Clinical

Clinical question: What is the relationship between crowding in the ED and the number of interventions adopted by the ED to address this?

Background: ED crowding results in long waits, prolonged lengths of stay, and delays in providing treatments, which can result in adverse events. Numerous interventions, including bedside registration, ED observation units, fast track, bed czar, surgical schedule smoothing, and pooled nursing, have been implemented to reduce crowding.

Study design: Retrospective, cross-sectional analysis.

Setting: U.S. hospitals in the National Hospital Ambulatory Medical Care Survey (NHAMCS).

Synopsis: From 2007 to 2010, an average of 341 hospitals per year were analyzed from the NHAMCS, representing 139,502 patient encounters. This study evaluated the adoption of nine crowding interventions at the emergency department level (bedside registration, electronic dashboard, RFID tracking, etc.) and eight crowding interventions at the hospital level (bed czar, pooled nursing, full-capacity protocol, board patients in inpatient hallways, etc.).

Bedside registration, electronic dashboard, RFID tracking, bed census, pooled nursing, full-capacity protocol, and boarding patients in the hallway had the highest statistically significant increases in adoption over the study period.

The average number of interventions adopted increased to 6.6 from 5.2, and more-crowded EDs adopted a greater number of interventions than less-crowded EDs. However, in the most-crowded quartile of EDs, 19% did not use bedside registration, and 94% did not use surgical schedule smoothing.

Given that this study is a retrospective, cross-sectional study, it is difficult to determine causality.

Bottom line: More interventions are being adopted by EDs and hospitals to decrease ED crowding, but several of the busiest EDs and hospitals have room for improvement.

Citation: Warner LS, Pines JM, Chambers JG, Schuur JD. The most crowded US hospital emergency departments did not adopt effective interventions to improve flow, 2007–10. Health Aff. 2015;34(12):2151-2159.

Clinical question: What is the relationship between crowding in the ED and the number of interventions adopted by the ED to address this?

Background: ED crowding results in long waits, prolonged lengths of stay, and delays in providing treatments, which can result in adverse events. Numerous interventions, including bedside registration, ED observation units, fast track, bed czar, surgical schedule smoothing, and pooled nursing, have been implemented to reduce crowding.

Study design: Retrospective, cross-sectional analysis.

Setting: U.S. hospitals in the National Hospital Ambulatory Medical Care Survey (NHAMCS).

Synopsis: From 2007 to 2010, an average of 341 hospitals per year were analyzed from the NHAMCS, representing 139,502 patient encounters. This study evaluated the adoption of nine crowding interventions at the emergency department level (bedside registration, electronic dashboard, RFID tracking, etc.) and eight crowding interventions at the hospital level (bed czar, pooled nursing, full-capacity protocol, board patients in inpatient hallways, etc.).

Bedside registration, electronic dashboard, RFID tracking, bed census, pooled nursing, full-capacity protocol, and boarding patients in the hallway had the highest statistically significant increases in adoption over the study period.

The average number of interventions adopted increased to 6.6 from 5.2, and more-crowded EDs adopted a greater number of interventions than less-crowded EDs. However, in the most-crowded quartile of EDs, 19% did not use bedside registration, and 94% did not use surgical schedule smoothing.

Given that this study is a retrospective, cross-sectional study, it is difficult to determine causality.

Bottom line: More interventions are being adopted by EDs and hospitals to decrease ED crowding, but several of the busiest EDs and hospitals have room for improvement.

Citation: Warner LS, Pines JM, Chambers JG, Schuur JD. The most crowded US hospital emergency departments did not adopt effective interventions to improve flow, 2007–10. Health Aff. 2015;34(12):2151-2159.

Clinical question: What is the relationship between crowding in the ED and the number of interventions adopted by the ED to address this?

Background: ED crowding results in long waits, prolonged lengths of stay, and delays in providing treatments, which can result in adverse events. Numerous interventions, including bedside registration, ED observation units, fast track, bed czar, surgical schedule smoothing, and pooled nursing, have been implemented to reduce crowding.

Study design: Retrospective, cross-sectional analysis.

Setting: U.S. hospitals in the National Hospital Ambulatory Medical Care Survey (NHAMCS).

Synopsis: From 2007 to 2010, an average of 341 hospitals per year were analyzed from the NHAMCS, representing 139,502 patient encounters. This study evaluated the adoption of nine crowding interventions at the emergency department level (bedside registration, electronic dashboard, RFID tracking, etc.) and eight crowding interventions at the hospital level (bed czar, pooled nursing, full-capacity protocol, board patients in inpatient hallways, etc.).

Bedside registration, electronic dashboard, RFID tracking, bed census, pooled nursing, full-capacity protocol, and boarding patients in the hallway had the highest statistically significant increases in adoption over the study period.

The average number of interventions adopted increased to 6.6 from 5.2, and more-crowded EDs adopted a greater number of interventions than less-crowded EDs. However, in the most-crowded quartile of EDs, 19% did not use bedside registration, and 94% did not use surgical schedule smoothing.

Given that this study is a retrospective, cross-sectional study, it is difficult to determine causality.

Bottom line: More interventions are being adopted by EDs and hospitals to decrease ED crowding, but several of the busiest EDs and hospitals have room for improvement.

Citation: Warner LS, Pines JM, Chambers JG, Schuur JD. The most crowded US hospital emergency departments did not adopt effective interventions to improve flow, 2007–10. Health Aff. 2015;34(12):2151-2159.

Clinical question: What is the appropriate frequency of INR monitoring in the hospital and its relationship to the risk of over-anticoagulation and warfarin-related adverse events?

Background: Warfarin use is a common cause of adverse drug events in hospitalized patients due to narrow therapeutic windows, drug interactions, and variability of metabolism. Current guidelines, including those by the American College of Chest Physicians, do not provide recommendations on how often to monitor INR or adjust warfarin dosing in the hospital.

Study design: Retrospective cohort.

Setting: Hospitalized patients included in the Medicare Patient Safety Monitoring System.

Synopsis: The study included 14,217 adult patients ≥18 years of age from the Medicare Patient Safety Monitoring System admitted from 2009 to 2013 with pneumonia, acute cardiac disease (myocardial infarction or congestive heart failure), or surgery and taking warfarin. Of those, 1,055 (7.4%) developed a warfarin-associated adverse event (bleeding, drop in hematocrit ≥3, hematoma, death, intracranial bleeding, or cardiac arrest). Patients admitted for acute cardiac disease (acute myocardial infarction or heart failure) or surgery on warfarin for ≥3 days but not monitored for ≥2 days had more warfarin-associated adverse events (OR 1.48; 95% CI, 1.02–2.17), but this association was not true in pneumonia patients. Cardiac and pneumonia patients with ≥1 day without INR being measured had higher rates of INR ≥6.0 (OR 1.61; 95% CI, 1.07–2.41, and OR 1.92, 95% CI, 1.36–2.71, respectively). A single-day rise in INR ≥0.9 had a likelihood ratio of 4.2 in predicting subsequent INR ≥6.0.

Bottom line: Frequent monitoring of INR may decrease warfarin-associated adverse events in hospitalized patients.

Citation: Metersky ML, Eldridge N, Wang Y, et al. Predictors of warfarin-associated adverse events in hospitalized patients: opportunities to prevent harm. J Hosp Med. 2016;11(4):276-282.

Short Take

CDC Guidelines on Prescribing Opioids

New CDC guidelines for chronic pain management stress the importance of non-pharmacologic (physical therapy, etc.) and non-opioid therapy (NSAIDs, etc.), using opioid therapy only if the expected benefits outweigh the risks.

