by the doctors (which seems most appropriate to me; why have a bonus otherwise?) and it is likely they will earn only 25% of all bonus dollars available? If the total available bonus is $20,000, then something like 25%, or $5,000, should be subtracted from the median to yield a total nonbonus compensation of $235,000.

Simple Thinking

I think it makes most sense to set total nonbonus compensation below the targeted total compensation. Failure to achieve any performance thresholds means no bonus and compensation will be below target that year. Meeting some thresholds (some improvement in performance) should result in matching the target compensation, and truly terrific performance that meets or exceeds all thresholds should result in the doctor being paid above the target.

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

Sorting out whether a hospitalist’s bonus and other compensation elements are in line with survey data often leads to confusion. The 2013 MGMA Physician Compensation and Production Survey report, based on 2012 data, shows median compensation of $240,352 for internal-medicine hospitalists (I’ll round it to $240,000 for the rest of this piece). So is your compensation in line with survey medians if your base pay is $230,000 and you have a performance bonus of up to $20,000?

The problem is that you can’t know in advance how much of the $20,000 performance bonus you will earn. And isn’t a bonus supposed to be on top of typical compensation? To be in line with the survey, shouldn’t your base pay equal the $240,000 median, with any available bonus dollars on top of that? (Base pay means all forms of compensation other than a performance bonus; it could be productivity-based compensation, pay connected to numbers of shifts or hours worked, or a fixed annual salary, etc.)

The short answer is no, and to demonstrate why, I’ll first review some facts about the survey itself, then apply that knowledge to the hospitalist marketplace.

I want to emphasize that in this article, I’m not taking a position on the right amount of workload, compensation, or bonus for any hospitalist practice. And I’m using survey medians just to simplify the discussion, not because they’re optimal for any particular practice.

Survey Data

The most important thing to know about the survey data is that the $240,000 figure takes into account all forms of pay, including extra shift pay and any bonuses that might have been paid to each provider in the data set. Such benefits as health insurance and retirement-plan contribution are not included in this figure.

There are several ways a hospitalist might have earned compensation that matches the survey median. He or she might have a fixed annual salary equal to the median with no bonus available or had a meaningful bonus (e.g. $10,000 to $20,000) available and failed to earn any of it. Or the base might have come to $230,000, and he or she earned half of the available $20,000 performance bonus. Many other permutations of bonus and other salary elements could occur to arrive at the same $240,000 figure.

The important thing to remember is that whatever bonus dollars were paid, they are included in the salary figure from the survey—not added on top of that figure. So if all bonus dollars earned were subtracted from the survey, the total “nonbonus” compensation would be lower than $240,000.

How much lower?

Typical Hospitalist Bonus Amounts

The MGMA survey doesn’t report the portion of compensation tied to a bonus, but SHM’s does. SHM’s 2012 State of Hospital Medicine Report, based on 2011 data (www.hospitalmedicine.org/survey), is based on the most recent data available, and it showed (on page 60) that an average of 7% of pay was tied to performance for nonacademic hospitalist groups serving adults only. This included any payments for good individual or group performance on quality, efficiency, service, satisfaction, and/or other nonproduction measures. In conversation, this often is referred to as a “bonus” rather than “performance compensation.”

One way to estimate the nonbonus compensation would be to reduce the total pay by 7%, which comes to $223,200. Keep in mind that there are all kinds of mathematical and methodological problems in manipulating the reported survey numbers from two separate surveys to derive additional benchmarks. But this seems like a reasonable guess.

An increasing portion of hospitalist groups have some pay tied to performance, and the portion of total pay tied to performance seems to be going up at least a little. It was 5% of pay in 2010 and 4% in 2011, compared with 7% in the 2012 survey.

Keep in mind two things. First, this 7% reflects the performance or bonus dollars actually paid out, not the total amount available. In other words, even if the median total bonus dollars available were 20% of compensation, hospitalists earned less than that. Some hospitalists earned all dollars available, and some earned only a portion of what was available. And second, some hospitalists fail to earn any bonus or don’t have one available at all. So the survey would show for them zero compensation tied to bonus.

Making Sense of the Numbers

If you follow the reasoning above, then you probably agree that if your goal is to match mean compensation from the MGMA survey (I’m not suggesting that is the best goal, merely using it for simplicity), then you would set nonbonus compensation 7% below median—as long as you’re likely to get the same portion of a bonus as the median practice.

In some practices, performance thresholds are set at a level that is very easy to achieve, meaning the hospitalists are almost guaranteed to get all of the bonus compensation available. To be consistent with survey medians, it would be appropriate for them to set nonbonus compensation by subtracting all bonus dollars from the survey median. For example, if a $20,000 bonus is available and all of it is likely to be earned by the hospitalists, then total nonbonus compensation would be $220,000.

However, what if the bonus requires significant improvements in performance by the doctors (which seems most appropriate to me; why have a bonus otherwise?) and it is likely they will earn only 25% of all bonus dollars available? If the total available bonus is $20,000, then something like 25%, or $5,000, should be subtracted from the median to yield a total nonbonus compensation of $235,000.

Simple Thinking

I think it makes most sense to set total nonbonus compensation below the targeted total compensation. Failure to achieve any performance thresholds means no bonus and compensation will be below target that year. Meeting some thresholds (some improvement in performance) should result in matching the target compensation, and truly terrific performance that meets or exceeds all thresholds should result in the doctor being paid above the target.

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