Clinical

Supplemental oxygen did not prevent mortality or rehospitalization among patients with suspected myocardial infarction whose oxygen saturation on room air exceeded 90%, investigators reported.

Rates of all-cause mortality at 1 year were 5% among patients who received supplemental oxygen through an open face mask (6 liters per minute for 6-12 hours) and 5.1% among patients who breathed room air, said Robin Hofmann, MD, of Karolinska Institutet, Stockholm, and his associates. In addition, rehospitalization for MI occurred in 3.8% of patients who received supplemental oxygen and 3.3% of those breathed room air. The findings of the randomized registry-based trial of 6,629 patients were presented at the annual congress of the European Society of Cardiology and published simultaneously in the New England Journal of Medicine.

Guidelines recommend oxygen supplementation in MI, and the practice has persisted for more than a century, but adequately powered trials of hard clinical endpoints are lacking. Above-normal oxygen saturation can potentially worsen reperfusion injury by causing coronary vasoconstriction and increasing production of reactive oxygen species, the researchers noted.

Notably, the Australian Air Versus Oxygen in Myocardial Infarction (AVOID) trial found that oxygen supplementation was associated with larger infarct sizes in patients with ST-segment elevation myocardial infarction, and a recent Cochrane report did not support routine oxygen supplementation for MI.

The current trial enrolled patients aged 30 years and older who had chest pain or shortness of breath lasting less than 6 hours, an oxygen saturation of at least 90% on pulse oximetry, and either electrocardiographic evidence of ischemia or elevated cardiac troponin T or I levels (N Engl J Med. 2017 Aug 28. doi: 10.1056/NEJMoa1706222).

Oxygen therapy lasted a median of 11.6 hours, after which median oxygen saturation levels were 99% in the intervention group and 97% in the control group.

A total of 62 patients (2%) who received oxygen developed hypoxemia, as did 254 patients (8%) who breathed room air. Median highest troponin levels during hospitalization were 946.5 ng per L and 983.0 ng per L, respectively. A total of 166 (5%) patients in the oxygen group and 168 (5.1%) control patients died from any cause by a year after treatment (hazard ratio, 0.97; P = .8). Likewise, supplemental oxygen did not prevent rehospitalization with MI within 1 year (HR, 1.13; P = .3).

“Because power for evaluation of the primary endpoint was lower than anticipated, we cannot completely rule out a small beneficial or detrimental effect of oxygen on mortality,” the researchers wrote. But clinical differences were unlikely, based on the superimposable time-to-event curves through 12 months, the consistent results across subgroups, and the neutral findings on secondary clinical endpoints, they added.

The Swedish Research Council, the Swedish Heart-Lung Foundation, and the Swedish Foundation for Strategic Research funded the study. Dr. Hofmann disclosed research grants from these entities.

Supplemental oxygen did not prevent mortality or rehospitalization among patients with suspected myocardial infarction whose oxygen saturation on room air exceeded 90%, investigators reported.

Rates of all-cause mortality at 1 year were 5% among patients who received supplemental oxygen through an open face mask (6 liters per minute for 6-12 hours) and 5.1% among patients who breathed room air, said Robin Hofmann, MD, of Karolinska Institutet, Stockholm, and his associates. In addition, rehospitalization for MI occurred in 3.8% of patients who received supplemental oxygen and 3.3% of those breathed room air. The findings of the randomized registry-based trial of 6,629 patients were presented at the annual congress of the European Society of Cardiology and published simultaneously in the New England Journal of Medicine.

Guidelines recommend oxygen supplementation in MI, and the practice has persisted for more than a century, but adequately powered trials of hard clinical endpoints are lacking. Above-normal oxygen saturation can potentially worsen reperfusion injury by causing coronary vasoconstriction and increasing production of reactive oxygen species, the researchers noted.

Notably, the Australian Air Versus Oxygen in Myocardial Infarction (AVOID) trial found that oxygen supplementation was associated with larger infarct sizes in patients with ST-segment elevation myocardial infarction, and a recent Cochrane report did not support routine oxygen supplementation for MI.

The current trial enrolled patients aged 30 years and older who had chest pain or shortness of breath lasting less than 6 hours, an oxygen saturation of at least 90% on pulse oximetry, and either electrocardiographic evidence of ischemia or elevated cardiac troponin T or I levels (N Engl J Med. 2017 Aug 28. doi: 10.1056/NEJMoa1706222).

Oxygen therapy lasted a median of 11.6 hours, after which median oxygen saturation levels were 99% in the intervention group and 97% in the control group.

A total of 62 patients (2%) who received oxygen developed hypoxemia, as did 254 patients (8%) who breathed room air. Median highest troponin levels during hospitalization were 946.5 ng per L and 983.0 ng per L, respectively. A total of 166 (5%) patients in the oxygen group and 168 (5.1%) control patients died from any cause by a year after treatment (hazard ratio, 0.97; P = .8). Likewise, supplemental oxygen did not prevent rehospitalization with MI within 1 year (HR, 1.13; P = .3).

“Because power for evaluation of the primary endpoint was lower than anticipated, we cannot completely rule out a small beneficial or detrimental effect of oxygen on mortality,” the researchers wrote. But clinical differences were unlikely, based on the superimposable time-to-event curves through 12 months, the consistent results across subgroups, and the neutral findings on secondary clinical endpoints, they added.

The Swedish Research Council, the Swedish Heart-Lung Foundation, and the Swedish Foundation for Strategic Research funded the study. Dr. Hofmann disclosed research grants from these entities.

Supplemental oxygen did not prevent mortality or rehospitalization among patients with suspected myocardial infarction whose oxygen saturation on room air exceeded 90%, investigators reported.

Rates of all-cause mortality at 1 year were 5% among patients who received supplemental oxygen through an open face mask (6 liters per minute for 6-12 hours) and 5.1% among patients who breathed room air, said Robin Hofmann, MD, of Karolinska Institutet, Stockholm, and his associates. In addition, rehospitalization for MI occurred in 3.8% of patients who received supplemental oxygen and 3.3% of those breathed room air. The findings of the randomized registry-based trial of 6,629 patients were presented at the annual congress of the European Society of Cardiology and published simultaneously in the New England Journal of Medicine.