Citation: CDC. CDC guideline for prescribing opioids for chronic pain. Available at: http://www.cdc.gov/drugoverdose/prescribing/guideline.html. Published March 16, 2016. Accessed April 8, 2016.

Clinical question: What is the appropriate frequency of INR monitoring in the hospital and its relationship to the risk of over-anticoagulation and warfarin-related adverse events?

Background: Warfarin use is a common cause of adverse drug events in hospitalized patients due to narrow therapeutic windows, drug interactions, and variability of metabolism. Current guidelines, including those by the American College of Chest Physicians, do not provide recommendations on how often to monitor INR or adjust warfarin dosing in the hospital.

Study design: Retrospective cohort.

Setting: Hospitalized patients included in the Medicare Patient Safety Monitoring System.

Synopsis: The study included 14,217 adult patients ≥18 years of age from the Medicare Patient Safety Monitoring System admitted from 2009 to 2013 with pneumonia, acute cardiac disease (myocardial infarction or congestive heart failure), or surgery and taking warfarin. Of those, 1,055 (7.4%) developed a warfarin-associated adverse event (bleeding, drop in hematocrit ≥3, hematoma, death, intracranial bleeding, or cardiac arrest). Patients admitted for acute cardiac disease (acute myocardial infarction or heart failure) or surgery on warfarin for ≥3 days but not monitored for ≥2 days had more warfarin-associated adverse events (OR 1.48; 95% CI, 1.02–2.17), but this association was not true in pneumonia patients. Cardiac and pneumonia patients with ≥1 day without INR being measured had higher rates of INR ≥6.0 (OR 1.61; 95% CI, 1.07–2.41, and OR 1.92, 95% CI, 1.36–2.71, respectively). A single-day rise in INR ≥0.9 had a likelihood ratio of 4.2 in predicting subsequent INR ≥6.0.

Bottom line: Frequent monitoring of INR may decrease warfarin-associated adverse events in hospitalized patients.

Citation: Metersky ML, Eldridge N, Wang Y, et al. Predictors of warfarin-associated adverse events in hospitalized patients: opportunities to prevent harm. J Hosp Med. 2016;11(4):276-282.

Short Take

CDC Guidelines on Prescribing Opioids

New CDC guidelines for chronic pain management stress the importance of non-pharmacologic (physical therapy, etc.) and non-opioid therapy (NSAIDs, etc.), using opioid therapy only if the expected benefits outweigh the risks.

Citation: CDC. CDC guideline for prescribing opioids for chronic pain. Available at: http://www.cdc.gov/drugoverdose/prescribing/guideline.html. Published March 16, 2016. Accessed April 8, 2016.

Clinical question: What is the appropriate frequency of INR monitoring in the hospital and its relationship to the risk of over-anticoagulation and warfarin-related adverse events?

Background: Warfarin use is a common cause of adverse drug events in hospitalized patients due to narrow therapeutic windows, drug interactions, and variability of metabolism. Current guidelines, including those by the American College of Chest Physicians, do not provide recommendations on how often to monitor INR or adjust warfarin dosing in the hospital.

Study design: Retrospective cohort.

Setting: Hospitalized patients included in the Medicare Patient Safety Monitoring System.

Synopsis: The study included 14,217 adult patients ≥18 years of age from the Medicare Patient Safety Monitoring System admitted from 2009 to 2013 with pneumonia, acute cardiac disease (myocardial infarction or congestive heart failure), or surgery and taking warfarin. Of those, 1,055 (7.4%) developed a warfarin-associated adverse event (bleeding, drop in hematocrit ≥3, hematoma, death, intracranial bleeding, or cardiac arrest). Patients admitted for acute cardiac disease (acute myocardial infarction or heart failure) or surgery on warfarin for ≥3 days but not monitored for ≥2 days had more warfarin-associated adverse events (OR 1.48; 95% CI, 1.02–2.17), but this association was not true in pneumonia patients. Cardiac and pneumonia patients with ≥1 day without INR being measured had higher rates of INR ≥6.0 (OR 1.61; 95% CI, 1.07–2.41, and OR 1.92, 95% CI, 1.36–2.71, respectively). A single-day rise in INR ≥0.9 had a likelihood ratio of 4.2 in predicting subsequent INR ≥6.0.

Bottom line: Frequent monitoring of INR may decrease warfarin-associated adverse events in hospitalized patients.

Citation: Metersky ML, Eldridge N, Wang Y, et al. Predictors of warfarin-associated adverse events in hospitalized patients: opportunities to prevent harm. J Hosp Med. 2016;11(4):276-282.

Short Take

CDC Guidelines on Prescribing Opioids

New CDC guidelines for chronic pain management stress the importance of non-pharmacologic (physical therapy, etc.) and non-opioid therapy (NSAIDs, etc.), using opioid therapy only if the expected benefits outweigh the risks.

Citation: CDC. CDC guideline for prescribing opioids for chronic pain. Available at: http://www.cdc.gov/drugoverdose/prescribing/guideline.html. Published March 16, 2016. Accessed April 8, 2016.

Clinical question: What is the role for inpatient polysomnograms for children with medical complexity?

Background: Sleep-disordered breathing is more common in certain pediatric populations. Children with neuromuscular disease, craniofacial or tracheobronchial malformations, or developmental delay have up to 10 times the rate of sleep-disordered breathing as compared to the general pediatric population, with a prevalence as high as 40%. It is recommended that patients with neuromuscular conditions get annual polysomnograms (PSGs). The medical complexity and requirement for nursing and respiratory care makes it challenging to obtain routine outpatient PSGs in this population. This study is the first of its kind to examine the characteristics of patients receiving inpatient PSGs and to determine the effects the findings of these studies had on the patients’ care.

Study design: Retrospective case series.

Setting: Single, large, academic medical center.

Synopsis: Eight-five PSGs were completed on 70 patients during the study period. These occurred primarily in the pediatric intensive care unit (50 patients) but also in the neonatal intensive care unit (five patients) and the general pediatric floor (15 patients). The mean age of patients was 6.5 years, and 60% were male.

The most common diagnoses in this group were airway obstruction due to craniofacial abnormalities or defects of the tracheobronchial tree (54%), chronic respiratory failure (34%), hypoxic ischemic encephalopathy (23%), and genetic syndromes (14%). All sleep studies were successfully completed using the center’s dedicated sleep technicians and PSG scoring staff. There were no complications associated with the PSGs.

The most common specific indications for obtaining the PSGs were chronic pulmonary failure with airway obstruction and ventilator requirement assessment. Eighty-nine percent of patients had some abnormality of their PSG. Obstructive sleep apnea, tachypnea and desaturation, and disorders of sleep architecture were the most commonly found abnormalities.

The most common interventions based upon the PSG results were adjustment of ventilator parameters (46%), ENT referral for upper airway assessment (31%), and initiation of positive pressure ventilation (CPAP or BiPAP, 25%). Follow-up PSGs after these interventions demonstrated statistically significant improvement in apnea-hypopnea index, arousal index, and lowest oxygen saturation.

Bottom line: Inpatient PSGs for children with medical complexity are safe and often have significant findings that alter care for the patient.

Citation: Tkachenko N, Singh K, Abreu N, et al. Establishing a role for polysomnography in hospitalized children. Pediatr Neurol. 2016;57:39-45.e1. doi:10.1016/j.pediatrneurol.2015.12.020.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: What is the role for inpatient polysomnograms for children with medical complexity?

