Clinical

Clinical question: Can we dignify death in the ICU and ease the grieving process by soliciting wishes from patients, families, and care team members?

Background: The death of the critically ill patient in the ICU can be dehumanizing and overwhelming for the patient’s family and friends, leading to prolonged physical and psychological stress. These deaths might have similar effects on the clinicians caring for the patients.

Study design: Mixed methods.

Setting: Medical-surgical ICU at a 21-bed, academic tertiary medical center in Ontario, Canada.

Synopsis: Semi-structured interviews were conducted with at least one family member and three clinicians per patient. A total of 40 patients were screened and deemed eligible for inclusion. Only seven patients were able to provide input on the wishes or interviews; the others had impaired consciousness. The team obtained 163 wishes from those individuals, and was able to implement 159 of them (97.5%). At least three wishes from each patient-family dyad were implemented.

The wishes were classified into five categories:

• Humanizing the environment;
• Personal tributes;
• Family reconnections;
• Rituals and observances; and
• Paying it forward.

These wishes were implemented before (51.6%) and after (48.4%) death and were generally inexpensive (less than $200 per patient).

From the 160 interviews of 170 individuals, the central theme that emerged was personalization of the dying process in the ICU through three related domains: dignifying the patient, giving the family a voice, and fostering clinician compassion.

The 3 Wishes Project provides a framework to foster discussion among care team members and families to ensure personalization and dignity in the dying process.

Bottom line: Solicitation of wishes from dying patients, their families, and their care team members can have a positive impact by allowing individualized end-of-life care.

Citation: Cook D, Swinton M, Toledo F, et al. Personalizing death in the intensive care unit: the 3 Wishes Project: a mixed-methods study. Ann Intern Med. 2015;163(4):271-279.

Clinical question: Can we dignify death in the ICU and ease the grieving process by soliciting wishes from patients, families, and care team members?

Background: The death of the critically ill patient in the ICU can be dehumanizing and overwhelming for the patient’s family and friends, leading to prolonged physical and psychological stress. These deaths might have similar effects on the clinicians caring for the patients.

Study design: Mixed methods.

Setting: Medical-surgical ICU at a 21-bed, academic tertiary medical center in Ontario, Canada.

Synopsis: Semi-structured interviews were conducted with at least one family member and three clinicians per patient. A total of 40 patients were screened and deemed eligible for inclusion. Only seven patients were able to provide input on the wishes or interviews; the others had impaired consciousness. The team obtained 163 wishes from those individuals, and was able to implement 159 of them (97.5%). At least three wishes from each patient-family dyad were implemented.

The wishes were classified into five categories:

• Humanizing the environment;
• Personal tributes;
• Family reconnections;
• Rituals and observances; and
• Paying it forward.

These wishes were implemented before (51.6%) and after (48.4%) death and were generally inexpensive (less than $200 per patient).

From the 160 interviews of 170 individuals, the central theme that emerged was personalization of the dying process in the ICU through three related domains: dignifying the patient, giving the family a voice, and fostering clinician compassion.

The 3 Wishes Project provides a framework to foster discussion among care team members and families to ensure personalization and dignity in the dying process.

Bottom line: Solicitation of wishes from dying patients, their families, and their care team members can have a positive impact by allowing individualized end-of-life care.

Citation: Cook D, Swinton M, Toledo F, et al. Personalizing death in the intensive care unit: the 3 Wishes Project: a mixed-methods study. Ann Intern Med. 2015;163(4):271-279.

Clinical question: Can we dignify death in the ICU and ease the grieving process by soliciting wishes from patients, families, and care team members?

Background: The death of the critically ill patient in the ICU can be dehumanizing and overwhelming for the patient’s family and friends, leading to prolonged physical and psychological stress. These deaths might have similar effects on the clinicians caring for the patients.

Study design: Mixed methods.

Setting: Medical-surgical ICU at a 21-bed, academic tertiary medical center in Ontario, Canada.

Synopsis: Semi-structured interviews were conducted with at least one family member and three clinicians per patient. A total of 40 patients were screened and deemed eligible for inclusion. Only seven patients were able to provide input on the wishes or interviews; the others had impaired consciousness. The team obtained 163 wishes from those individuals, and was able to implement 159 of them (97.5%). At least three wishes from each patient-family dyad were implemented.

The wishes were classified into five categories:

• Humanizing the environment;
• Personal tributes;
• Family reconnections;
• Rituals and observances; and
• Paying it forward.

These wishes were implemented before (51.6%) and after (48.4%) death and were generally inexpensive (less than $200 per patient).

From the 160 interviews of 170 individuals, the central theme that emerged was personalization of the dying process in the ICU through three related domains: dignifying the patient, giving the family a voice, and fostering clinician compassion.

The 3 Wishes Project provides a framework to foster discussion among care team members and families to ensure personalization and dignity in the dying process.

Bottom line: Solicitation of wishes from dying patients, their families, and their care team members can have a positive impact by allowing individualized end-of-life care.

Citation: Cook D, Swinton M, Toledo F, et al. Personalizing death in the intensive care unit: the 3 Wishes Project: a mixed-methods study. Ann Intern Med. 2015;163(4):271-279.

The delicate balance involved in providing hospitalized patients with needed anticoagulant, anti-platelet, and thrombolytic therapies for stroke and possible cardiac complications while minimizing bleed risks was explored by several speakers at the University of California San Francisco’s annual Management of the Hospitalized Patient Conference.

“These are dynamic issues and they’re moving all the time,” said Tracy Minichiello, MD, a former hospitalist who now runs the Anticoagulation and Thrombosis Service at the San Francisco VA Medical Center. Dosing and monitoring choices for physicians have grown more complicated with the new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), and she said another balancing act is emerging in hospitals trying to avoid unnecessary and wasteful treatments.

“There is interest on both sides of that question,” Dr. Minichiello said, adding the stakes are high. “We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion of the other side of the issue—over-diagnosis and over-treatment—where we’re also trying to avoid, for example, overuse of CT scans.”

Another major thrust of Dr. Minichiello’s presentations involved bridging therapies, the application of a parenteral, short-acting anticoagulant therapy during the temporary interruption of warfarin anticoagulation for an invasive procedure. Bridging decreases stroke and embolism risk, but with an increased risk for bleeding.

“Full intensity bridging therapy for anticoagulation potentially can do more harm than good,” she said, noting a dearth of data to support mortality benefits of bridging therapy.

Literature increasingly recommends hospitalists be more selective about the use of bridging therapies that might have been employed reflexively in the past, she noted.

“[Hospitalists] must be mindful of the risks and benefits,” she said.

Physicians should also think twice about concomitant antiplatelet therapy like aspirin with anticoagulants. “We need to work collaboratively with our cardiology colleagues when a patient is on two or three of these therapies,” she said. “Recommendations in this area are in evolution.”

Elise Bouchard, MD, an internist at Centre Maria-Chapdelaine in Dolbeau-Mistassini, Quebec, attended Dr. Minichiello’s breakout session on challenging cases.

“I learned that we shouldn’t use aspirin with Coumadin or other anticoagulants, except for cases like acute coronary syndrome,” Dr. Bouchard said. She also explained a number of her patients with cancer, for example, need anticoagulation treatment and hate getting another injection, so she tries when possible to offer the oral anticoagulants.