Guidelines recommend oxygen supplementation in MI, and the practice has persisted for more than a century, but adequately powered trials of hard clinical endpoints are lacking. Above-normal oxygen saturation can potentially worsen reperfusion injury by causing coronary vasoconstriction and increasing production of reactive oxygen species, the researchers noted.

Notably, the Australian Air Versus Oxygen in Myocardial Infarction (AVOID) trial found that oxygen supplementation was associated with larger infarct sizes in patients with ST-segment elevation myocardial infarction, and a recent Cochrane report did not support routine oxygen supplementation for MI.

The current trial enrolled patients aged 30 years and older who had chest pain or shortness of breath lasting less than 6 hours, an oxygen saturation of at least 90% on pulse oximetry, and either electrocardiographic evidence of ischemia or elevated cardiac troponin T or I levels (N Engl J Med. 2017 Aug 28. doi: 10.1056/NEJMoa1706222).

Oxygen therapy lasted a median of 11.6 hours, after which median oxygen saturation levels were 99% in the intervention group and 97% in the control group.

A total of 62 patients (2%) who received oxygen developed hypoxemia, as did 254 patients (8%) who breathed room air. Median highest troponin levels during hospitalization were 946.5 ng per L and 983.0 ng per L, respectively. A total of 166 (5%) patients in the oxygen group and 168 (5.1%) control patients died from any cause by a year after treatment (hazard ratio, 0.97; P = .8). Likewise, supplemental oxygen did not prevent rehospitalization with MI within 1 year (HR, 1.13; P = .3).

“Because power for evaluation of the primary endpoint was lower than anticipated, we cannot completely rule out a small beneficial or detrimental effect of oxygen on mortality,” the researchers wrote. But clinical differences were unlikely, based on the superimposable time-to-event curves through 12 months, the consistent results across subgroups, and the neutral findings on secondary clinical endpoints, they added.

The Swedish Research Council, the Swedish Heart-Lung Foundation, and the Swedish Foundation for Strategic Research funded the study. Dr. Hofmann disclosed research grants from these entities.

Clinical Question: Can a single high-sensitivity cardiac troponin-T (hs-cTnT) reliably rule-out acute myocardial infarction (AMI) to safely enable earlier discharge?

Background: Current practice includes serial measures of hs-cTnT to rule out AMI.

Study Design: A meta-analysis of 11 prospective cohorts at various international locations

Setting: Patients presenting to emergency departments with chest pain.

Dr. Dogra is clinical instructor of medicine in the University of Kentucky division of hospital medicine.

Clinical Question: Can a single high-sensitivity cardiac troponin-T (hs-cTnT) reliably rule-out acute myocardial infarction (AMI) to safely enable earlier discharge?

Background: Current practice includes serial measures of hs-cTnT to rule out AMI.

Study Design: A meta-analysis of 11 prospective cohorts at various international locations

Setting: Patients presenting to emergency departments with chest pain.

Dr. Dogra is clinical instructor of medicine in the University of Kentucky division of hospital medicine.

Clinical Question: Can a single high-sensitivity cardiac troponin-T (hs-cTnT) reliably rule-out acute myocardial infarction (AMI) to safely enable earlier discharge?

Background: Current practice includes serial measures of hs-cTnT to rule out AMI.

Study Design: A meta-analysis of 11 prospective cohorts at various international locations

Setting: Patients presenting to emergency departments with chest pain.

Dr. Dogra is clinical instructor of medicine in the University of Kentucky division of hospital medicine.

Over an 18-month period, small, insertable cardiac monitors detected atrial fibrillation in 29% of previously undiagnosed patients who were at high risk of both AF and stroke, and in 40% of patients over 30 months, according to investigators. The study was presented at the annual congress of the European Society of Cardiology and simultaneously published in JAMA Cardiology.

More than half (56%) of patients consequently started oral anticoagulation therapy, noted James A. Reiffel, MD, of Columbia University College of Physicians and Surgeons, New York, with his associates, for the REVEAL AF investigators.

“The incidence of previously undiagnosed atrial fibrillation may be substantial in patients with risk factors for AF and stroke,” they concluded. “Atrial fibrillation would have gone undetected in most patients had monitoring been limited to 30 days. Further trials regarding the value of detecting subclinical AF and of prophylactic therapies are warranted.”

Atrial fibrillation affects millions worldwide and is associated with older age, hypertension, diabetes, and heart failure, all of which also independently increase the risk of stroke. Minimally invasive prolonged electrocardiographic monitoring with insertable cardiac monitors might help hasten detection and treatment of AF, but diagnostic yield in high-risk patients has been unclear.

In this single-arm, multicenter, prospective study, researchers inserted Reveal XT or Reveal LINQ (Medtronic) cardiac monitors in 385 adults who had either CHAD2 scores of 3, or CHAD2 scores of 2 and one additional risk factor for AF, such as coronary artery disease, sleep apnea, chronic obstructive pulmonary disease, or renal insufficiency. The primary endpoint was AF lasting at least 6 minutes (JAMA Cardiol. 2017 Aug 26. doi: 10.1001/jamacardio.2017.3180). Median follow-up time was 22.5 months. Rates of detecting AF were 6% at 30 days compared with 20% at 6 months, 27% at 12 months, 34% at 24 months, and 40% at 30 months. Patients typically had their first AF episode about 4 months (median, 123 days) after the device was inserted. Among patients who had experienced AF by 18 months, 10% had one or more episodes lasting at least 24 hours, and 72 (56%) were prescribed oral anticoagulation therapy.

The recent PREDATE AF and ASSERT-II studies also found that previously undiagnosed AF was common among high-risk patients, the researchers noted. However, whether anticoagulating patients who have only brief episodes of AF significantly reduces their risk of stroke remains unclear, they added. Three trials (ARTESiA, NOAH, and LOOP) are underway to assess whether oral anticoagulation therapy improves outcomes in patients with device-detected AF.

Medtronic funded the study. Dr. Reiffel and five coinvestigators disclosed consulting for and receiving “modest honoraria” from Medtronic. Two other coinvestigators reported employment with and stock ownership in Medtronic.

Over an 18-month period, small, insertable cardiac monitors detected atrial fibrillation in 29% of previously undiagnosed patients who were at high risk of both AF and stroke, and in 40% of patients over 30 months, according to investigators. The study was presented at the annual congress of the European Society of Cardiology and simultaneously published in JAMA Cardiology.