Background: Sleep-disordered breathing is more common in certain pediatric populations. Children with neuromuscular disease, craniofacial or tracheobronchial malformations, or developmental delay have up to 10 times the rate of sleep-disordered breathing as compared to the general pediatric population, with a prevalence as high as 40%. It is recommended that patients with neuromuscular conditions get annual polysomnograms (PSGs). The medical complexity and requirement for nursing and respiratory care makes it challenging to obtain routine outpatient PSGs in this population. This study is the first of its kind to examine the characteristics of patients receiving inpatient PSGs and to determine the effects the findings of these studies had on the patients’ care.

Study design: Retrospective case series.

Setting: Single, large, academic medical center.

Synopsis: Eight-five PSGs were completed on 70 patients during the study period. These occurred primarily in the pediatric intensive care unit (50 patients) but also in the neonatal intensive care unit (five patients) and the general pediatric floor (15 patients). The mean age of patients was 6.5 years, and 60% were male.

The most common diagnoses in this group were airway obstruction due to craniofacial abnormalities or defects of the tracheobronchial tree (54%), chronic respiratory failure (34%), hypoxic ischemic encephalopathy (23%), and genetic syndromes (14%). All sleep studies were successfully completed using the center’s dedicated sleep technicians and PSG scoring staff. There were no complications associated with the PSGs.

The most common specific indications for obtaining the PSGs were chronic pulmonary failure with airway obstruction and ventilator requirement assessment. Eighty-nine percent of patients had some abnormality of their PSG. Obstructive sleep apnea, tachypnea and desaturation, and disorders of sleep architecture were the most commonly found abnormalities.

The most common interventions based upon the PSG results were adjustment of ventilator parameters (46%), ENT referral for upper airway assessment (31%), and initiation of positive pressure ventilation (CPAP or BiPAP, 25%). Follow-up PSGs after these interventions demonstrated statistically significant improvement in apnea-hypopnea index, arousal index, and lowest oxygen saturation.

Bottom line: Inpatient PSGs for children with medical complexity are safe and often have significant findings that alter care for the patient.

Citation: Tkachenko N, Singh K, Abreu N, et al. Establishing a role for polysomnography in hospitalized children. Pediatr Neurol. 2016;57:39-45.e1. doi:10.1016/j.pediatrneurol.2015.12.020.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: What is the role for inpatient polysomnograms for children with medical complexity?

Background: Sleep-disordered breathing is more common in certain pediatric populations. Children with neuromuscular disease, craniofacial or tracheobronchial malformations, or developmental delay have up to 10 times the rate of sleep-disordered breathing as compared to the general pediatric population, with a prevalence as high as 40%. It is recommended that patients with neuromuscular conditions get annual polysomnograms (PSGs). The medical complexity and requirement for nursing and respiratory care makes it challenging to obtain routine outpatient PSGs in this population. This study is the first of its kind to examine the characteristics of patients receiving inpatient PSGs and to determine the effects the findings of these studies had on the patients’ care.

Study design: Retrospective case series.

Setting: Single, large, academic medical center.

Synopsis: Eight-five PSGs were completed on 70 patients during the study period. These occurred primarily in the pediatric intensive care unit (50 patients) but also in the neonatal intensive care unit (five patients) and the general pediatric floor (15 patients). The mean age of patients was 6.5 years, and 60% were male.

The most common diagnoses in this group were airway obstruction due to craniofacial abnormalities or defects of the tracheobronchial tree (54%), chronic respiratory failure (34%), hypoxic ischemic encephalopathy (23%), and genetic syndromes (14%). All sleep studies were successfully completed using the center’s dedicated sleep technicians and PSG scoring staff. There were no complications associated with the PSGs.

The most common specific indications for obtaining the PSGs were chronic pulmonary failure with airway obstruction and ventilator requirement assessment. Eighty-nine percent of patients had some abnormality of their PSG. Obstructive sleep apnea, tachypnea and desaturation, and disorders of sleep architecture were the most commonly found abnormalities.

The most common interventions based upon the PSG results were adjustment of ventilator parameters (46%), ENT referral for upper airway assessment (31%), and initiation of positive pressure ventilation (CPAP or BiPAP, 25%). Follow-up PSGs after these interventions demonstrated statistically significant improvement in apnea-hypopnea index, arousal index, and lowest oxygen saturation.

Bottom line: Inpatient PSGs for children with medical complexity are safe and often have significant findings that alter care for the patient.

Citation: Tkachenko N, Singh K, Abreu N, et al. Establishing a role for polysomnography in hospitalized children. Pediatr Neurol. 2016;57:39-45.e1. doi:10.1016/j.pediatrneurol.2015.12.020.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: What are the factors that promote education in delivering high-value, cost-conscious care?

Background: Healthcare costs are increasing, with most recent numbers showing U.S. expenditures on healthcare of more than $3 trillion, almost 18% of the gross domestic product. High-value care focuses on understanding the benefits, risks, and costs of care and promoting interventions that add value.

Study design: Systematic review.

Setting: Physicians, resident physicians, and medical students in North America, Asia, and Oceania.

Synopsis: Seventy-nine articles were included in the analysis, with 14 being RCTs. Most of the studies were conducted in North America (78.5%) and used a pre-post interventional design (58.2%). Practicing physicians (36.7%) made up the majority of participants in the study, with residents (15.2%) and medical students (6.3%) in smaller numbers. Analysis of the studies identified three factors for successful learning:

• effective transmission of knowledge about prices of services and general health economics, scientific evidence, and patient preferences;
• facilitation of reflective practice through feedback and/or stimulating reflection; and
• creation of a supportive environment.

Bottom line: The most-effective interventions in educating physicians, resident physicians, and medical students on high-value, cost-conscious care are effective transmission of knowledge, reflective practice, and supportive environment.

Citation: Stammen LA, Stalmeijer RE, Paternotte E, et al. Training physicians to provide high-value, cost-conscious care: a systematic review. JAMA. 2015;314(22):2384-2400.

Clinical question: What are the factors that promote education in delivering high-value, cost-conscious care?

Background: Healthcare costs are increasing, with most recent numbers showing U.S. expenditures on healthcare of more than $3 trillion, almost 18% of the gross domestic product. High-value care focuses on understanding the benefits, risks, and costs of care and promoting interventions that add value.

Study design: Systematic review.

Setting: Physicians, resident physicians, and medical students in North America, Asia, and Oceania.

Synopsis: Seventy-nine articles were included in the analysis, with 14 being RCTs. Most of the studies were conducted in North America (78.5%) and used a pre-post interventional design (58.2%). Practicing physicians (36.7%) made up the majority of participants in the study, with residents (15.2%) and medical students (6.3%) in smaller numbers. Analysis of the studies identified three factors for successful learning:

• effective transmission of knowledge about prices of services and general health economics, scientific evidence, and patient preferences;
• facilitation of reflective practice through feedback and/or stimulating reflection; and
• creation of a supportive environment.

Bottom line: The most-effective interventions in educating physicians, resident physicians, and medical students on high-value, cost-conscious care are effective transmission of knowledge, reflective practice, and supportive environment.

Citation: Stammen LA, Stalmeijer RE, Paternotte E, et al. Training physicians to provide high-value, cost-conscious care: a systematic review. JAMA. 2015;314(22):2384-2400.

Clinical question: What are the factors that promote education in delivering high-value, cost-conscious care?

Background: Healthcare costs are increasing, with most recent numbers showing U.S. expenditures on healthcare of more than $3 trillion, almost 18% of the gross domestic product. High-value care focuses on understanding the benefits, risks, and costs of care and promoting interventions that add value.

Study design: Systematic review.

Setting: Physicians, resident physicians, and medical students in North America, Asia, and Oceania.