Dr. Minichiello works with hospitalists at the San Francisco VA who seek consults around procedures, anticoagulant choices, and when to restart treatments.

“Most hospitalists don’t have access to a service like ours, although they might be able to call on a hematology consult service [or pharmacist],” she said. She suggested hospitalists trying to develop their own evidenced-based protocols use websites like the University of Washington’s anticoagulation service website, or the American Society of Health System Pharmacists’ anticoagulation resource center. TH

The delicate balance involved in providing hospitalized patients with needed anticoagulant, anti-platelet, and thrombolytic therapies for stroke and possible cardiac complications while minimizing bleed risks was explored by several speakers at the University of California San Francisco’s annual Management of the Hospitalized Patient Conference.

“These are dynamic issues and they’re moving all the time,” said Tracy Minichiello, MD, a former hospitalist who now runs the Anticoagulation and Thrombosis Service at the San Francisco VA Medical Center. Dosing and monitoring choices for physicians have grown more complicated with the new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), and she said another balancing act is emerging in hospitals trying to avoid unnecessary and wasteful treatments.

“There is interest on both sides of that question,” Dr. Minichiello said, adding the stakes are high. “We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion of the other side of the issue—over-diagnosis and over-treatment—where we’re also trying to avoid, for example, overuse of CT scans.”

Another major thrust of Dr. Minichiello’s presentations involved bridging therapies, the application of a parenteral, short-acting anticoagulant therapy during the temporary interruption of warfarin anticoagulation for an invasive procedure. Bridging decreases stroke and embolism risk, but with an increased risk for bleeding.

“Full intensity bridging therapy for anticoagulation potentially can do more harm than good,” she said, noting a dearth of data to support mortality benefits of bridging therapy.

Literature increasingly recommends hospitalists be more selective about the use of bridging therapies that might have been employed reflexively in the past, she noted.

“[Hospitalists] must be mindful of the risks and benefits,” she said.

Physicians should also think twice about concomitant antiplatelet therapy like aspirin with anticoagulants. “We need to work collaboratively with our cardiology colleagues when a patient is on two or three of these therapies,” she said. “Recommendations in this area are in evolution.”

Elise Bouchard, MD, an internist at Centre Maria-Chapdelaine in Dolbeau-Mistassini, Quebec, attended Dr. Minichiello’s breakout session on challenging cases.

“I learned that we shouldn’t use aspirin with Coumadin or other anticoagulants, except for cases like acute coronary syndrome,” Dr. Bouchard said. She also explained a number of her patients with cancer, for example, need anticoagulation treatment and hate getting another injection, so she tries when possible to offer the oral anticoagulants.

Dr. Minichiello works with hospitalists at the San Francisco VA who seek consults around procedures, anticoagulant choices, and when to restart treatments.

“Most hospitalists don’t have access to a service like ours, although they might be able to call on a hematology consult service [or pharmacist],” she said. She suggested hospitalists trying to develop their own evidenced-based protocols use websites like the University of Washington’s anticoagulation service website, or the American Society of Health System Pharmacists’ anticoagulation resource center. TH

The delicate balance involved in providing hospitalized patients with needed anticoagulant, anti-platelet, and thrombolytic therapies for stroke and possible cardiac complications while minimizing bleed risks was explored by several speakers at the University of California San Francisco’s annual Management of the Hospitalized Patient Conference.

“These are dynamic issues and they’re moving all the time,” said Tracy Minichiello, MD, a former hospitalist who now runs the Anticoagulation and Thrombosis Service at the San Francisco VA Medical Center. Dosing and monitoring choices for physicians have grown more complicated with the new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), and she said another balancing act is emerging in hospitals trying to avoid unnecessary and wasteful treatments.

“There is interest on both sides of that question,” Dr. Minichiello said, adding the stakes are high. “We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion of the other side of the issue—over-diagnosis and over-treatment—where we’re also trying to avoid, for example, overuse of CT scans.”

Another major thrust of Dr. Minichiello’s presentations involved bridging therapies, the application of a parenteral, short-acting anticoagulant therapy during the temporary interruption of warfarin anticoagulation for an invasive procedure. Bridging decreases stroke and embolism risk, but with an increased risk for bleeding.

“Full intensity bridging therapy for anticoagulation potentially can do more harm than good,” she said, noting a dearth of data to support mortality benefits of bridging therapy.

Literature increasingly recommends hospitalists be more selective about the use of bridging therapies that might have been employed reflexively in the past, she noted.

“[Hospitalists] must be mindful of the risks and benefits,” she said.

Physicians should also think twice about concomitant antiplatelet therapy like aspirin with anticoagulants. “We need to work collaboratively with our cardiology colleagues when a patient is on two or three of these therapies,” she said. “Recommendations in this area are in evolution.”

Elise Bouchard, MD, an internist at Centre Maria-Chapdelaine in Dolbeau-Mistassini, Quebec, attended Dr. Minichiello’s breakout session on challenging cases.

“I learned that we shouldn’t use aspirin with Coumadin or other anticoagulants, except for cases like acute coronary syndrome,” Dr. Bouchard said. She also explained a number of her patients with cancer, for example, need anticoagulation treatment and hate getting another injection, so she tries when possible to offer the oral anticoagulants.

Dr. Minichiello works with hospitalists at the San Francisco VA who seek consults around procedures, anticoagulant choices, and when to restart treatments.

“Most hospitalists don’t have access to a service like ours, although they might be able to call on a hematology consult service [or pharmacist],” she said. She suggested hospitalists trying to develop their own evidenced-based protocols use websites like the University of Washington’s anticoagulation service website, or the American Society of Health System Pharmacists’ anticoagulation resource center. TH

Even before HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), hospital leaders and clinicians were striving to provide not only high quality care, but a place patients choose to meet their future healthcare needs. Just this week, US News and World Report published an article entitled "The Patient Wish List." Although not a list generated from a scientific study, the author, Peter Pronovost, MD, PhD, who is the director of the Armstrong Institute for Patient Safety and Quality and senior vice president for patient safety and quality at Johns Hopkins Medicine, worked with Jan Hill, patient relations director at Johns Hopkins, to develop a list intended to be a "conversation starter."

So, how does this apply to hospitalists? Many of the items on the list are an easy fix and don't cost a thing. Here are a few areas hospitalist can impact:

1. I want to sleep. For example: are there standing overnight test orders that could be provided during the day?
2. Reduce noise outside my room, particularly at night. How can hospitalists contribute to reducing hallway and nursing station noise?
3. Knock before entering. It's a sign of respect to knock before entering the patient's room. Sitting down while talking to the patient and introducing yourself are also key.
4. Keep me (and my family) updated. Are you always updating the patient and family about the plan of care and if things change?
5. I want to be a part of my care. Do you always use language patients (and families) can easily understand? How do you ensure patients (and families) understand the plan of care?
6. Be professional, always. No matter where you are in the hospital, patients and families are watching you closely. Ask yourself, "How I perceive you is often how I perceive the hospital and care that I am receiving."