More than half (56%) of patients consequently started oral anticoagulation therapy, noted James A. Reiffel, MD, of Columbia University College of Physicians and Surgeons, New York, with his associates, for the REVEAL AF investigators.

“The incidence of previously undiagnosed atrial fibrillation may be substantial in patients with risk factors for AF and stroke,” they concluded. “Atrial fibrillation would have gone undetected in most patients had monitoring been limited to 30 days. Further trials regarding the value of detecting subclinical AF and of prophylactic therapies are warranted.”

Atrial fibrillation affects millions worldwide and is associated with older age, hypertension, diabetes, and heart failure, all of which also independently increase the risk of stroke. Minimally invasive prolonged electrocardiographic monitoring with insertable cardiac monitors might help hasten detection and treatment of AF, but diagnostic yield in high-risk patients has been unclear.

In this single-arm, multicenter, prospective study, researchers inserted Reveal XT or Reveal LINQ (Medtronic) cardiac monitors in 385 adults who had either CHAD2 scores of 3, or CHAD2 scores of 2 and one additional risk factor for AF, such as coronary artery disease, sleep apnea, chronic obstructive pulmonary disease, or renal insufficiency. The primary endpoint was AF lasting at least 6 minutes (JAMA Cardiol. 2017 Aug 26. doi: 10.1001/jamacardio.2017.3180). Median follow-up time was 22.5 months. Rates of detecting AF were 6% at 30 days compared with 20% at 6 months, 27% at 12 months, 34% at 24 months, and 40% at 30 months. Patients typically had their first AF episode about 4 months (median, 123 days) after the device was inserted. Among patients who had experienced AF by 18 months, 10% had one or more episodes lasting at least 24 hours, and 72 (56%) were prescribed oral anticoagulation therapy.

The recent PREDATE AF and ASSERT-II studies also found that previously undiagnosed AF was common among high-risk patients, the researchers noted. However, whether anticoagulating patients who have only brief episodes of AF significantly reduces their risk of stroke remains unclear, they added. Three trials (ARTESiA, NOAH, and LOOP) are underway to assess whether oral anticoagulation therapy improves outcomes in patients with device-detected AF.

Medtronic funded the study. Dr. Reiffel and five coinvestigators disclosed consulting for and receiving “modest honoraria” from Medtronic. Two other coinvestigators reported employment with and stock ownership in Medtronic.

Over an 18-month period, small, insertable cardiac monitors detected atrial fibrillation in 29% of previously undiagnosed patients who were at high risk of both AF and stroke, and in 40% of patients over 30 months, according to investigators. The study was presented at the annual congress of the European Society of Cardiology and simultaneously published in JAMA Cardiology.

More than half (56%) of patients consequently started oral anticoagulation therapy, noted James A. Reiffel, MD, of Columbia University College of Physicians and Surgeons, New York, with his associates, for the REVEAL AF investigators.

“The incidence of previously undiagnosed atrial fibrillation may be substantial in patients with risk factors for AF and stroke,” they concluded. “Atrial fibrillation would have gone undetected in most patients had monitoring been limited to 30 days. Further trials regarding the value of detecting subclinical AF and of prophylactic therapies are warranted.”

Atrial fibrillation affects millions worldwide and is associated with older age, hypertension, diabetes, and heart failure, all of which also independently increase the risk of stroke. Minimally invasive prolonged electrocardiographic monitoring with insertable cardiac monitors might help hasten detection and treatment of AF, but diagnostic yield in high-risk patients has been unclear.

In this single-arm, multicenter, prospective study, researchers inserted Reveal XT or Reveal LINQ (Medtronic) cardiac monitors in 385 adults who had either CHAD2 scores of 3, or CHAD2 scores of 2 and one additional risk factor for AF, such as coronary artery disease, sleep apnea, chronic obstructive pulmonary disease, or renal insufficiency. The primary endpoint was AF lasting at least 6 minutes (JAMA Cardiol. 2017 Aug 26. doi: 10.1001/jamacardio.2017.3180). Median follow-up time was 22.5 months. Rates of detecting AF were 6% at 30 days compared with 20% at 6 months, 27% at 12 months, 34% at 24 months, and 40% at 30 months. Patients typically had their first AF episode about 4 months (median, 123 days) after the device was inserted. Among patients who had experienced AF by 18 months, 10% had one or more episodes lasting at least 24 hours, and 72 (56%) were prescribed oral anticoagulation therapy.

The recent PREDATE AF and ASSERT-II studies also found that previously undiagnosed AF was common among high-risk patients, the researchers noted. However, whether anticoagulating patients who have only brief episodes of AF significantly reduces their risk of stroke remains unclear, they added. Three trials (ARTESiA, NOAH, and LOOP) are underway to assess whether oral anticoagulation therapy improves outcomes in patients with device-detected AF.

Medtronic funded the study. Dr. Reiffel and five coinvestigators disclosed consulting for and receiving “modest honoraria” from Medtronic. Two other coinvestigators reported employment with and stock ownership in Medtronic.

Clinical Question: What is the frequency of short-term corticosteroid prescriptions and adverse events associated with their use?

Background: Long-term corticosteroid use is usually avoided given risks of complications. Less is known about the risk and frequency of short-term corticosteroid use.

Study Design: Retrospective cohort study and self-controlled case series.

Setting: National U.S. dataset of private insurance claims.

Dr. Gray is assistant professor in the University of Kentucky division of hospital medicine and the Lexington VA Medical Center.

Clinical Question: What is the frequency of short-term corticosteroid prescriptions and adverse events associated with their use?

Background: Long-term corticosteroid use is usually avoided given risks of complications. Less is known about the risk and frequency of short-term corticosteroid use.

Study Design: Retrospective cohort study and self-controlled case series.

Setting: National U.S. dataset of private insurance claims.

Dr. Gray is assistant professor in the University of Kentucky division of hospital medicine and the Lexington VA Medical Center.

Clinical Question: What is the frequency of short-term corticosteroid prescriptions and adverse events associated with their use?

Background: Long-term corticosteroid use is usually avoided given risks of complications. Less is known about the risk and frequency of short-term corticosteroid use.

Study Design: Retrospective cohort study and self-controlled case series.