Synopsis: Seventy-nine articles were included in the analysis, with 14 being RCTs. Most of the studies were conducted in North America (78.5%) and used a pre-post interventional design (58.2%). Practicing physicians (36.7%) made up the majority of participants in the study, with residents (15.2%) and medical students (6.3%) in smaller numbers. Analysis of the studies identified three factors for successful learning:

• effective transmission of knowledge about prices of services and general health economics, scientific evidence, and patient preferences;
• facilitation of reflective practice through feedback and/or stimulating reflection; and
• creation of a supportive environment.

Bottom line: The most-effective interventions in educating physicians, resident physicians, and medical students on high-value, cost-conscious care are effective transmission of knowledge, reflective practice, and supportive environment.

Citation: Stammen LA, Stalmeijer RE, Paternotte E, et al. Training physicians to provide high-value, cost-conscious care: a systematic review. JAMA. 2015;314(22):2384-2400.

Clinical question: Is there a clinical difference in rates of return of spontaneous circulation (ROSC) and survival to discharge in patients with in-hospital cardiac arrest (IHCA) depending on time of day and day of the week?

Background: Current U.S. data from the American Hospital Association’s “Get with the Guidelines-Resuscitation” (AHA GWTG-R) show hospital survival is lower at night and on the weekends. However, little data exist in the U.K. describing patients already hospitalized and the outcomes of in-hospital cardiac arrest with respect to time of day and day of the week.

Study design: Observational cohort study.

Setting: One hundred forty-six hospitals in the United Kingdom.

Synopsis: Study investigators included 27,700 patients ≥16 years of age receiving chest compressions and/or defibrillation from the U.K. National Cardiac Arrest Audit (NCAA) from April 2011 to September 2013. When compared to weekday daytime, the risk-adjusted rates of ROSC were worse for weekend daytime (odds ratio [OR] ROSC >20 min. 0.88; 95% CI, 0.81–0.95) and nighttime (OR ROSC >20 min. 0.72; 95% CI, 0.68–0.76). Hospital survival had similar trends, with OR for the weekend daytime of 0.72 (95% CI, 0.64–0.80) and OR for nighttime 0.58 (95% CI, 0.54–0.63; P value for all was <0.001).

IHCAs were equally likely to occur during the day and night, and the patients were broadly similar, thus suggesting differences in outcomes were secondary to care differences. However, unmeasured patient characteristics may have affected the outcomes. Given that the study was observational, it is difficult to attribute causality, but results are similar to the large, multicenter study published by the AHA GWTG-R registry.

Bottom line: IHCAs that occur during the night or on weekends have increased odds of worse outcomes.

Citation: Robinson EJ, Smith GB, Power GS, et al. Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study [published online ahead of print December 11, 2015]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-004223.

Short Take

USPSTF Recommends Statins for More Americans

The U.S. Preventive Services Task Force recommends a low- to moderate-dose statin for adults ages 40–75 with no history of cardiovascular disease and a calculated 10-year cardiovascular disease event risk of ≥10%.

Citation: U.S. Preventive Services Task Force. Draft recommendation statement: statin use for the primary prevention of cardiovascular disease in adults: preventive medication. Available at:

http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement175/statin-use-in-adults-preventive-medication1. Published December 2015. Accessed April 1, 2016.

Clinical question: Is there a clinical difference in rates of return of spontaneous circulation (ROSC) and survival to discharge in patients with in-hospital cardiac arrest (IHCA) depending on time of day and day of the week?

Background: Current U.S. data from the American Hospital Association’s “Get with the Guidelines-Resuscitation” (AHA GWTG-R) show hospital survival is lower at night and on the weekends. However, little data exist in the U.K. describing patients already hospitalized and the outcomes of in-hospital cardiac arrest with respect to time of day and day of the week.

Study design: Observational cohort study.

Setting: One hundred forty-six hospitals in the United Kingdom.

Synopsis: Study investigators included 27,700 patients ≥16 years of age receiving chest compressions and/or defibrillation from the U.K. National Cardiac Arrest Audit (NCAA) from April 2011 to September 2013. When compared to weekday daytime, the risk-adjusted rates of ROSC were worse for weekend daytime (odds ratio [OR] ROSC >20 min. 0.88; 95% CI, 0.81–0.95) and nighttime (OR ROSC >20 min. 0.72; 95% CI, 0.68–0.76). Hospital survival had similar trends, with OR for the weekend daytime of 0.72 (95% CI, 0.64–0.80) and OR for nighttime 0.58 (95% CI, 0.54–0.63; P value for all was <0.001).

IHCAs were equally likely to occur during the day and night, and the patients were broadly similar, thus suggesting differences in outcomes were secondary to care differences. However, unmeasured patient characteristics may have affected the outcomes. Given that the study was observational, it is difficult to attribute causality, but results are similar to the large, multicenter study published by the AHA GWTG-R registry.

Bottom line: IHCAs that occur during the night or on weekends have increased odds of worse outcomes.

Citation: Robinson EJ, Smith GB, Power GS, et al. Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study [published online ahead of print December 11, 2015]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-004223.

Short Take

USPSTF Recommends Statins for More Americans

The U.S. Preventive Services Task Force recommends a low- to moderate-dose statin for adults ages 40–75 with no history of cardiovascular disease and a calculated 10-year cardiovascular disease event risk of ≥10%.

Citation: U.S. Preventive Services Task Force. Draft recommendation statement: statin use for the primary prevention of cardiovascular disease in adults: preventive medication. Available at:

http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement175/statin-use-in-adults-preventive-medication1. Published December 2015. Accessed April 1, 2016.

Clinical question: Is there a clinical difference in rates of return of spontaneous circulation (ROSC) and survival to discharge in patients with in-hospital cardiac arrest (IHCA) depending on time of day and day of the week?

Background: Current U.S. data from the American Hospital Association’s “Get with the Guidelines-Resuscitation” (AHA GWTG-R) show hospital survival is lower at night and on the weekends. However, little data exist in the U.K. describing patients already hospitalized and the outcomes of in-hospital cardiac arrest with respect to time of day and day of the week.

Study design: Observational cohort study.

Setting: One hundred forty-six hospitals in the United Kingdom.

Synopsis: Study investigators included 27,700 patients ≥16 years of age receiving chest compressions and/or defibrillation from the U.K. National Cardiac Arrest Audit (NCAA) from April 2011 to September 2013. When compared to weekday daytime, the risk-adjusted rates of ROSC were worse for weekend daytime (odds ratio [OR] ROSC >20 min. 0.88; 95% CI, 0.81–0.95) and nighttime (OR ROSC >20 min. 0.72; 95% CI, 0.68–0.76). Hospital survival had similar trends, with OR for the weekend daytime of 0.72 (95% CI, 0.64–0.80) and OR for nighttime 0.58 (95% CI, 0.54–0.63; P value for all was <0.001).

IHCAs were equally likely to occur during the day and night, and the patients were broadly similar, thus suggesting differences in outcomes were secondary to care differences. However, unmeasured patient characteristics may have affected the outcomes. Given that the study was observational, it is difficult to attribute causality, but results are similar to the large, multicenter study published by the AHA GWTG-R registry.

Bottom line: IHCAs that occur during the night or on weekends have increased odds of worse outcomes.

Citation: Robinson EJ, Smith GB, Power GS, et al. Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study [published online ahead of print December 11, 2015]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-004223.

Short Take

USPSTF Recommends Statins for More Americans

The U.S. Preventive Services Task Force recommends a low- to moderate-dose statin for adults ages 40–75 with no history of cardiovascular disease and a calculated 10-year cardiovascular disease event risk of ≥10%.