What else can you do to improve the patient's experience in your hospital? TH

Even before HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), hospital leaders and clinicians were striving to provide not only high quality care, but a place patients choose to meet their future healthcare needs. Just this week, US News and World Report published an article entitled "The Patient Wish List." Although not a list generated from a scientific study, the author, Peter Pronovost, MD, PhD, who is the director of the Armstrong Institute for Patient Safety and Quality and senior vice president for patient safety and quality at Johns Hopkins Medicine, worked with Jan Hill, patient relations director at Johns Hopkins, to develop a list intended to be a "conversation starter."

So, how does this apply to hospitalists? Many of the items on the list are an easy fix and don't cost a thing. Here are a few areas hospitalist can impact:

1. I want to sleep. For example: are there standing overnight test orders that could be provided during the day?
2. Reduce noise outside my room, particularly at night. How can hospitalists contribute to reducing hallway and nursing station noise?
3. Knock before entering. It's a sign of respect to knock before entering the patient's room. Sitting down while talking to the patient and introducing yourself are also key.
4. Keep me (and my family) updated. Are you always updating the patient and family about the plan of care and if things change?
5. I want to be a part of my care. Do you always use language patients (and families) can easily understand? How do you ensure patients (and families) understand the plan of care?
6. Be professional, always. No matter where you are in the hospital, patients and families are watching you closely. Ask yourself, "How I perceive you is often how I perceive the hospital and care that I am receiving."

What else can you do to improve the patient's experience in your hospital? TH

Even before HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), hospital leaders and clinicians were striving to provide not only high quality care, but a place patients choose to meet their future healthcare needs. Just this week, US News and World Report published an article entitled "The Patient Wish List." Although not a list generated from a scientific study, the author, Peter Pronovost, MD, PhD, who is the director of the Armstrong Institute for Patient Safety and Quality and senior vice president for patient safety and quality at Johns Hopkins Medicine, worked with Jan Hill, patient relations director at Johns Hopkins, to develop a list intended to be a "conversation starter."

So, how does this apply to hospitalists? Many of the items on the list are an easy fix and don't cost a thing. Here are a few areas hospitalist can impact:

1. I want to sleep. For example: are there standing overnight test orders that could be provided during the day?
2. Reduce noise outside my room, particularly at night. How can hospitalists contribute to reducing hallway and nursing station noise?
3. Knock before entering. It's a sign of respect to knock before entering the patient's room. Sitting down while talking to the patient and introducing yourself are also key.
4. Keep me (and my family) updated. Are you always updating the patient and family about the plan of care and if things change?
5. I want to be a part of my care. Do you always use language patients (and families) can easily understand? How do you ensure patients (and families) understand the plan of care?
6. Be professional, always. No matter where you are in the hospital, patients and families are watching you closely. Ask yourself, "How I perceive you is often how I perceive the hospital and care that I am receiving."

What else can you do to improve the patient's experience in your hospital? TH

Clinical question: In infants younger than three months of age with bacteremic urinary tract infection (UTI), how sensitive and specific are urinalysis (UA) findings?

Background: Infants are commonly hospitalized with UTIs. The gold standard for diagnosis is considered to be urine culture. When compared to this gold standard, the sensitivity of UA findings for the diagnosis of UTI has been previously reported to be around 75% to 85%; however, a positive urine culture alone in the setting of negative UA may not be reflective of a UTI due to asymptomatic bacteriuria or contamination. The 2011 American Academy of Pediatrics clinical guideline for UTIs suggests that the diagnosis should require positive urine culture in addition to abnormal UA. These guidelines do not include infants younger than two months of age, and positive cultures in this age group are generally regarded as a UTI and treated as such. Positive culture results with the same organism in the urine and blood indicates very low likelihood of contamination or asymptomatic bacteriuria, and patients with bacteremic UTI are likely to have a true infection.

Study design: Multicenter, retrospective, cross-sectional study.

Setting: Twenty hospitals in eleven hospital systems.

Synopsis: Researchers used a multicenter microbiology database to identify infants younger than three months of age with bacteremic UTI (same pathogenic organism in blood and urine). Data was collected on UA, including microscopy [white blood cells per high-power field (WBC/HPF), bacteria], dipstick [nitrites, leukocyte esterase (LE)], and urine culture in colony-forming units per mL (CFU/mL).

Exclusions included:

• Major comorbidities (defined in this study as neuromuscular conditions such as spina bifida, previous urologic surgery other than circumcision, or immunodeficiency);
• Patients managed in an ICU setting; and
• Patients with indwelling urinary or central venous catheters at the time of culture.

A total of 276 infants with bacteremic UTI were identified, with 31 exclusions (12 with no UA performed, 19 with cultures with <50,000 CFU/mL). The remaining 245 infants were included for analysis. The control group was a random sampling of 115 similarly aged infants who underwent evaluation for serious bacterial infection and had negative urine cultures.

Comparison between the study group (bacteremic UTI) and the controls showed:

• LE (including any “positive” LE) had a sensitivity of 97.6%, specificity of 93.9%;
• Considering “trace” LE as negative changed the sensitivity and specificity to 95.7% and 97.4%, respectively; and
• Positive nitrites had a specificity of 100%.

A definition of positive UA that includes pyuria (greater than 3 WBC/HPF) and/or any LE was highly sensitive (99.5%) and specific (87.8%). All but one of 203 infants with bacteremic UTI who had complete UA results were positive for LE and/or WBC/HPF. The one exception was a 64-day-old girl with Group B Streptococcus infection. Bacteria on microscopy showed poor specificity.

The authors discussed two possible explanations for the study’s finding of high sensitivity of the UA, including:

• The UA is in fact highly sensitive, and previous studies have been flawed by a faulty gold standard (positive cultures due to asymptomatic bacteriuria or contamination); or
• Screening tests are more sensitive in the setting of severe disease (in this case, UTI with bacteremia).

The second explanation is controversial, and the authors of this article cite previous studies showing minimal differences between UTI with or without bacteremia.

Bottom line: In infants younger than three months of age with bacteremic UTI, the findings of pyuria and/or any LE on UA are reliable predictors of infection, with higher sensitivity than previously reported.

Citation: Schroeder AR, Chang PW, Shen MW, Biondi EA, Greenhow TL. Diagnostic accuracy of the urinalysis for urinary tract infection in infants <3 months of age. Pediatrics. 2015;135(6):965-71.

 

---

Dr. Galloway is a pediatric hospitalist at Sanford Children’s Hospital in Sioux Falls, S.D., assistant professor of pediatrics at the University of South Dakota Sanford School of Medicine, and vice chief of the division of hospital pediatrics at USD SSOM and Sanford Children’s Hospital.

Clinical question: In infants younger than three months of age with bacteremic urinary tract infection (UTI), how sensitive and specific are urinalysis (UA) findings?

Background: Infants are commonly hospitalized with UTIs. The gold standard for diagnosis is considered to be urine culture. When compared to this gold standard, the sensitivity of UA findings for the diagnosis of UTI has been previously reported to be around 75% to 85%; however, a positive urine culture alone in the setting of negative UA may not be reflective of a UTI due to asymptomatic bacteriuria or contamination. The 2011 American Academy of Pediatrics clinical guideline for UTIs suggests that the diagnosis should require positive urine culture in addition to abnormal UA. These guidelines do not include infants younger than two months of age, and positive cultures in this age group are generally regarded as a UTI and treated as such. Positive culture results with the same organism in the urine and blood indicates very low likelihood of contamination or asymptomatic bacteriuria, and patients with bacteremic UTI are likely to have a true infection.