Setting: National U.S. dataset of private insurance claims.

Dr. Gray is assistant professor in the University of Kentucky division of hospital medicine and the Lexington VA Medical Center.

NASHVILLE, TENN. – Axillary thermometry outperformed both rectal and temporal artery thermometry in 205 newborns aged 12-72 hours in a study performed at the University of North Carolina at Chapel Hill.

The infants had two temperatures taken by each method over a period of 15 minutes, for a total of six readings per child and 1,230 measurements overall. Axillary thermometry proved both accurate and reliable. Rectal thermometry was accurate but less reliable, and temporal thermometry was reliable but less accurate.

M. Alexander Otto/Frontline Medical News

[email protected]

NASHVILLE, TENN. – Axillary thermometry outperformed both rectal and temporal artery thermometry in 205 newborns aged 12-72 hours in a study performed at the University of North Carolina at Chapel Hill.

The infants had two temperatures taken by each method over a period of 15 minutes, for a total of six readings per child and 1,230 measurements overall. Axillary thermometry proved both accurate and reliable. Rectal thermometry was accurate but less reliable, and temporal thermometry was reliable but less accurate.

M. Alexander Otto/Frontline Medical News

[email protected]

NASHVILLE, TENN. – Axillary thermometry outperformed both rectal and temporal artery thermometry in 205 newborns aged 12-72 hours in a study performed at the University of North Carolina at Chapel Hill.

The infants had two temperatures taken by each method over a period of 15 minutes, for a total of six readings per child and 1,230 measurements overall. Axillary thermometry proved both accurate and reliable. Rectal thermometry was accurate but less reliable, and temporal thermometry was reliable but less accurate.

M. Alexander Otto/Frontline Medical News

[email protected]

Global mortality due to rheumatic heart disease fell by about 48% during a recent 25-year-period, but some of the poorest areas of the world were left behind, according to a report in the New England Journal of Medicine.

Those regions included Oceania, South Asia, and central sub-Saharan Africa, where rheumatic heart disease remains endemic, wrote David A. Watkins, MD, MPH, of the University of Washington, Seattle, and his coinvestigators. “We estimate that 10 persons per 1,000 population living in South Asia and central sub-Saharan Africa and 15 persons per 1,000 population in Oceania were living with rheumatic heart disease in the year 2015,” they wrote. “Improvements in the measurement of the burden of rheumatic heart disease will assist in planning for its control and will help identify countries where further investments are needed.”

Global mortality due to rheumatic heart disease fell by about 48% during a recent 25-year-period, but some of the poorest areas of the world were left behind, according to a report in the New England Journal of Medicine.

Those regions included Oceania, South Asia, and central sub-Saharan Africa, where rheumatic heart disease remains endemic, wrote David A. Watkins, MD, MPH, of the University of Washington, Seattle, and his coinvestigators. “We estimate that 10 persons per 1,000 population living in South Asia and central sub-Saharan Africa and 15 persons per 1,000 population in Oceania were living with rheumatic heart disease in the year 2015,” they wrote. “Improvements in the measurement of the burden of rheumatic heart disease will assist in planning for its control and will help identify countries where further investments are needed.”

Global mortality due to rheumatic heart disease fell by about 48% during a recent 25-year-period, but some of the poorest areas of the world were left behind, according to a report in the New England Journal of Medicine.

Those regions included Oceania, South Asia, and central sub-Saharan Africa, where rheumatic heart disease remains endemic, wrote David A. Watkins, MD, MPH, of the University of Washington, Seattle, and his coinvestigators. “We estimate that 10 persons per 1,000 population living in South Asia and central sub-Saharan Africa and 15 persons per 1,000 population in Oceania were living with rheumatic heart disease in the year 2015,” they wrote. “Improvements in the measurement of the burden of rheumatic heart disease will assist in planning for its control and will help identify countries where further investments are needed.”

Clinical Question: What is the epidemiology of meningitis and encephalitis in adults in the United States?

Background: Previous epidemiologic studies have been smaller with less clinical information available and without steroid usage rates.

Study Design: A retrospective database review.

Setting: The Premier HealthCare Database, including hospitals of all types and sizes.

Dr. Hall is an assistant professor in the University of Kentucky division of hospital medicine and pediatrics.

Clinical Question: What is the epidemiology of meningitis and encephalitis in adults in the United States?

Background: Previous epidemiologic studies have been smaller with less clinical information available and without steroid usage rates.

Study Design: A retrospective database review.

Setting: The Premier HealthCare Database, including hospitals of all types and sizes.

Dr. Hall is an assistant professor in the University of Kentucky division of hospital medicine and pediatrics.

Clinical Question: What is the epidemiology of meningitis and encephalitis in adults in the United States?

Background: Previous epidemiologic studies have been smaller with less clinical information available and without steroid usage rates.

Study Design: A retrospective database review.

Setting: The Premier HealthCare Database, including hospitals of all types and sizes.

Dr. Hall is an assistant professor in the University of Kentucky division of hospital medicine and pediatrics.

BACKGROUND: There is increasing recognition that patients have critical insights into care experiences, including about breakdowns in care. Harnessing patient perspectives for hospital improvement requires an in-depth understanding of the types of breakdowns patients identify and the impact of these events.

Also in JHM

Excess readmission vs. excess penalties: Maximum readmission penalties as a function of socioeconomics and geography

AUTHORS: Chris M. Caracciolo, MPH, Devin M. Parker, MS, Emily Marshall, MS, Jeremiah R. Brown, PhD, MS

Impact of a safety huddle-based intervention on monitor alarm rates in low-acuity pediatric intensive care unit patientsAUTHORS: Maya Dewan, MD, MPH, Heather Wolfe, MD, MSHP, Richard Lin, MD, Eileen Ware, RN, Michelle Weiss, RN, Lihai Song, MS, Matthew MacMurchy, BA, Daniela Davis, MD, MSCE, Christopher P. Bonafide MD MSCE

Perspectives of clinicians at skilled nursing facilities on 30-day hospital readmissions: A qualitative studyAUTHORS: Bennett W. Clark, MD, Katelyn Baron, MSIOP, Kathleen Tynan-McKiernan, RN, MSN, Meredith Campbell Britton, LMSW, Karl E. Minges, PhD, Sarwat I. Chaudhry, MD