Citation: U.S. Preventive Services Task Force. Draft recommendation statement: statin use for the primary prevention of cardiovascular disease in adults: preventive medication. Available at:

http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement175/statin-use-in-adults-preventive-medication1. Published December 2015. Accessed April 1, 2016.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each column will focus on how the contributor applies one of the “Key Communication” areas in practice.

View a chart outlining key communication tactics

What I Say and Do

I counsel and deliver the diagnosis or give recommendations through a dialogue, instead of a monologue, using active listening.

Why I Do It

The monologue, or lecture, is among the least effective ways to instill behavior change. Research studies have demonstrated that, after a monologue, only around 20% to 60% of medical information is remembered by the end of a visit. Out of what is remembered, less than 50% is accurate. Furthermore, 47% of Americans have health literacy levels below the intermediate range, defined as the ability to determine when to take a medication with food from reading the label.

Lecturing the patient without first understanding what the patient knows and finds important, and understanding the barriers to plan implementation, runs the risk of decreased comprehension, a lack of understanding, or a lack of personal relevance—all leading to decreased adherence. Doing the opposite, by involving the patient in decision making, inspires change that comes from within in the context of the patient’s own needs. This approach is more enduring, emphasizes self-accountability, and ultimately leads to better outcomes.

How I Do It

I open up a dialogue using the Cleveland Clinic’s ARIA approach as adapted from the REDE model of healthcare communication.1

• First, assess: What does the patient know about diagnosis and treatment? How much and what type of education does the patient desire/need? What are the patient’s treatment preferences and health literacy?
• Second, reflect on what the patient just said. Validate meaning and emotion.
• Third, inform the patient within the context of the patient’s perspectives and preferences. Speak slowly and provide small chunks of information at a time. Use understandable language and visual aids. (This will increase recall by 60%.)
• Finally, assess the patient’s understanding and emotional reaction to information provided.
• Repeat the cycle to introduce other chunks of information.

Dr. Velez is director of faculty development in the Center for Excellence in Healthcare Communication at the Cleveland Clinic.

Reference

1. Windover A, Boissy A, Rice T, Gilligan T, Velez V, Merlino J. The REDE model of healthcare communication: optimizing relationship as a therapeutic agent. J Patient Exp. 2014;1(1):8-13.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each column will focus on how the contributor applies one of the “Key Communication” areas in practice.

View a chart outlining key communication tactics

What I Say and Do

I counsel and deliver the diagnosis or give recommendations through a dialogue, instead of a monologue, using active listening.

Why I Do It

The monologue, or lecture, is among the least effective ways to instill behavior change. Research studies have demonstrated that, after a monologue, only around 20% to 60% of medical information is remembered by the end of a visit. Out of what is remembered, less than 50% is accurate. Furthermore, 47% of Americans have health literacy levels below the intermediate range, defined as the ability to determine when to take a medication with food from reading the label.

Lecturing the patient without first understanding what the patient knows and finds important, and understanding the barriers to plan implementation, runs the risk of decreased comprehension, a lack of understanding, or a lack of personal relevance—all leading to decreased adherence. Doing the opposite, by involving the patient in decision making, inspires change that comes from within in the context of the patient’s own needs. This approach is more enduring, emphasizes self-accountability, and ultimately leads to better outcomes.

How I Do It

I open up a dialogue using the Cleveland Clinic’s ARIA approach as adapted from the REDE model of healthcare communication.1

• First, assess: What does the patient know about diagnosis and treatment? How much and what type of education does the patient desire/need? What are the patient’s treatment preferences and health literacy?
• Second, reflect on what the patient just said. Validate meaning and emotion.
• Third, inform the patient within the context of the patient’s perspectives and preferences. Speak slowly and provide small chunks of information at a time. Use understandable language and visual aids. (This will increase recall by 60%.)
• Finally, assess the patient’s understanding and emotional reaction to information provided.
• Repeat the cycle to introduce other chunks of information.

Dr. Velez is director of faculty development in the Center for Excellence in Healthcare Communication at the Cleveland Clinic.

Reference

1. Windover A, Boissy A, Rice T, Gilligan T, Velez V, Merlino J. The REDE model of healthcare communication: optimizing relationship as a therapeutic agent. J Patient Exp. 2014;1(1):8-13.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each column will focus on how the contributor applies one of the “Key Communication” areas in practice.

View a chart outlining key communication tactics

What I Say and Do

I counsel and deliver the diagnosis or give recommendations through a dialogue, instead of a monologue, using active listening.

Why I Do It

The monologue, or lecture, is among the least effective ways to instill behavior change. Research studies have demonstrated that, after a monologue, only around 20% to 60% of medical information is remembered by the end of a visit. Out of what is remembered, less than 50% is accurate. Furthermore, 47% of Americans have health literacy levels below the intermediate range, defined as the ability to determine when to take a medication with food from reading the label.

Lecturing the patient without first understanding what the patient knows and finds important, and understanding the barriers to plan implementation, runs the risk of decreased comprehension, a lack of understanding, or a lack of personal relevance—all leading to decreased adherence. Doing the opposite, by involving the patient in decision making, inspires change that comes from within in the context of the patient’s own needs. This approach is more enduring, emphasizes self-accountability, and ultimately leads to better outcomes.

How I Do It

I open up a dialogue using the Cleveland Clinic’s ARIA approach as adapted from the REDE model of healthcare communication.1

• First, assess: What does the patient know about diagnosis and treatment? How much and what type of education does the patient desire/need? What are the patient’s treatment preferences and health literacy?
• Second, reflect on what the patient just said. Validate meaning and emotion.
• Third, inform the patient within the context of the patient’s perspectives and preferences. Speak slowly and provide small chunks of information at a time. Use understandable language and visual aids. (This will increase recall by 60%.)
• Finally, assess the patient’s understanding and emotional reaction to information provided.
• Repeat the cycle to introduce other chunks of information.

Dr. Velez is director of faculty development in the Center for Excellence in Healthcare Communication at the Cleveland Clinic.

Reference

1. Windover A, Boissy A, Rice T, Gilligan T, Velez V, Merlino J. The REDE model of healthcare communication: optimizing relationship as a therapeutic agent. J Patient Exp. 2014;1(1):8-13.

Clinical question: What is the harm associated with long-term beta-blocker therapy in patients with uncomplicated hypertension undergoing non-cardiac surgery?

Background: Given the recent concerns over the validity of prior studies, there is uncertainty about which patients benefit most from perioperative beta-blockade. Current guidelines suggest continuing beta-blockers in the perioperative period. More data are needed to delineate which patients maximally benefit from perioperative beta-blockade.

Study design: Association study.

Setting: Danish nationwide cohort of patients.

Synopsis: Study investigators included 55,320 uncomplicated hypertension (no cardiovascular, renal, or liver disease) patients >19 years of age on ≥2 antihypertensive drugs undergoing non-cardiac surgery. In the 14,664 patients who received beta-blockers, the rates of 30-day major adverse cardiovascular events (MACE; cardiovascular death, nonfatal ischemic stroke, and nonfatal myocardial infarction) and 30-day all-cause mortality were 1.32% and 1.93%, respectively. However, in the 40,676 patients who did not receive beta-blockers, 30-day MACEs and 30-day all-cause mortality rates were 0.84% and 1.32%, respectively (P<0.001). When looking at the individual MACEs, cardiovascular death was the only statistically significant event with higher incidence (0.9% versus 0.45%, P<0.001).