Study design: Multicenter, retrospective, cross-sectional study.

Setting: Twenty hospitals in eleven hospital systems.

Synopsis: Researchers used a multicenter microbiology database to identify infants younger than three months of age with bacteremic UTI (same pathogenic organism in blood and urine). Data was collected on UA, including microscopy [white blood cells per high-power field (WBC/HPF), bacteria], dipstick [nitrites, leukocyte esterase (LE)], and urine culture in colony-forming units per mL (CFU/mL).

Exclusions included:

• Major comorbidities (defined in this study as neuromuscular conditions such as spina bifida, previous urologic surgery other than circumcision, or immunodeficiency);
• Patients managed in an ICU setting; and
• Patients with indwelling urinary or central venous catheters at the time of culture.

A total of 276 infants with bacteremic UTI were identified, with 31 exclusions (12 with no UA performed, 19 with cultures with <50,000 CFU/mL). The remaining 245 infants were included for analysis. The control group was a random sampling of 115 similarly aged infants who underwent evaluation for serious bacterial infection and had negative urine cultures.

Comparison between the study group (bacteremic UTI) and the controls showed:

• LE (including any “positive” LE) had a sensitivity of 97.6%, specificity of 93.9%;
• Considering “trace” LE as negative changed the sensitivity and specificity to 95.7% and 97.4%, respectively; and
• Positive nitrites had a specificity of 100%.

A definition of positive UA that includes pyuria (greater than 3 WBC/HPF) and/or any LE was highly sensitive (99.5%) and specific (87.8%). All but one of 203 infants with bacteremic UTI who had complete UA results were positive for LE and/or WBC/HPF. The one exception was a 64-day-old girl with Group B Streptococcus infection. Bacteria on microscopy showed poor specificity.

The authors discussed two possible explanations for the study’s finding of high sensitivity of the UA, including:

• The UA is in fact highly sensitive, and previous studies have been flawed by a faulty gold standard (positive cultures due to asymptomatic bacteriuria or contamination); or
• Screening tests are more sensitive in the setting of severe disease (in this case, UTI with bacteremia).

The second explanation is controversial, and the authors of this article cite previous studies showing minimal differences between UTI with or without bacteremia.

Bottom line: In infants younger than three months of age with bacteremic UTI, the findings of pyuria and/or any LE on UA are reliable predictors of infection, with higher sensitivity than previously reported.

Citation: Schroeder AR, Chang PW, Shen MW, Biondi EA, Greenhow TL. Diagnostic accuracy of the urinalysis for urinary tract infection in infants <3 months of age. Pediatrics. 2015;135(6):965-71.

 

---

Dr. Galloway is a pediatric hospitalist at Sanford Children’s Hospital in Sioux Falls, S.D., assistant professor of pediatrics at the University of South Dakota Sanford School of Medicine, and vice chief of the division of hospital pediatrics at USD SSOM and Sanford Children’s Hospital.

Clinical question: In infants younger than three months of age with bacteremic urinary tract infection (UTI), how sensitive and specific are urinalysis (UA) findings?

Background: Infants are commonly hospitalized with UTIs. The gold standard for diagnosis is considered to be urine culture. When compared to this gold standard, the sensitivity of UA findings for the diagnosis of UTI has been previously reported to be around 75% to 85%; however, a positive urine culture alone in the setting of negative UA may not be reflective of a UTI due to asymptomatic bacteriuria or contamination. The 2011 American Academy of Pediatrics clinical guideline for UTIs suggests that the diagnosis should require positive urine culture in addition to abnormal UA. These guidelines do not include infants younger than two months of age, and positive cultures in this age group are generally regarded as a UTI and treated as such. Positive culture results with the same organism in the urine and blood indicates very low likelihood of contamination or asymptomatic bacteriuria, and patients with bacteremic UTI are likely to have a true infection.

Study design: Multicenter, retrospective, cross-sectional study.

Setting: Twenty hospitals in eleven hospital systems.

Synopsis: Researchers used a multicenter microbiology database to identify infants younger than three months of age with bacteremic UTI (same pathogenic organism in blood and urine). Data was collected on UA, including microscopy [white blood cells per high-power field (WBC/HPF), bacteria], dipstick [nitrites, leukocyte esterase (LE)], and urine culture in colony-forming units per mL (CFU/mL).

Exclusions included:

• Major comorbidities (defined in this study as neuromuscular conditions such as spina bifida, previous urologic surgery other than circumcision, or immunodeficiency);
• Patients managed in an ICU setting; and
• Patients with indwelling urinary or central venous catheters at the time of culture.

A total of 276 infants with bacteremic UTI were identified, with 31 exclusions (12 with no UA performed, 19 with cultures with <50,000 CFU/mL). The remaining 245 infants were included for analysis. The control group was a random sampling of 115 similarly aged infants who underwent evaluation for serious bacterial infection and had negative urine cultures.

Comparison between the study group (bacteremic UTI) and the controls showed:

• LE (including any “positive” LE) had a sensitivity of 97.6%, specificity of 93.9%;
• Considering “trace” LE as negative changed the sensitivity and specificity to 95.7% and 97.4%, respectively; and
• Positive nitrites had a specificity of 100%.

A definition of positive UA that includes pyuria (greater than 3 WBC/HPF) and/or any LE was highly sensitive (99.5%) and specific (87.8%). All but one of 203 infants with bacteremic UTI who had complete UA results were positive for LE and/or WBC/HPF. The one exception was a 64-day-old girl with Group B Streptococcus infection. Bacteria on microscopy showed poor specificity.

The authors discussed two possible explanations for the study’s finding of high sensitivity of the UA, including:

• The UA is in fact highly sensitive, and previous studies have been flawed by a faulty gold standard (positive cultures due to asymptomatic bacteriuria or contamination); or
• Screening tests are more sensitive in the setting of severe disease (in this case, UTI with bacteremia).

The second explanation is controversial, and the authors of this article cite previous studies showing minimal differences between UTI with or without bacteremia.

Bottom line: In infants younger than three months of age with bacteremic UTI, the findings of pyuria and/or any LE on UA are reliable predictors of infection, with higher sensitivity than previously reported.

Citation: Schroeder AR, Chang PW, Shen MW, Biondi EA, Greenhow TL. Diagnostic accuracy of the urinalysis for urinary tract infection in infants <3 months of age. Pediatrics. 2015;135(6):965-71.

 

---

Dr. Galloway is a pediatric hospitalist at Sanford Children’s Hospital in Sioux Falls, S.D., assistant professor of pediatrics at the University of South Dakota Sanford School of Medicine, and vice chief of the division of hospital pediatrics at USD SSOM and Sanford Children’s Hospital.

Clinical question: In post-operative cardiothoracic surgery patients, is high-flow nasal oxygen therapy inferior to BiPAP for resolution of acute respiratory failure?

Background: Acute respiratory failure is common following cardiothoracic surgery, and noninvasive ventilation often is used to avoid intubation. Noninvasive ventilation is resource-intensive and might be uncomfortable to patients. High-flow nasal oxygen therapy is an alternative modality, which provides large amounts of oxygen with more ease and patient comfort.

Study design: Multi-center, randomized, noninferiority trial.

Setting: Six ICUs in France.