Use of postacute facility care in children hospitalized with acute respiratory illnessAUTHORS: Jay G. Berry, MD, MPH, Karen M. Wilson, MD, MPH, FAAP, Helene Dumas, PT, MS, Edwin Simpser, MD, Jane O’Brien, MD, Kathleen Whitford, PNP, Rachna May, MD, Vineeta Mittal, MD, Nancy Murphy, MD, David Steinhorn, MD, Rishi Agrawal, MD, MPH, Kris Rehm, MD, Michelle Marks, DO, FAAP, SFHM, Christine Traul, MD, Michael Dribbon, PhD, Christopher J. Haines, DO, MBA, FAAP, FACEP, Matt Hall, PhD

A contemporary assessment of mechanical complication rates and trainee perceptions of central venous catheter insertionAUTHORS: Lauren Heidemann, MD, Niket Nathani, MD, Rommel Sagana, MD, Vineet Chopra, MD, MSc, Michael Heung, MD, MS

For more articles and subscription information, visit www.journalofhospitalmedicine.com.

BACKGROUND: There is increasing recognition that patients have critical insights into care experiences, including about breakdowns in care. Harnessing patient perspectives for hospital improvement requires an in-depth understanding of the types of breakdowns patients identify and the impact of these events.

Also in JHM

Excess readmission vs. excess penalties: Maximum readmission penalties as a function of socioeconomics and geography

AUTHORS: Chris M. Caracciolo, MPH, Devin M. Parker, MS, Emily Marshall, MS, Jeremiah R. Brown, PhD, MS

Impact of a safety huddle-based intervention on monitor alarm rates in low-acuity pediatric intensive care unit patientsAUTHORS: Maya Dewan, MD, MPH, Heather Wolfe, MD, MSHP, Richard Lin, MD, Eileen Ware, RN, Michelle Weiss, RN, Lihai Song, MS, Matthew MacMurchy, BA, Daniela Davis, MD, MSCE, Christopher P. Bonafide MD MSCE

Perspectives of clinicians at skilled nursing facilities on 30-day hospital readmissions: A qualitative studyAUTHORS: Bennett W. Clark, MD, Katelyn Baron, MSIOP, Kathleen Tynan-McKiernan, RN, MSN, Meredith Campbell Britton, LMSW, Karl E. Minges, PhD, Sarwat I. Chaudhry, MD

Use of postacute facility care in children hospitalized with acute respiratory illnessAUTHORS: Jay G. Berry, MD, MPH, Karen M. Wilson, MD, MPH, FAAP, Helene Dumas, PT, MS, Edwin Simpser, MD, Jane O’Brien, MD, Kathleen Whitford, PNP, Rachna May, MD, Vineeta Mittal, MD, Nancy Murphy, MD, David Steinhorn, MD, Rishi Agrawal, MD, MPH, Kris Rehm, MD, Michelle Marks, DO, FAAP, SFHM, Christine Traul, MD, Michael Dribbon, PhD, Christopher J. Haines, DO, MBA, FAAP, FACEP, Matt Hall, PhD

A contemporary assessment of mechanical complication rates and trainee perceptions of central venous catheter insertionAUTHORS: Lauren Heidemann, MD, Niket Nathani, MD, Rommel Sagana, MD, Vineet Chopra, MD, MSc, Michael Heung, MD, MS

For more articles and subscription information, visit www.journalofhospitalmedicine.com.

BACKGROUND: There is increasing recognition that patients have critical insights into care experiences, including about breakdowns in care. Harnessing patient perspectives for hospital improvement requires an in-depth understanding of the types of breakdowns patients identify and the impact of these events.

Also in JHM

Excess readmission vs. excess penalties: Maximum readmission penalties as a function of socioeconomics and geography

AUTHORS: Chris M. Caracciolo, MPH, Devin M. Parker, MS, Emily Marshall, MS, Jeremiah R. Brown, PhD, MS

Impact of a safety huddle-based intervention on monitor alarm rates in low-acuity pediatric intensive care unit patientsAUTHORS: Maya Dewan, MD, MPH, Heather Wolfe, MD, MSHP, Richard Lin, MD, Eileen Ware, RN, Michelle Weiss, RN, Lihai Song, MS, Matthew MacMurchy, BA, Daniela Davis, MD, MSCE, Christopher P. Bonafide MD MSCE

Perspectives of clinicians at skilled nursing facilities on 30-day hospital readmissions: A qualitative studyAUTHORS: Bennett W. Clark, MD, Katelyn Baron, MSIOP, Kathleen Tynan-McKiernan, RN, MSN, Meredith Campbell Britton, LMSW, Karl E. Minges, PhD, Sarwat I. Chaudhry, MD

Use of postacute facility care in children hospitalized with acute respiratory illnessAUTHORS: Jay G. Berry, MD, MPH, Karen M. Wilson, MD, MPH, FAAP, Helene Dumas, PT, MS, Edwin Simpser, MD, Jane O’Brien, MD, Kathleen Whitford, PNP, Rachna May, MD, Vineeta Mittal, MD, Nancy Murphy, MD, David Steinhorn, MD, Rishi Agrawal, MD, MPH, Kris Rehm, MD, Michelle Marks, DO, FAAP, SFHM, Christine Traul, MD, Michael Dribbon, PhD, Christopher J. Haines, DO, MBA, FAAP, FACEP, Matt Hall, PhD

A contemporary assessment of mechanical complication rates and trainee perceptions of central venous catheter insertionAUTHORS: Lauren Heidemann, MD, Niket Nathani, MD, Rommel Sagana, MD, Vineet Chopra, MD, MSc, Michael Heung, MD, MS

For more articles and subscription information, visit www.journalofhospitalmedicine.com.

Background

Hospital-acquired pneumonia (HAP) is defined as pneumonia that develops 48 hours or more after admission that was not present on admission; and ventilator-associated pneumonia (VAP) is pneumonia that develops 48 hours or more after endotracheal intubation.

HAP and VAP are common afflictions in hospitalized patients, accounting for nearly one-quarter of all hospital-acquired infections. They confer mortality rates of 24%-50%, increasing to nearly 75% if caused by resistant organisms.^1,2 Given the high prevalence and significant mortality associated with these types of pneumonia, diagnosis and treatment are essential. Treatment must be balanced against potential unintended consequences of antibiotic use including Clostridium difficile infections and the promotion of resistant bacteria caused by poor antibiotic stewardship.