Combination therapy with beta-blocker and RAS inhibitor, calcium channel blockers, or thiazide was associated with statistically significant higher risks of MACEs and all-cause mortality when compared to the combination of RAS inhibitor plus thiazide. Men >70 years of age or undergoing urgent surgery had the highest risk of harm. This study was not a randomized control trial, so caution must be used when attributing causality to beta-blockers, MACEs, and all-cause mortality.

Bottom line: Antihypertensive regimens containing beta-blockers may increase risk of perioperative MACEs and all-cause mortality in patients with uncomplicated hypertension.

Citation: Jorgensen ME, Hlatky MA, Kober L, et al. β-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.

Clinical question: What is the harm associated with long-term beta-blocker therapy in patients with uncomplicated hypertension undergoing non-cardiac surgery?

Background: Given the recent concerns over the validity of prior studies, there is uncertainty about which patients benefit most from perioperative beta-blockade. Current guidelines suggest continuing beta-blockers in the perioperative period. More data are needed to delineate which patients maximally benefit from perioperative beta-blockade.

Study design: Association study.

Setting: Danish nationwide cohort of patients.

Synopsis: Study investigators included 55,320 uncomplicated hypertension (no cardiovascular, renal, or liver disease) patients >19 years of age on ≥2 antihypertensive drugs undergoing non-cardiac surgery. In the 14,664 patients who received beta-blockers, the rates of 30-day major adverse cardiovascular events (MACE; cardiovascular death, nonfatal ischemic stroke, and nonfatal myocardial infarction) and 30-day all-cause mortality were 1.32% and 1.93%, respectively. However, in the 40,676 patients who did not receive beta-blockers, 30-day MACEs and 30-day all-cause mortality rates were 0.84% and 1.32%, respectively (P<0.001). When looking at the individual MACEs, cardiovascular death was the only statistically significant event with higher incidence (0.9% versus 0.45%, P<0.001).

Combination therapy with beta-blocker and RAS inhibitor, calcium channel blockers, or thiazide was associated with statistically significant higher risks of MACEs and all-cause mortality when compared to the combination of RAS inhibitor plus thiazide. Men >70 years of age or undergoing urgent surgery had the highest risk of harm. This study was not a randomized control trial, so caution must be used when attributing causality to beta-blockers, MACEs, and all-cause mortality.

Bottom line: Antihypertensive regimens containing beta-blockers may increase risk of perioperative MACEs and all-cause mortality in patients with uncomplicated hypertension.

Citation: Jorgensen ME, Hlatky MA, Kober L, et al. β-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.

Clinical question: What is the harm associated with long-term beta-blocker therapy in patients with uncomplicated hypertension undergoing non-cardiac surgery?

Background: Given the recent concerns over the validity of prior studies, there is uncertainty about which patients benefit most from perioperative beta-blockade. Current guidelines suggest continuing beta-blockers in the perioperative period. More data are needed to delineate which patients maximally benefit from perioperative beta-blockade.

Study design: Association study.

Setting: Danish nationwide cohort of patients.

Synopsis: Study investigators included 55,320 uncomplicated hypertension (no cardiovascular, renal, or liver disease) patients >19 years of age on ≥2 antihypertensive drugs undergoing non-cardiac surgery. In the 14,664 patients who received beta-blockers, the rates of 30-day major adverse cardiovascular events (MACE; cardiovascular death, nonfatal ischemic stroke, and nonfatal myocardial infarction) and 30-day all-cause mortality were 1.32% and 1.93%, respectively. However, in the 40,676 patients who did not receive beta-blockers, 30-day MACEs and 30-day all-cause mortality rates were 0.84% and 1.32%, respectively (P<0.001). When looking at the individual MACEs, cardiovascular death was the only statistically significant event with higher incidence (0.9% versus 0.45%, P<0.001).

Combination therapy with beta-blocker and RAS inhibitor, calcium channel blockers, or thiazide was associated with statistically significant higher risks of MACEs and all-cause mortality when compared to the combination of RAS inhibitor plus thiazide. Men >70 years of age or undergoing urgent surgery had the highest risk of harm. This study was not a randomized control trial, so caution must be used when attributing causality to beta-blockers, MACEs, and all-cause mortality.

Bottom line: Antihypertensive regimens containing beta-blockers may increase risk of perioperative MACEs and all-cause mortality in patients with uncomplicated hypertension.

Citation: Jorgensen ME, Hlatky MA, Kober L, et al. β-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.

Clinical question: What is the prevalence of depression or depressive symptoms in resident physicians?

Background: Depression in resident physicians can lead to poor-quality medical care, increased errors, and long-term morbidity. Prevalence of depression or depressive symptoms has varied in prior studies, and more data are needed to better understand the true prevalence.

Study design: Systematic review and meta-analysis.

Setting: Surgical and nonsurgical residency programs in North America, Asia, Europe, South America, and Africa

Synopsis: Thirty-one cross-sectional studies (9,447 individuals) and 23 longitudinal studies (8,113 individuals) from January 1963 to September 2015 were included in this analysis, with the majority using self-reporting to identify residents with depression or depressive symptoms. Overall prevalence of depression or depressive symptoms was 28.8%, with a range of 20.9% to 43.2%, depending on the screening tool (95% CI, 25.3%–32.5%; P<0.001). There was an increased prevalence in depression or depressive symptoms as the calendar year progressed (slope=0.5% per calendar year increase; 95% CI, 0.03%–0.09%), with no difference in prevalence rates between surgical versus nonsurgical residents, U.S. versus elsewhere, cross-sectional versus longitudinal, or interns versus upper-level residents.

Because studies were heterogeneous with respect to the screening tools and resident population, the prevalence of depression or depressive symptoms cannot be precisely determined.

Bottom line: Prevalence of depression or depressive symptoms ranged from 20.9% to 43.2%, with pooled prevalence of 28.8%, and increased with time.

Citation: Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and met-analysis. JAMA. 2015;314(22):2373-2383.

Clinical question: What is the prevalence of depression or depressive symptoms in resident physicians?

Background: Depression in resident physicians can lead to poor-quality medical care, increased errors, and long-term morbidity. Prevalence of depression or depressive symptoms has varied in prior studies, and more data are needed to better understand the true prevalence.

Study design: Systematic review and meta-analysis.

Setting: Surgical and nonsurgical residency programs in North America, Asia, Europe, South America, and Africa

Synopsis: Thirty-one cross-sectional studies (9,447 individuals) and 23 longitudinal studies (8,113 individuals) from January 1963 to September 2015 were included in this analysis, with the majority using self-reporting to identify residents with depression or depressive symptoms. Overall prevalence of depression or depressive symptoms was 28.8%, with a range of 20.9% to 43.2%, depending on the screening tool (95% CI, 25.3%–32.5%; P<0.001). There was an increased prevalence in depression or depressive symptoms as the calendar year progressed (slope=0.5% per calendar year increase; 95% CI, 0.03%–0.09%), with no difference in prevalence rates between surgical versus nonsurgical residents, U.S. versus elsewhere, cross-sectional versus longitudinal, or interns versus upper-level residents.

Because studies were heterogeneous with respect to the screening tools and resident population, the prevalence of depression or depressive symptoms cannot be precisely determined.

Bottom line: Prevalence of depression or depressive symptoms ranged from 20.9% to 43.2%, with pooled prevalence of 28.8%, and increased with time.

Citation: Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and met-analysis. JAMA. 2015;314(22):2373-2383.

Clinical question: What is the prevalence of depression or depressive symptoms in resident physicians?

Background: Depression in resident physicians can lead to poor-quality medical care, increased errors, and long-term morbidity. Prevalence of depression or depressive symptoms has varied in prior studies, and more data are needed to better understand the true prevalence.