Synopsis: Investigators randomized 830 patients who met criteria (obesity, heart failure, or failure of spontaneous breathing trial) after cardiothoracic surgery. These patients were prophylactically treated with high-flow nasal oxygen or BiPAP. Patients with sleep apnea, nausea/vomiting, agitation/confusion, or hemodynamic instability were excluded. Data collected included arterial blood gas, respiratory rate, and patient-rated dyspnea. The primary outcome was treatment failure as defined by reintubation and mechanical ventilation, a switch to the other study treatment, or study treatment discontinuation.

Complications included pneumothorax, colonic pseudoobstruction, and nosocomial pneumonia. The expected rate of failure for BiPAP was 20%. High-flow nasal oxygen therapy was not inferior to BiPAP, with similar treatment failure rates occurring in both groups (21.9% in BiPAP patients vs. 21% of high-flow nasal oxygen patients); 20% of patients experienced persistent discomfort with either treatment method.

There were no significant differences in complications between the two study groups. Limitations included lack of blinding and potential for bias, leading to treatment failure and crossover.

Bottom line: High-flow nasal oxygen was noninferior to BiPAP in patients with respiratory failure after cardiothoracic surgery.

Citation: Stéphan F, Barrucand B, Petit P, et al. High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial. JAMA. 2015;313(23):2331-2339.

Clinical question: In post-operative cardiothoracic surgery patients, is high-flow nasal oxygen therapy inferior to BiPAP for resolution of acute respiratory failure?

Background: Acute respiratory failure is common following cardiothoracic surgery, and noninvasive ventilation often is used to avoid intubation. Noninvasive ventilation is resource-intensive and might be uncomfortable to patients. High-flow nasal oxygen therapy is an alternative modality, which provides large amounts of oxygen with more ease and patient comfort.

Study design: Multi-center, randomized, noninferiority trial.

Setting: Six ICUs in France.

Synopsis: Investigators randomized 830 patients who met criteria (obesity, heart failure, or failure of spontaneous breathing trial) after cardiothoracic surgery. These patients were prophylactically treated with high-flow nasal oxygen or BiPAP. Patients with sleep apnea, nausea/vomiting, agitation/confusion, or hemodynamic instability were excluded. Data collected included arterial blood gas, respiratory rate, and patient-rated dyspnea. The primary outcome was treatment failure as defined by reintubation and mechanical ventilation, a switch to the other study treatment, or study treatment discontinuation.

Complications included pneumothorax, colonic pseudoobstruction, and nosocomial pneumonia. The expected rate of failure for BiPAP was 20%. High-flow nasal oxygen therapy was not inferior to BiPAP, with similar treatment failure rates occurring in both groups (21.9% in BiPAP patients vs. 21% of high-flow nasal oxygen patients); 20% of patients experienced persistent discomfort with either treatment method.

There were no significant differences in complications between the two study groups. Limitations included lack of blinding and potential for bias, leading to treatment failure and crossover.

Bottom line: High-flow nasal oxygen was noninferior to BiPAP in patients with respiratory failure after cardiothoracic surgery.

Citation: Stéphan F, Barrucand B, Petit P, et al. High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial. JAMA. 2015;313(23):2331-2339.

Clinical question: In post-operative cardiothoracic surgery patients, is high-flow nasal oxygen therapy inferior to BiPAP for resolution of acute respiratory failure?

Background: Acute respiratory failure is common following cardiothoracic surgery, and noninvasive ventilation often is used to avoid intubation. Noninvasive ventilation is resource-intensive and might be uncomfortable to patients. High-flow nasal oxygen therapy is an alternative modality, which provides large amounts of oxygen with more ease and patient comfort.

Study design: Multi-center, randomized, noninferiority trial.

Setting: Six ICUs in France.

Synopsis: Investigators randomized 830 patients who met criteria (obesity, heart failure, or failure of spontaneous breathing trial) after cardiothoracic surgery. These patients were prophylactically treated with high-flow nasal oxygen or BiPAP. Patients with sleep apnea, nausea/vomiting, agitation/confusion, or hemodynamic instability were excluded. Data collected included arterial blood gas, respiratory rate, and patient-rated dyspnea. The primary outcome was treatment failure as defined by reintubation and mechanical ventilation, a switch to the other study treatment, or study treatment discontinuation.

Complications included pneumothorax, colonic pseudoobstruction, and nosocomial pneumonia. The expected rate of failure for BiPAP was 20%. High-flow nasal oxygen therapy was not inferior to BiPAP, with similar treatment failure rates occurring in both groups (21.9% in BiPAP patients vs. 21% of high-flow nasal oxygen patients); 20% of patients experienced persistent discomfort with either treatment method.

There were no significant differences in complications between the two study groups. Limitations included lack of blinding and potential for bias, leading to treatment failure and crossover.

Bottom line: High-flow nasal oxygen was noninferior to BiPAP in patients with respiratory failure after cardiothoracic surgery.

Citation: Stéphan F, Barrucand B, Petit P, et al. High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial. JAMA. 2015;313(23):2331-2339.

Clinical question: Does routine oxygen supplementation in patients with STEMI increase myocardial injury?

Background: Because of physiologic and clinical studies conducted before the era of acute coronary intervention, supplemental oxygen routinely is administered to patients with STEMI, regardless of oxygen saturation; however, recent studies have shown possible adverse effects of oxygen, including increased reperfusion injury and increased adverse outcomes in small clinical trials.

Study design: Multicenter, prospective, randomized, controlled trial (RCT).

Setting: Nine metropolitan hospitals.

Synopsis: This multicenter study included 441 patients with STEMI who were 18 years or older and were randomized by paramedics to receive either 8 L/min of oxygen or no supplemental oxygen. All patients then received protocolized care. The primary endpoint of myocardial infarct size, determined by mean peak of creatine kinase, was significantly increased in the oxygen group compared to the no oxygen group (1948 vs. 1543 U/L; means ratio, 1.27; 95% confidence interval, 1.04-1.52; P=0.01). There were nonsignificant increases of secondary endpoints in the oxygen group, including rate of recurrent myocardial infarction (5.5% vs. 0.9%; P=0.006), frequency of arrhythmia (40.4% vs. 31.4%; P=0.05), and size of infarct on six-month cardiac MRI (n=139; 20.3 vs. 13.1 g; P=0.04).

This study has several limitations: It was powered to detect differences in biomarkers (not clinical endpoints) and the treatment was not blinded to paramedics, patients, or cardiology teams.

Bottom line: Supplemental oxygen administration in patients with STEMI might increase infarct size and lead to poorer clinical outcomes; however, larger clinical trials are warranted.

Citation: Stub D, Smith K, Bernard S, et al. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation. 2015;131(24):2143-2150.

Clinical question: Does routine oxygen supplementation in patients with STEMI increase myocardial injury?

Background: Because of physiologic and clinical studies conducted before the era of acute coronary intervention, supplemental oxygen routinely is administered to patients with STEMI, regardless of oxygen saturation; however, recent studies have shown possible adverse effects of oxygen, including increased reperfusion injury and increased adverse outcomes in small clinical trials.

Study design: Multicenter, prospective, randomized, controlled trial (RCT).

Setting: Nine metropolitan hospitals.