Given the frequency with which HAP and VAP occur, and the need for equipoise with antibiotic use, it is essential that all practicing clinicians have an evidence-based construct for the diagnosis and treatment of HAP and VAP.
 

Guideline updates

In 2016, the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) reconvened after 11 years to update their recommendations for the treatment of HAP and VAP.² The decision to update their recommendations was based on the availability of new evidence regarding the diagnosis and treatment of these conditions.

Methods for Diagnosis: The use of semi-quantitative, noninvasive sampling of respiratory cultures is preferred for HAP and VAP, rather than empiric treatment or quantitative cultures (i.e., bronchoalveolar lavage, protected-specimen brush and blind bronchial sampling).

Initial antibiotic choice: For HAP and VAP, clinicians should include therapy targeting S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli. Therapy for methicillin-resistant S. aureus should be included if patients are at high risk for death (i.e., septic shock or ventilated patients) or if local drug-resistant prevalence is greater than 10%-20%. Similarly, two antipseudomonal antibiotics should be used only with empiric therapy if the patient is at high risk for mortality or local drug-resistant prevalence is greater than 10%.

Duration of therapy: HAP and VAP should be treated for 7 days with regimens that are tailored to culture data when available, assuming there has been appropriate clinical response. Procalcitonin may be paired with clinical judgment when considering antibiotic discontinuation.

Guideline analysis

There are several notable differences between the 2016 IDSA/ATS guidelines and the 2005 guidelines.³ The earlier guidelines recommended strong consideration of invasive respiratory cultures such as bronchoalveolar lavage or protected-specimen brush sampling for HAP/VAP. It is now recommended that only noninvasive cultures be performed in most clinical scenarios.

Takeaways

When considering the diagnosis of HAP and VAP, clinicians should be aware that the category of HCAP has been removed from current guidelines, and methods for microbiological diagnosis have been simplified.⁷ In addition, initial antibiotic selection should rely on institution-specific antibiograms and local resistance patterns when available. Recommended duration of therapy has been shortened, and should not include aminoglycosides.

Finally, antibiotic stewardship is the responsibility of each clinician and de-escalation of therapy for HAP and VAP should be guided by available respiratory cultures.
 

Dr. Hippensteel is a pulmonologist in Aurora, Colo. Dr. Sippel is visiting associate professor of clinical practice, medicine-pulmonary sciences & critical care at the University of Colorado School of Medicine.

References

1. Masterton R, Galloway A, French G, Street M, Armstrong J, Brown E, Cleverley J, Dilworth P, Fry C, Gascoigne A. Guidelines for the management of hospital-acquired pneumonia in the UK: report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother. 2008;62(1):5-34.

2. Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O’grady NP, Bartlett JG, Carratalà J. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016:ciw353.

3. Society AT, America IDSo. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416.

4. Dalhoff K, Abele-Horn M, Andreas S, Bauer T, von Baum H, Deja M, Ewig S, Gastmeier P, Gatermann S, Gerlach H. Epidemiology, diagnosis, and treatment of adult patients with nosocomial pneumonia. S-3 Guideline of the German Society for Anaesthesiology and Intensive Care Medicine, the German Society for Infectious Diseases, the German Society for Hygiene and Microbiology, the German Respiratory Society and the Paul-Ehrlich-Society for Chemotherapy. Pneumologie (Stuttgart, Germany). 2012;66(12):707-65.

5. Rotstein C, Evans G, Born A, Grossman R, Light RB, Magder S, McTaggart B, Weiss K, Zhanel GG. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Canadian Journal of Infectious Diseases and Medical Microbiology. 2008;19(1):19-53.

6. Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Dubberke ER, Fraser V. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(S1):S31-S40.

7. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing healthcare-associated pneumonia, 2003. MMWR. 2004;53(RR-3):1-36.

Background

Hospital-acquired pneumonia (HAP) is defined as pneumonia that develops 48 hours or more after admission that was not present on admission; and ventilator-associated pneumonia (VAP) is pneumonia that develops 48 hours or more after endotracheal intubation.

HAP and VAP are common afflictions in hospitalized patients, accounting for nearly one-quarter of all hospital-acquired infections. They confer mortality rates of 24%-50%, increasing to nearly 75% if caused by resistant organisms.^1,2 Given the high prevalence and significant mortality associated with these types of pneumonia, diagnosis and treatment are essential. Treatment must be balanced against potential unintended consequences of antibiotic use including Clostridium difficile infections and the promotion of resistant bacteria caused by poor antibiotic stewardship.

Given the frequency with which HAP and VAP occur, and the need for equipoise with antibiotic use, it is essential that all practicing clinicians have an evidence-based construct for the diagnosis and treatment of HAP and VAP.
 

Guideline updates

In 2016, the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) reconvened after 11 years to update their recommendations for the treatment of HAP and VAP.² The decision to update their recommendations was based on the availability of new evidence regarding the diagnosis and treatment of these conditions.

Methods for Diagnosis: The use of semi-quantitative, noninvasive sampling of respiratory cultures is preferred for HAP and VAP, rather than empiric treatment or quantitative cultures (i.e., bronchoalveolar lavage, protected-specimen brush and blind bronchial sampling).

Initial antibiotic choice: For HAP and VAP, clinicians should include therapy targeting S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli. Therapy for methicillin-resistant S. aureus should be included if patients are at high risk for death (i.e., septic shock or ventilated patients) or if local drug-resistant prevalence is greater than 10%-20%. Similarly, two antipseudomonal antibiotics should be used only with empiric therapy if the patient is at high risk for mortality or local drug-resistant prevalence is greater than 10%.

Duration of therapy: HAP and VAP should be treated for 7 days with regimens that are tailored to culture data when available, assuming there has been appropriate clinical response. Procalcitonin may be paired with clinical judgment when considering antibiotic discontinuation.

Guideline analysis

There are several notable differences between the 2016 IDSA/ATS guidelines and the 2005 guidelines.³ The earlier guidelines recommended strong consideration of invasive respiratory cultures such as bronchoalveolar lavage or protected-specimen brush sampling for HAP/VAP. It is now recommended that only noninvasive cultures be performed in most clinical scenarios.