Study design: Systematic review and meta-analysis.

Setting: Surgical and nonsurgical residency programs in North America, Asia, Europe, South America, and Africa

Synopsis: Thirty-one cross-sectional studies (9,447 individuals) and 23 longitudinal studies (8,113 individuals) from January 1963 to September 2015 were included in this analysis, with the majority using self-reporting to identify residents with depression or depressive symptoms. Overall prevalence of depression or depressive symptoms was 28.8%, with a range of 20.9% to 43.2%, depending on the screening tool (95% CI, 25.3%–32.5%; P<0.001). There was an increased prevalence in depression or depressive symptoms as the calendar year progressed (slope=0.5% per calendar year increase; 95% CI, 0.03%–0.09%), with no difference in prevalence rates between surgical versus nonsurgical residents, U.S. versus elsewhere, cross-sectional versus longitudinal, or interns versus upper-level residents.

Because studies were heterogeneous with respect to the screening tools and resident population, the prevalence of depression or depressive symptoms cannot be precisely determined.

Bottom line: Prevalence of depression or depressive symptoms ranged from 20.9% to 43.2%, with pooled prevalence of 28.8%, and increased with time.

Citation: Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and met-analysis. JAMA. 2015;314(22):2373-2383.

NEW YORK (Reuters Health) - A breakfast rich in whey protein may help people with type 2 diabetes manage their illness better, new research from Israel suggests.

"Whey protein, a byproduct of cheese manufacturing, lowers postprandial glycemia more than other protein sources," said lead author Dr. Daniela Jakubowicz from Wolfson Medical Center at Tel Aviv University."

We found that in type 2 diabetes, increasing protein content at breakfast has a greater impact on weight loss, glycated hemoglobin (HbA1C), satiety and postprandial glycemia when the protein source is whey protein, compared with other protein sources, such as eggs, tuna and soy," she told Reuters Health by email.

Dr. Jakubowicz and her group presented their findings April 1 at ENDO 2016, the annual meeting of the Endocrine Society, in Boston.

They randomly assigned 48 overweight and obese patients with type 2 diabetes to one of three isocaloric diets. Over 12 weeks, everyone ate a large breakfast, a medium-sized lunch and a small dinner, but the amount and source of each group's breakfast proteins differed.

At breakfast, the 17 participants in the whey group ate 36 g of protein as part of a whey protein shake consisting of 40% carbohydrate, 40% protein and 20% fat. The 16 participants in the high-protein group ate 36 g of protein in the form of eggs, tuna and cheese (40% carbs; 40% protein; 20% fat). The 15 in the high-carbohydrate group ate 13 g of protein in ready-to-eat cereals (65% carbs; 15% protein; 20% fat).

All three diets included a 660 kcal breakfast, a 567 cal lunch and a 276 cal dinner, with the same composition at lunch and dinner.

After 12 weeks, the participants in the whey protein group lost the most weight (7.6 kg vs. 6.1 kg for participants in the high-protein group and 3.5 kg for those in the high-carbohydrate group (p&lt;0.0001).

Participants on the whey protein diet were less hungry during the day and had lower glucose spikes after meals compared with those on the other two diets.

The drop in HbA1C was 11.5% in the whey group, 7.7% in the protein group and 4.6% in the carbohydrate group (p&lt;0.0001). Compared with the carbohydrate group, the percentage drop in HbA1c was greater by 41% in the protein group and by 64% in the whey group (p&lt;0.0001).

"Whey protein was consumed only at breakfast; however, the improvement of glucose, insulin and glucagon-like peptide 1 (GLP-1) was also observed after lunch and dinner. The mechanism of this persistent beneficial effect of whey protein needs further research," Dr. Jakubowicz said.

Co-author Dr. Julio Wainstein, also at Wolfson Medical Center, added by email, "Usually, patients with type 2 diabetes are treated with a combination of several antidiabetic drugs to achieve adequate glucose regulation and decrease HbA1c. Whey protein should be considered an important adjuvant in the management of type 2 diabetes."

"Furthermore," Dr. Wainstein added, "it is possible that by adding whey protein to the diet, glucose regulation might be achieved with less medication, which is a valuable advantage in type 2 diabetes treatment."

The study had no commercial funding, and the authors declared no conflicts of interest.

NEW YORK (Reuters Health) - A breakfast rich in whey protein may help people with type 2 diabetes manage their illness better, new research from Israel suggests.

"Whey protein, a byproduct of cheese manufacturing, lowers postprandial glycemia more than other protein sources," said lead author Dr. Daniela Jakubowicz from Wolfson Medical Center at Tel Aviv University."

We found that in type 2 diabetes, increasing protein content at breakfast has a greater impact on weight loss, glycated hemoglobin (HbA1C), satiety and postprandial glycemia when the protein source is whey protein, compared with other protein sources, such as eggs, tuna and soy," she told Reuters Health by email.

Dr. Jakubowicz and her group presented their findings April 1 at ENDO 2016, the annual meeting of the Endocrine Society, in Boston.

They randomly assigned 48 overweight and obese patients with type 2 diabetes to one of three isocaloric diets. Over 12 weeks, everyone ate a large breakfast, a medium-sized lunch and a small dinner, but the amount and source of each group's breakfast proteins differed.

At breakfast, the 17 participants in the whey group ate 36 g of protein as part of a whey protein shake consisting of 40% carbohydrate, 40% protein and 20% fat. The 16 participants in the high-protein group ate 36 g of protein in the form of eggs, tuna and cheese (40% carbs; 40% protein; 20% fat). The 15 in the high-carbohydrate group ate 13 g of protein in ready-to-eat cereals (65% carbs; 15% protein; 20% fat).

All three diets included a 660 kcal breakfast, a 567 cal lunch and a 276 cal dinner, with the same composition at lunch and dinner.

After 12 weeks, the participants in the whey protein group lost the most weight (7.6 kg vs. 6.1 kg for participants in the high-protein group and 3.5 kg for those in the high-carbohydrate group (p&lt;0.0001).

Participants on the whey protein diet were less hungry during the day and had lower glucose spikes after meals compared with those on the other two diets.

The drop in HbA1C was 11.5% in the whey group, 7.7% in the protein group and 4.6% in the carbohydrate group (p&lt;0.0001). Compared with the carbohydrate group, the percentage drop in HbA1c was greater by 41% in the protein group and by 64% in the whey group (p&lt;0.0001).

"Whey protein was consumed only at breakfast; however, the improvement of glucose, insulin and glucagon-like peptide 1 (GLP-1) was also observed after lunch and dinner. The mechanism of this persistent beneficial effect of whey protein needs further research," Dr. Jakubowicz said.

Co-author Dr. Julio Wainstein, also at Wolfson Medical Center, added by email, "Usually, patients with type 2 diabetes are treated with a combination of several antidiabetic drugs to achieve adequate glucose regulation and decrease HbA1c. Whey protein should be considered an important adjuvant in the management of type 2 diabetes."

"Furthermore," Dr. Wainstein added, "it is possible that by adding whey protein to the diet, glucose regulation might be achieved with less medication, which is a valuable advantage in type 2 diabetes treatment."

The study had no commercial funding, and the authors declared no conflicts of interest.

NEW YORK (Reuters Health) - A breakfast rich in whey protein may help people with type 2 diabetes manage their illness better, new research from Israel suggests.

"Whey protein, a byproduct of cheese manufacturing, lowers postprandial glycemia more than other protein sources," said lead author Dr. Daniela Jakubowicz from Wolfson Medical Center at Tel Aviv University."