Synopsis: This multicenter study included 441 patients with STEMI who were 18 years or older and were randomized by paramedics to receive either 8 L/min of oxygen or no supplemental oxygen. All patients then received protocolized care. The primary endpoint of myocardial infarct size, determined by mean peak of creatine kinase, was significantly increased in the oxygen group compared to the no oxygen group (1948 vs. 1543 U/L; means ratio, 1.27; 95% confidence interval, 1.04-1.52; P=0.01). There were nonsignificant increases of secondary endpoints in the oxygen group, including rate of recurrent myocardial infarction (5.5% vs. 0.9%; P=0.006), frequency of arrhythmia (40.4% vs. 31.4%; P=0.05), and size of infarct on six-month cardiac MRI (n=139; 20.3 vs. 13.1 g; P=0.04).

This study has several limitations: It was powered to detect differences in biomarkers (not clinical endpoints) and the treatment was not blinded to paramedics, patients, or cardiology teams.

Bottom line: Supplemental oxygen administration in patients with STEMI might increase infarct size and lead to poorer clinical outcomes; however, larger clinical trials are warranted.

Citation: Stub D, Smith K, Bernard S, et al. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation. 2015;131(24):2143-2150.

Clinical question: Does routine oxygen supplementation in patients with STEMI increase myocardial injury?

Background: Because of physiologic and clinical studies conducted before the era of acute coronary intervention, supplemental oxygen routinely is administered to patients with STEMI, regardless of oxygen saturation; however, recent studies have shown possible adverse effects of oxygen, including increased reperfusion injury and increased adverse outcomes in small clinical trials.

Study design: Multicenter, prospective, randomized, controlled trial (RCT).

Setting: Nine metropolitan hospitals.

Synopsis: This multicenter study included 441 patients with STEMI who were 18 years or older and were randomized by paramedics to receive either 8 L/min of oxygen or no supplemental oxygen. All patients then received protocolized care. The primary endpoint of myocardial infarct size, determined by mean peak of creatine kinase, was significantly increased in the oxygen group compared to the no oxygen group (1948 vs. 1543 U/L; means ratio, 1.27; 95% confidence interval, 1.04-1.52; P=0.01). There were nonsignificant increases of secondary endpoints in the oxygen group, including rate of recurrent myocardial infarction (5.5% vs. 0.9%; P=0.006), frequency of arrhythmia (40.4% vs. 31.4%; P=0.05), and size of infarct on six-month cardiac MRI (n=139; 20.3 vs. 13.1 g; P=0.04).

This study has several limitations: It was powered to detect differences in biomarkers (not clinical endpoints) and the treatment was not blinded to paramedics, patients, or cardiology teams.

Bottom line: Supplemental oxygen administration in patients with STEMI might increase infarct size and lead to poorer clinical outcomes; however, larger clinical trials are warranted.

Citation: Stub D, Smith K, Bernard S, et al. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation. 2015;131(24):2143-2150.

Clinical question: Does thrombectomy, in conjunction with medical therapy, improve functional independence in patients with an acute proximal anterior stroke?

Background: Revascularization of proximal anterior strokes with alteplase alone occurs less than 50% of the time. First-generation thrombectomy devices (i.e., Merci and Penumbra) have not shown improvement in revascularization or functional outcomes; however, the development of thrombectomy stent retriever devices has led to more promising results, with several recent studies demonstrating functional improvement using endovascular retrieval in addition to medical therapy in proximal anterior circulation strokes.

Study design: Prospective, multicenter, randomized, sequential, open-label, phase 3 study with blinded evaluation.

Setting: Four hospitals in Spain.

Synopsis: Approximately 200 patients who were diagnosed within eight hours of onset of a large vessel anterior stroke were randomly assigned to medical therapy (alteplase) plus endovascular treatment versus medical therapy alone. In order to reduce selection bias, the study was conducted within a population-based registry of acute stroke patients from the same area. The major exclusion criterion was evidence of a large infarct on imaging. The primary outcome was severity of disability at 90 days based on the modified Rankin score.

Study results showed a significant improvement in functional status in the thrombectomy group, with 66% of patients demonstrating revascularization. The rate of death and intracranial hemorrhage was similar between both groups.

The trial stopped recruitment after the first interim analysis given lack of equipoise, with emerging literature supporting endovascular therapy.

Bottom line: Thrombectomy performed in proximal, large vessel anterior circulation strokes within eight hours of onset of symptoms improves functional status at 90 days.

Citation: Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptoms onset in ischemic stroke. New Engl J Med. 2015;372(24):2296-2306.

Clinical question: Does thrombectomy, in conjunction with medical therapy, improve functional independence in patients with an acute proximal anterior stroke?

Background: Revascularization of proximal anterior strokes with alteplase alone occurs less than 50% of the time. First-generation thrombectomy devices (i.e., Merci and Penumbra) have not shown improvement in revascularization or functional outcomes; however, the development of thrombectomy stent retriever devices has led to more promising results, with several recent studies demonstrating functional improvement using endovascular retrieval in addition to medical therapy in proximal anterior circulation strokes.

Study design: Prospective, multicenter, randomized, sequential, open-label, phase 3 study with blinded evaluation.

Setting: Four hospitals in Spain.

Synopsis: Approximately 200 patients who were diagnosed within eight hours of onset of a large vessel anterior stroke were randomly assigned to medical therapy (alteplase) plus endovascular treatment versus medical therapy alone. In order to reduce selection bias, the study was conducted within a population-based registry of acute stroke patients from the same area. The major exclusion criterion was evidence of a large infarct on imaging. The primary outcome was severity of disability at 90 days based on the modified Rankin score.

Study results showed a significant improvement in functional status in the thrombectomy group, with 66% of patients demonstrating revascularization. The rate of death and intracranial hemorrhage was similar between both groups.

The trial stopped recruitment after the first interim analysis given lack of equipoise, with emerging literature supporting endovascular therapy.

Bottom line: Thrombectomy performed in proximal, large vessel anterior circulation strokes within eight hours of onset of symptoms improves functional status at 90 days.

Citation: Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptoms onset in ischemic stroke. New Engl J Med. 2015;372(24):2296-2306.

Clinical question: Does thrombectomy, in conjunction with medical therapy, improve functional independence in patients with an acute proximal anterior stroke?

Background: Revascularization of proximal anterior strokes with alteplase alone occurs less than 50% of the time. First-generation thrombectomy devices (i.e., Merci and Penumbra) have not shown improvement in revascularization or functional outcomes; however, the development of thrombectomy stent retriever devices has led to more promising results, with several recent studies demonstrating functional improvement using endovascular retrieval in addition to medical therapy in proximal anterior circulation strokes.

Study design: Prospective, multicenter, randomized, sequential, open-label, phase 3 study with blinded evaluation.

Setting: Four hospitals in Spain.

Synopsis: Approximately 200 patients who were diagnosed within eight hours of onset of a large vessel anterior stroke were randomly assigned to medical therapy (alteplase) plus endovascular treatment versus medical therapy alone. In order to reduce selection bias, the study was conducted within a population-based registry of acute stroke patients from the same area. The major exclusion criterion was evidence of a large infarct on imaging. The primary outcome was severity of disability at 90 days based on the modified Rankin score.

Study results showed a significant improvement in functional status in the thrombectomy group, with 66% of patients demonstrating revascularization. The rate of death and intracranial hemorrhage was similar between both groups.