Takeaways

When considering the diagnosis of HAP and VAP, clinicians should be aware that the category of HCAP has been removed from current guidelines, and methods for microbiological diagnosis have been simplified.⁷ In addition, initial antibiotic selection should rely on institution-specific antibiograms and local resistance patterns when available. Recommended duration of therapy has been shortened, and should not include aminoglycosides.

Finally, antibiotic stewardship is the responsibility of each clinician and de-escalation of therapy for HAP and VAP should be guided by available respiratory cultures.
 

Dr. Hippensteel is a pulmonologist in Aurora, Colo. Dr. Sippel is visiting associate professor of clinical practice, medicine-pulmonary sciences & critical care at the University of Colorado School of Medicine.

References

1. Masterton R, Galloway A, French G, Street M, Armstrong J, Brown E, Cleverley J, Dilworth P, Fry C, Gascoigne A. Guidelines for the management of hospital-acquired pneumonia in the UK: report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother. 2008;62(1):5-34.

2. Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O’grady NP, Bartlett JG, Carratalà J. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016:ciw353.

3. Society AT, America IDSo. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416.

4. Dalhoff K, Abele-Horn M, Andreas S, Bauer T, von Baum H, Deja M, Ewig S, Gastmeier P, Gatermann S, Gerlach H. Epidemiology, diagnosis, and treatment of adult patients with nosocomial pneumonia. S-3 Guideline of the German Society for Anaesthesiology and Intensive Care Medicine, the German Society for Infectious Diseases, the German Society for Hygiene and Microbiology, the German Respiratory Society and the Paul-Ehrlich-Society for Chemotherapy. Pneumologie (Stuttgart, Germany). 2012;66(12):707-65.

5. Rotstein C, Evans G, Born A, Grossman R, Light RB, Magder S, McTaggart B, Weiss K, Zhanel GG. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Canadian Journal of Infectious Diseases and Medical Microbiology. 2008;19(1):19-53.

6. Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Dubberke ER, Fraser V. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(S1):S31-S40.

7. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing healthcare-associated pneumonia, 2003. MMWR. 2004;53(RR-3):1-36.

Background

Hospital-acquired pneumonia (HAP) is defined as pneumonia that develops 48 hours or more after admission that was not present on admission; and ventilator-associated pneumonia (VAP) is pneumonia that develops 48 hours or more after endotracheal intubation.

HAP and VAP are common afflictions in hospitalized patients, accounting for nearly one-quarter of all hospital-acquired infections. They confer mortality rates of 24%-50%, increasing to nearly 75% if caused by resistant organisms.^1,2 Given the high prevalence and significant mortality associated with these types of pneumonia, diagnosis and treatment are essential. Treatment must be balanced against potential unintended consequences of antibiotic use including Clostridium difficile infections and the promotion of resistant bacteria caused by poor antibiotic stewardship.

Given the frequency with which HAP and VAP occur, and the need for equipoise with antibiotic use, it is essential that all practicing clinicians have an evidence-based construct for the diagnosis and treatment of HAP and VAP.
 

Guideline updates

In 2016, the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) reconvened after 11 years to update their recommendations for the treatment of HAP and VAP.² The decision to update their recommendations was based on the availability of new evidence regarding the diagnosis and treatment of these conditions.

Methods for Diagnosis: The use of semi-quantitative, noninvasive sampling of respiratory cultures is preferred for HAP and VAP, rather than empiric treatment or quantitative cultures (i.e., bronchoalveolar lavage, protected-specimen brush and blind bronchial sampling).

Initial antibiotic choice: For HAP and VAP, clinicians should include therapy targeting S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli. Therapy for methicillin-resistant S. aureus should be included if patients are at high risk for death (i.e., septic shock or ventilated patients) or if local drug-resistant prevalence is greater than 10%-20%. Similarly, two antipseudomonal antibiotics should be used only with empiric therapy if the patient is at high risk for mortality or local drug-resistant prevalence is greater than 10%.

Duration of therapy: HAP and VAP should be treated for 7 days with regimens that are tailored to culture data when available, assuming there has been appropriate clinical response. Procalcitonin may be paired with clinical judgment when considering antibiotic discontinuation.

Guideline analysis

There are several notable differences between the 2016 IDSA/ATS guidelines and the 2005 guidelines.³ The earlier guidelines recommended strong consideration of invasive respiratory cultures such as bronchoalveolar lavage or protected-specimen brush sampling for HAP/VAP. It is now recommended that only noninvasive cultures be performed in most clinical scenarios.

Takeaways

When considering the diagnosis of HAP and VAP, clinicians should be aware that the category of HCAP has been removed from current guidelines, and methods for microbiological diagnosis have been simplified.⁷ In addition, initial antibiotic selection should rely on institution-specific antibiograms and local resistance patterns when available. Recommended duration of therapy has been shortened, and should not include aminoglycosides.

Finally, antibiotic stewardship is the responsibility of each clinician and de-escalation of therapy for HAP and VAP should be guided by available respiratory cultures.
 

Dr. Hippensteel is a pulmonologist in Aurora, Colo. Dr. Sippel is visiting associate professor of clinical practice, medicine-pulmonary sciences & critical care at the University of Colorado School of Medicine.

References

1. Masterton R, Galloway A, French G, Street M, Armstrong J, Brown E, Cleverley J, Dilworth P, Fry C, Gascoigne A. Guidelines for the management of hospital-acquired pneumonia in the UK: report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother. 2008;62(1):5-34.

2. Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O’grady NP, Bartlett JG, Carratalà J. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016:ciw353.

3. Society AT, America IDSo. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416.

4. Dalhoff K, Abele-Horn M, Andreas S, Bauer T, von Baum H, Deja M, Ewig S, Gastmeier P, Gatermann S, Gerlach H. Epidemiology, diagnosis, and treatment of adult patients with nosocomial pneumonia. S-3 Guideline of the German Society for Anaesthesiology and Intensive Care Medicine, the German Society for Infectious Diseases, the German Society for Hygiene and Microbiology, the German Respiratory Society and the Paul-Ehrlich-Society for Chemotherapy. Pneumologie (Stuttgart, Germany). 2012;66(12):707-65.