We found that in type 2 diabetes, increasing protein content at breakfast has a greater impact on weight loss, glycated hemoglobin (HbA1C), satiety and postprandial glycemia when the protein source is whey protein, compared with other protein sources, such as eggs, tuna and soy," she told Reuters Health by email.

Dr. Jakubowicz and her group presented their findings April 1 at ENDO 2016, the annual meeting of the Endocrine Society, in Boston.

They randomly assigned 48 overweight and obese patients with type 2 diabetes to one of three isocaloric diets. Over 12 weeks, everyone ate a large breakfast, a medium-sized lunch and a small dinner, but the amount and source of each group's breakfast proteins differed.

At breakfast, the 17 participants in the whey group ate 36 g of protein as part of a whey protein shake consisting of 40% carbohydrate, 40% protein and 20% fat. The 16 participants in the high-protein group ate 36 g of protein in the form of eggs, tuna and cheese (40% carbs; 40% protein; 20% fat). The 15 in the high-carbohydrate group ate 13 g of protein in ready-to-eat cereals (65% carbs; 15% protein; 20% fat).

All three diets included a 660 kcal breakfast, a 567 cal lunch and a 276 cal dinner, with the same composition at lunch and dinner.

After 12 weeks, the participants in the whey protein group lost the most weight (7.6 kg vs. 6.1 kg for participants in the high-protein group and 3.5 kg for those in the high-carbohydrate group (p&lt;0.0001).

Participants on the whey protein diet were less hungry during the day and had lower glucose spikes after meals compared with those on the other two diets.

The drop in HbA1C was 11.5% in the whey group, 7.7% in the protein group and 4.6% in the carbohydrate group (p&lt;0.0001). Compared with the carbohydrate group, the percentage drop in HbA1c was greater by 41% in the protein group and by 64% in the whey group (p&lt;0.0001).

"Whey protein was consumed only at breakfast; however, the improvement of glucose, insulin and glucagon-like peptide 1 (GLP-1) was also observed after lunch and dinner. The mechanism of this persistent beneficial effect of whey protein needs further research," Dr. Jakubowicz said.

Co-author Dr. Julio Wainstein, also at Wolfson Medical Center, added by email, "Usually, patients with type 2 diabetes are treated with a combination of several antidiabetic drugs to achieve adequate glucose regulation and decrease HbA1c. Whey protein should be considered an important adjuvant in the management of type 2 diabetes."

"Furthermore," Dr. Wainstein added, "it is possible that by adding whey protein to the diet, glucose regulation might be achieved with less medication, which is a valuable advantage in type 2 diabetes treatment."

The study had no commercial funding, and the authors declared no conflicts of interest.

Clinical question: How frequent is contamination of skin and clothing during personal protective equipment (PPE) removal, and can it be prevented?

Background: PPE reduces transmission of pathogens to healthcare personnel and patients. However, improper removal can lead to contamination of the skin and clothing. Little information exists describing the frequency and sites of contamination after the removal of gloves or gowns.

Study design: Point prevalence study and quasi-experimental intervention.

Setting: Four northeast Ohio hospitals (university, community, county, and VA); intervention performed at VA hospital.

Synopsis: This study began with 435 glove and gown removal simulations performed at four northeast Ohio hospitals. Skin or clothing contamination occurred in 200 (46%) simulations, with similar frequencies across the four hospitals (42.5%–50.3%). Contamination occurred more frequently in the glove removal versus gown removal (52.9% versus 37.8%, P=0.002). Most common causes of contamination were gloves not covering the wrists, removing the gown over the head, donning gloves before the gown, and touching contaminated gloves.

The intervention, performed at the VA hospital, consisted of educational sessions, videos, demonstrations, and practice donning and doffing PPE, which resulted in reduced skin and clothing contamination (60% before versus 18.9% after, P<0.001) that was sustained at one and three months.

Given that the intervention was quasi-experimental and not randomized, it is difficult to attribute

causality to the intervention, and results must be interpreted with caution.

Bottom line: During the removal of gloves and gowns, skin and clothing contamination is frequent, and a simple educational intervention with visual feedback may reduce rates of contamination.

Citation: Tomas ME, Kundrapu S, Thota P, et al. Contamination of health care personnel during removal of personal protective equipment. JAMA Intern Med. 2015;175(12):1904-1910.

Clinical question: How frequent is contamination of skin and clothing during personal protective equipment (PPE) removal, and can it be prevented?

Background: PPE reduces transmission of pathogens to healthcare personnel and patients. However, improper removal can lead to contamination of the skin and clothing. Little information exists describing the frequency and sites of contamination after the removal of gloves or gowns.

Study design: Point prevalence study and quasi-experimental intervention.

Setting: Four northeast Ohio hospitals (university, community, county, and VA); intervention performed at VA hospital.

Synopsis: This study began with 435 glove and gown removal simulations performed at four northeast Ohio hospitals. Skin or clothing contamination occurred in 200 (46%) simulations, with similar frequencies across the four hospitals (42.5%–50.3%). Contamination occurred more frequently in the glove removal versus gown removal (52.9% versus 37.8%, P=0.002). Most common causes of contamination were gloves not covering the wrists, removing the gown over the head, donning gloves before the gown, and touching contaminated gloves.

The intervention, performed at the VA hospital, consisted of educational sessions, videos, demonstrations, and practice donning and doffing PPE, which resulted in reduced skin and clothing contamination (60% before versus 18.9% after, P<0.001) that was sustained at one and three months.

Given that the intervention was quasi-experimental and not randomized, it is difficult to attribute

causality to the intervention, and results must be interpreted with caution.

Bottom line: During the removal of gloves and gowns, skin and clothing contamination is frequent, and a simple educational intervention with visual feedback may reduce rates of contamination.

Citation: Tomas ME, Kundrapu S, Thota P, et al. Contamination of health care personnel during removal of personal protective equipment. JAMA Intern Med. 2015;175(12):1904-1910.

Clinical question: How frequent is contamination of skin and clothing during personal protective equipment (PPE) removal, and can it be prevented?

Background: PPE reduces transmission of pathogens to healthcare personnel and patients. However, improper removal can lead to contamination of the skin and clothing. Little information exists describing the frequency and sites of contamination after the removal of gloves or gowns.

Study design: Point prevalence study and quasi-experimental intervention.

Setting: Four northeast Ohio hospitals (university, community, county, and VA); intervention performed at VA hospital.

Synopsis: This study began with 435 glove and gown removal simulations performed at four northeast Ohio hospitals. Skin or clothing contamination occurred in 200 (46%) simulations, with similar frequencies across the four hospitals (42.5%–50.3%). Contamination occurred more frequently in the glove removal versus gown removal (52.9% versus 37.8%, P=0.002). Most common causes of contamination were gloves not covering the wrists, removing the gown over the head, donning gloves before the gown, and touching contaminated gloves.

The intervention, performed at the VA hospital, consisted of educational sessions, videos, demonstrations, and practice donning and doffing PPE, which resulted in reduced skin and clothing contamination (60% before versus 18.9% after, P<0.001) that was sustained at one and three months.

Given that the intervention was quasi-experimental and not randomized, it is difficult to attribute

causality to the intervention, and results must be interpreted with caution.

Bottom line: During the removal of gloves and gowns, skin and clothing contamination is frequent, and a simple educational intervention with visual feedback may reduce rates of contamination.

Citation: Tomas ME, Kundrapu S, Thota P, et al. Contamination of health care personnel during removal of personal protective equipment. JAMA Intern Med. 2015;175(12):1904-1910.