The trial stopped recruitment after the first interim analysis given lack of equipoise, with emerging literature supporting endovascular therapy.

Bottom line: Thrombectomy performed in proximal, large vessel anterior circulation strokes within eight hours of onset of symptoms improves functional status at 90 days.

Citation: Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptoms onset in ischemic stroke. New Engl J Med. 2015;372(24):2296-2306.

Clinical question: Does interdisciplinary care on general medical wards improve patient outcomes?

Background: Patients on general medical wards might experience errors and/or preventable deaths. One mechanism that could reduce the risk of errors or preventable death is the utilization of interdisciplinary team care.

Study design: Systematic review.

Setting: Studies published in English from 1998 through 2013 in Embase, MEDLINE, and PsycINFO.

Synopsis: Reports of interdisciplinary team care interventions on general medical wards in which the care was evaluated against an objective patient outcome were reviewed. Outcomes were grouped into early (less than 30 days) or late (30 days to 12 months). Thirty studies of more than 66,000 total patients were included; these were composed of RCTs, nonrandomized cluster trials, and controlled before-after studies.

Interventions either altered the composition of the care team or addressed the logistics of team practice. Studies evaluated complications of care, length of stay, readmissions, and mortality. Although some evidence showed interdisciplinary care reduces complications, the majority of studies did not show significant improvements in any other outcomes.

Bottom line: In a systematic review, interdisciplinary team care in general medical wards is not associated with reduced complications, length of stay, readmissions, or mortality.

Citation: Pannick S, Davis R, Ashrafian H, et al. Effects of interdisciplinary team care interventions on general medical wards: a systematic review. JAMA Intern Med. 2015;175(8):1288-1298.

Clinical question: Does interdisciplinary care on general medical wards improve patient outcomes?

Background: Patients on general medical wards might experience errors and/or preventable deaths. One mechanism that could reduce the risk of errors or preventable death is the utilization of interdisciplinary team care.

Study design: Systematic review.

Setting: Studies published in English from 1998 through 2013 in Embase, MEDLINE, and PsycINFO.

Synopsis: Reports of interdisciplinary team care interventions on general medical wards in which the care was evaluated against an objective patient outcome were reviewed. Outcomes were grouped into early (less than 30 days) or late (30 days to 12 months). Thirty studies of more than 66,000 total patients were included; these were composed of RCTs, nonrandomized cluster trials, and controlled before-after studies.

Interventions either altered the composition of the care team or addressed the logistics of team practice. Studies evaluated complications of care, length of stay, readmissions, and mortality. Although some evidence showed interdisciplinary care reduces complications, the majority of studies did not show significant improvements in any other outcomes.

Bottom line: In a systematic review, interdisciplinary team care in general medical wards is not associated with reduced complications, length of stay, readmissions, or mortality.

Citation: Pannick S, Davis R, Ashrafian H, et al. Effects of interdisciplinary team care interventions on general medical wards: a systematic review. JAMA Intern Med. 2015;175(8):1288-1298.

Clinical question: Does interdisciplinary care on general medical wards improve patient outcomes?

Background: Patients on general medical wards might experience errors and/or preventable deaths. One mechanism that could reduce the risk of errors or preventable death is the utilization of interdisciplinary team care.

Study design: Systematic review.

Setting: Studies published in English from 1998 through 2013 in Embase, MEDLINE, and PsycINFO.

Synopsis: Reports of interdisciplinary team care interventions on general medical wards in which the care was evaluated against an objective patient outcome were reviewed. Outcomes were grouped into early (less than 30 days) or late (30 days to 12 months). Thirty studies of more than 66,000 total patients were included; these were composed of RCTs, nonrandomized cluster trials, and controlled before-after studies.

Interventions either altered the composition of the care team or addressed the logistics of team practice. Studies evaluated complications of care, length of stay, readmissions, and mortality. Although some evidence showed interdisciplinary care reduces complications, the majority of studies did not show significant improvements in any other outcomes.

Bottom line: In a systematic review, interdisciplinary team care in general medical wards is not associated with reduced complications, length of stay, readmissions, or mortality.

Citation: Pannick S, Davis R, Ashrafian H, et al. Effects of interdisciplinary team care interventions on general medical wards: a systematic review. JAMA Intern Med. 2015;175(8):1288-1298.

Clinical question: Is there an association between objective measures of surgical quality and patient satisfaction as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey?

Background: The Centers for Medicare and Medicaid Services (CMS) has tied financial reimbursement to patient satisfaction scores. It is unknown whether high-quality surgery correlates with higher patient satisfaction scores.

Study design: Retrospective, observational study.

Setting: One hundred eighty hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).

Synopsis: The study included 103,866 Medicare patients 65 and older who had surgery at a participating ACS NSQIP hospital between 2004-2008. Data regarding these patients were collected from a linked database (including Medicare inpatient claims, ACS NSQIP, the American Hospital Association annual survey, and Hospital Compare). Analysis of five 30-day outcomes was performed in order to assess surgical quality:

• Post-operative mortality;
• Major complication;
• Minor complication;
• Death following a complication; and
• Readmission.

Participating hospitals were grouped into quartiles based upon their performance on the HCAHPS survey.

Hospitals that performed in the highest quartile on the HCAHPS survey had significantly lower 30-day mortality, death following complications, and minor complications. No differences were detected in hospital readmissions or major complications based on patient satisfaction.

The results of this study may not be generalizable to all hospitals given the fact that the dataset is from Medicare patients only and participation in the ACS NSQIP is voluntary.

Bottom line: Using data from a national database, researchers found a positive association between patient satisfaction scores and objective measures of surgical quality.

Citation: Sacks GD, Lawson EH, Dawes AJ, et al. Relationship between hospital performance on a patient satisfaction survey and surgical quality [published online ahead of print June 24, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.1108.

Clinical question: Is there an association between objective measures of surgical quality and patient satisfaction as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey?

Background: The Centers for Medicare and Medicaid Services (CMS) has tied financial reimbursement to patient satisfaction scores. It is unknown whether high-quality surgery correlates with higher patient satisfaction scores.

Study design: Retrospective, observational study.

Setting: One hundred eighty hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).

Synopsis: The study included 103,866 Medicare patients 65 and older who had surgery at a participating ACS NSQIP hospital between 2004-2008. Data regarding these patients were collected from a linked database (including Medicare inpatient claims, ACS NSQIP, the American Hospital Association annual survey, and Hospital Compare). Analysis of five 30-day outcomes was performed in order to assess surgical quality:

• Post-operative mortality;
• Major complication;
• Minor complication;
• Death following a complication; and
• Readmission.

Participating hospitals were grouped into quartiles based upon their performance on the HCAHPS survey.

Hospitals that performed in the highest quartile on the HCAHPS survey had significantly lower 30-day mortality, death following complications, and minor complications. No differences were detected in hospital readmissions or major complications based on patient satisfaction.

The results of this study may not be generalizable to all hospitals given the fact that the dataset is from Medicare patients only and participation in the ACS NSQIP is voluntary.

Bottom line: Using data from a national database, researchers found a positive association between patient satisfaction scores and objective measures of surgical quality.

Citation: Sacks GD, Lawson EH, Dawes AJ, et al. Relationship between hospital performance on a patient satisfaction survey and surgical quality [published online ahead of print June 24, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.1108.