5. Rotstein C, Evans G, Born A, Grossman R, Light RB, Magder S, McTaggart B, Weiss K, Zhanel GG. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Canadian Journal of Infectious Diseases and Medical Microbiology. 2008;19(1):19-53.

6. Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Dubberke ER, Fraser V. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(S1):S31-S40.

7. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing healthcare-associated pneumonia, 2003. MMWR. 2004;53(RR-3):1-36.

Rates of phlebitis associated with peripheral venous catheters (PVC) ranged from less than 1% to 34% depending on which assessment tool researchers used in a large cross-sectional study.

Rates also varied within individual instruments because they included several possible case definitions, Katarina Göransson, PhD, and her associates reported in Lancet Haematology. “We find it concerning that our study shows variation of the proportion of PVCs causing phlebitis both within and across the instruments investigated,” they wrote. “How to best measure phlebitis outcomes is still unclear, since no universally accepted instrument exists that has had rigorous testing. From a work environment and patient safety perspective, clinical staff engaged in PVC management should be aware of the absence of adequately validated instruments for phlebitis assessment.”

There are many tools to measure PVC-related phlebitis, but no consensus on which to use, and past studies have reported rates of anywhere from 2% to 62%. Hypothesizing that instrument variability contributed to this discrepancy, the researchers tested 17 instruments in 1,032 patients who had 1,175 PVCs placed at 12 inpatient units in Sweden. Eight tools used clinical definitions, seven used severity rating systems, and two used scoring systems (Lancet Haematol. 2017 doi: 10.1016/S2352-3026[17]30122-9).

Rates of PVC-induced phlebitis reached 12% (137 cases) when the researchers used case definition tools, up to 31% when they used scoring systems (P less than .0001), and up to 34% when they used severity rating systems (P less than .0001, compared with the 12% rate). “The proportion within instruments ranged from less than 1% to 28%,” they added. “We [also] identified face validity issues, such as use of indistinct or complex measurements and inconsistent measurements or definitions.”

The investigators did not perform a systematic review to identify these instruments, and they did not necessarily use the most recent versions, they noted. Nevertheless, the findings have direct implications for hospital quality control measures, which require using a single validated instrument over time to generate meaningful results, they said. Hence, the investigators recommended developing a joint research program to develop reliable measures of PVC-related adverse events and better support clinicians who are trying to decide whether to remove PVCs.

The investigators reported having no funding sources and no competing interests.

[email protected]

Rates of phlebitis associated with peripheral venous catheters (PVC) ranged from less than 1% to 34% depending on which assessment tool researchers used in a large cross-sectional study.

Rates also varied within individual instruments because they included several possible case definitions, Katarina Göransson, PhD, and her associates reported in Lancet Haematology. “We find it concerning that our study shows variation of the proportion of PVCs causing phlebitis both within and across the instruments investigated,” they wrote. “How to best measure phlebitis outcomes is still unclear, since no universally accepted instrument exists that has had rigorous testing. From a work environment and patient safety perspective, clinical staff engaged in PVC management should be aware of the absence of adequately validated instruments for phlebitis assessment.”

There are many tools to measure PVC-related phlebitis, but no consensus on which to use, and past studies have reported rates of anywhere from 2% to 62%. Hypothesizing that instrument variability contributed to this discrepancy, the researchers tested 17 instruments in 1,032 patients who had 1,175 PVCs placed at 12 inpatient units in Sweden. Eight tools used clinical definitions, seven used severity rating systems, and two used scoring systems (Lancet Haematol. 2017 doi: 10.1016/S2352-3026[17]30122-9).

Rates of PVC-induced phlebitis reached 12% (137 cases) when the researchers used case definition tools, up to 31% when they used scoring systems (P less than .0001), and up to 34% when they used severity rating systems (P less than .0001, compared with the 12% rate). “The proportion within instruments ranged from less than 1% to 28%,” they added. “We [also] identified face validity issues, such as use of indistinct or complex measurements and inconsistent measurements or definitions.”

The investigators did not perform a systematic review to identify these instruments, and they did not necessarily use the most recent versions, they noted. Nevertheless, the findings have direct implications for hospital quality control measures, which require using a single validated instrument over time to generate meaningful results, they said. Hence, the investigators recommended developing a joint research program to develop reliable measures of PVC-related adverse events and better support clinicians who are trying to decide whether to remove PVCs.

The investigators reported having no funding sources and no competing interests.

[email protected]

Rates of phlebitis associated with peripheral venous catheters (PVC) ranged from less than 1% to 34% depending on which assessment tool researchers used in a large cross-sectional study.

Rates also varied within individual instruments because they included several possible case definitions, Katarina Göransson, PhD, and her associates reported in Lancet Haematology. “We find it concerning that our study shows variation of the proportion of PVCs causing phlebitis both within and across the instruments investigated,” they wrote. “How to best measure phlebitis outcomes is still unclear, since no universally accepted instrument exists that has had rigorous testing. From a work environment and patient safety perspective, clinical staff engaged in PVC management should be aware of the absence of adequately validated instruments for phlebitis assessment.”

There are many tools to measure PVC-related phlebitis, but no consensus on which to use, and past studies have reported rates of anywhere from 2% to 62%. Hypothesizing that instrument variability contributed to this discrepancy, the researchers tested 17 instruments in 1,032 patients who had 1,175 PVCs placed at 12 inpatient units in Sweden. Eight tools used clinical definitions, seven used severity rating systems, and two used scoring systems (Lancet Haematol. 2017 doi: 10.1016/S2352-3026[17]30122-9).

Rates of PVC-induced phlebitis reached 12% (137 cases) when the researchers used case definition tools, up to 31% when they used scoring systems (P less than .0001), and up to 34% when they used severity rating systems (P less than .0001, compared with the 12% rate). “The proportion within instruments ranged from less than 1% to 28%,” they added. “We [also] identified face validity issues, such as use of indistinct or complex measurements and inconsistent measurements or definitions.”

The investigators did not perform a systematic review to identify these instruments, and they did not necessarily use the most recent versions, they noted. Nevertheless, the findings have direct implications for hospital quality control measures, which require using a single validated instrument over time to generate meaningful results, they said. Hence, the investigators recommended developing a joint research program to develop reliable measures of PVC-related adverse events and better support clinicians who are trying to decide whether to remove PVCs.

The investigators reported having no funding sources and no competing interests.

[email protected]