Clinical question: Is there an association between objective measures of surgical quality and patient satisfaction as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey?

Background: The Centers for Medicare and Medicaid Services (CMS) has tied financial reimbursement to patient satisfaction scores. It is unknown whether high-quality surgery correlates with higher patient satisfaction scores.

Study design: Retrospective, observational study.

Setting: One hundred eighty hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).

Synopsis: The study included 103,866 Medicare patients 65 and older who had surgery at a participating ACS NSQIP hospital between 2004-2008. Data regarding these patients were collected from a linked database (including Medicare inpatient claims, ACS NSQIP, the American Hospital Association annual survey, and Hospital Compare). Analysis of five 30-day outcomes was performed in order to assess surgical quality:

• Post-operative mortality;
• Major complication;
• Minor complication;
• Death following a complication; and
• Readmission.

Participating hospitals were grouped into quartiles based upon their performance on the HCAHPS survey.

Hospitals that performed in the highest quartile on the HCAHPS survey had significantly lower 30-day mortality, death following complications, and minor complications. No differences were detected in hospital readmissions or major complications based on patient satisfaction.

The results of this study may not be generalizable to all hospitals given the fact that the dataset is from Medicare patients only and participation in the ACS NSQIP is voluntary.

Bottom line: Using data from a national database, researchers found a positive association between patient satisfaction scores and objective measures of surgical quality.

Citation: Sacks GD, Lawson EH, Dawes AJ, et al. Relationship between hospital performance on a patient satisfaction survey and surgical quality [published online ahead of print June 24, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.1108.

Clinical question: Among patients with a first episode of unprovoked pulmonary embolism (PE), what are the benefits and harms of extending the duration of anticoagulation for secondary prophylaxis against recurrent VTE?

Background: Optimal duration of anticoagulation after initial unprovoked PE is not known. Prior studies demonstrated risk reduction of recurrent VTE while on therapy but have had inadequate long-term monitoring of patients or enrollment of patients with PE, who are known to have a higher case-fatality rate of recurrent VTE than patients with DVT.

Study design: Multicenter, randomized, double-blinded, parallel-grouped, placebo-controlled trial.

Setting: Fourteen French hospitals from 2007 to 2012.

Synopsis: Investigators randomized 371 patients with a first episode of symptomatic unprovoked PE who had completed six months of warfarin to 18 additional months of warfarin or placebo. Patients were followed for 24 months after discontinuation of therapy.

During the treatment period, the primary outcome (composite of recurrent VTE and major bleeding) occurred in 3.3% of the warfarin group vs. 13.5% of the placebo group (HR 0.22). This difference was primarily due to reduction in risk of recurrent VTE (1.7% vs. 13.5%, HR 0.15), with only minimal increased bleeding risk (2.2% vs. 0.5%, NS).

There was no significant difference in the composite outcome (20.8% in warfarin group vs. 24% in placebo) on analysis of the entire study period (treatment and follow-up), however, suggesting the benefit of extended warfarin therapy upon recurrent VTE risk diminished upon cessation.

Bottom line: Patients treated with extended-therapy warfarin after a first unprovoked PE have a decreased risk of recurrent VTE compared to standard therapy only while on treatment; the risk of recurrent VTE returns upon cessation of therapy.

Citation: Couturand F, Sanchez O, Pernod G, et al. Six months vs extended oral anticoagulation after a first episode of pulmonary embolism: The PADIS-PE randomized clinical trial. JAMA. 2015;314(1):31-40.

Clinical question: Among patients with a first episode of unprovoked pulmonary embolism (PE), what are the benefits and harms of extending the duration of anticoagulation for secondary prophylaxis against recurrent VTE?

Background: Optimal duration of anticoagulation after initial unprovoked PE is not known. Prior studies demonstrated risk reduction of recurrent VTE while on therapy but have had inadequate long-term monitoring of patients or enrollment of patients with PE, who are known to have a higher case-fatality rate of recurrent VTE than patients with DVT.

Study design: Multicenter, randomized, double-blinded, parallel-grouped, placebo-controlled trial.

Setting: Fourteen French hospitals from 2007 to 2012.

Synopsis: Investigators randomized 371 patients with a first episode of symptomatic unprovoked PE who had completed six months of warfarin to 18 additional months of warfarin or placebo. Patients were followed for 24 months after discontinuation of therapy.

During the treatment period, the primary outcome (composite of recurrent VTE and major bleeding) occurred in 3.3% of the warfarin group vs. 13.5% of the placebo group (HR 0.22). This difference was primarily due to reduction in risk of recurrent VTE (1.7% vs. 13.5%, HR 0.15), with only minimal increased bleeding risk (2.2% vs. 0.5%, NS).

There was no significant difference in the composite outcome (20.8% in warfarin group vs. 24% in placebo) on analysis of the entire study period (treatment and follow-up), however, suggesting the benefit of extended warfarin therapy upon recurrent VTE risk diminished upon cessation.

Bottom line: Patients treated with extended-therapy warfarin after a first unprovoked PE have a decreased risk of recurrent VTE compared to standard therapy only while on treatment; the risk of recurrent VTE returns upon cessation of therapy.

Citation: Couturand F, Sanchez O, Pernod G, et al. Six months vs extended oral anticoagulation after a first episode of pulmonary embolism: The PADIS-PE randomized clinical trial. JAMA. 2015;314(1):31-40.

Clinical question: Among patients with a first episode of unprovoked pulmonary embolism (PE), what are the benefits and harms of extending the duration of anticoagulation for secondary prophylaxis against recurrent VTE?

Background: Optimal duration of anticoagulation after initial unprovoked PE is not known. Prior studies demonstrated risk reduction of recurrent VTE while on therapy but have had inadequate long-term monitoring of patients or enrollment of patients with PE, who are known to have a higher case-fatality rate of recurrent VTE than patients with DVT.

Study design: Multicenter, randomized, double-blinded, parallel-grouped, placebo-controlled trial.

Setting: Fourteen French hospitals from 2007 to 2012.

Synopsis: Investigators randomized 371 patients with a first episode of symptomatic unprovoked PE who had completed six months of warfarin to 18 additional months of warfarin or placebo. Patients were followed for 24 months after discontinuation of therapy.

During the treatment period, the primary outcome (composite of recurrent VTE and major bleeding) occurred in 3.3% of the warfarin group vs. 13.5% of the placebo group (HR 0.22). This difference was primarily due to reduction in risk of recurrent VTE (1.7% vs. 13.5%, HR 0.15), with only minimal increased bleeding risk (2.2% vs. 0.5%, NS).

There was no significant difference in the composite outcome (20.8% in warfarin group vs. 24% in placebo) on analysis of the entire study period (treatment and follow-up), however, suggesting the benefit of extended warfarin therapy upon recurrent VTE risk diminished upon cessation.

Bottom line: Patients treated with extended-therapy warfarin after a first unprovoked PE have a decreased risk of recurrent VTE compared to standard therapy only while on treatment; the risk of recurrent VTE returns upon cessation of therapy.

Citation: Couturand F, Sanchez O, Pernod G, et al. Six months vs extended oral anticoagulation after a first episode of pulmonary embolism: The PADIS-PE randomized clinical trial. JAMA. 2015;314(1):31-40.