Clinical

ROBERT COBEN, MD, Program director of the gastroenterology fellowship program at Thomas Jefferson University Hospital in Philadelphia, discusses GI bleeds and colon cancer.

ROBERT COBEN, MD, Program director of the gastroenterology fellowship program at Thomas Jefferson University Hospital in Philadelphia, discusses GI bleeds and colon cancer.

ROBERT COBEN, MD, Program director of the gastroenterology fellowship program at Thomas Jefferson University Hospital in Philadelphia, discusses GI bleeds and colon cancer.

John Pandolfino, MD, chief of gastroenterology and hepatology at Northwestern University’s Feinberg School of Medicine in Chicago, talks about best practices for colonoscopies and treating C. diff infections.

John Pandolfino, MD, chief of gastroenterology and hepatology at Northwestern University’s Feinberg School of Medicine in Chicago, talks about best practices for colonoscopies and treating C. diff infections.

John Pandolfino, MD, chief of gastroenterology and hepatology at Northwestern University’s Feinberg School of Medicine in Chicago, talks about best practices for colonoscopies and treating C. diff infections.

Clinical question: Can novel configured rapid response teams (RRTs) improve non-ICU cardiopulmonary arrest (CPA) and overall hospital mortality rate?

Background: RRTs are primarily executed in hospital settings to avert non-ICU CPA through early detection and intervention. Prevailing evidence has not shown consistent clear benefit of RRTs in this regard.

Study design: A parallel-controlled, before-after design.

Setting: Two urban university hospitals with approximately 500 medical/surgical beds.

Synopsis: Researchers compared annual non-ICU CPA rates from two university hospitals with newly configured RRTs (implemented in November 2007) from July 2005 through June 2011 and found a decline in the incidence of non-ICU CPA to 1.1 from 2.7 per 1000 discharges (P<0.0001) while comparing pre- (2005/2006 to 2006/2007) to post- RRT implementation (2007-2011), respectively. Post-implementation, the overall hospital mortality dropped to 1.74% from 2.12% (P<0.001). With year-over-year, the RRT activation was found to be inversely related to Code Blue activations (r=-0.68, P<0.001), while the case mix index coefficients were still high.

The study lacks internal validation and may carry bias by including just one pre-implementation year (2006) data. It demonstrates that the rounding of unit manager (charge nurse) on “at risk” patients might avert decompensation; however, there was no determination of their decision-making process, with regard to RRT activation. No comparison was done with other RRT configurations.

Bottom line: Novel configured RRTs may improve non-ICU CPA and overall hospital mortality rate.

Citation: Davis DP, Aguilar SA, Graham PG, et al. A novel configuration of a traditional rapid response team decreases non-intensive care unit arrests and overall hospital mortality. J Hosp Med. 2015;10(6):352-357.

Clinical question: Can novel configured rapid response teams (RRTs) improve non-ICU cardiopulmonary arrest (CPA) and overall hospital mortality rate?

Background: RRTs are primarily executed in hospital settings to avert non-ICU CPA through early detection and intervention. Prevailing evidence has not shown consistent clear benefit of RRTs in this regard.

Study design: A parallel-controlled, before-after design.

Setting: Two urban university hospitals with approximately 500 medical/surgical beds.

Synopsis: Researchers compared annual non-ICU CPA rates from two university hospitals with newly configured RRTs (implemented in November 2007) from July 2005 through June 2011 and found a decline in the incidence of non-ICU CPA to 1.1 from 2.7 per 1000 discharges (P<0.0001) while comparing pre- (2005/2006 to 2006/2007) to post- RRT implementation (2007-2011), respectively. Post-implementation, the overall hospital mortality dropped to 1.74% from 2.12% (P<0.001). With year-over-year, the RRT activation was found to be inversely related to Code Blue activations (r=-0.68, P<0.001), while the case mix index coefficients were still high.

The study lacks internal validation and may carry bias by including just one pre-implementation year (2006) data. It demonstrates that the rounding of unit manager (charge nurse) on “at risk” patients might avert decompensation; however, there was no determination of their decision-making process, with regard to RRT activation. No comparison was done with other RRT configurations.

Bottom line: Novel configured RRTs may improve non-ICU CPA and overall hospital mortality rate.

Citation: Davis DP, Aguilar SA, Graham PG, et al. A novel configuration of a traditional rapid response team decreases non-intensive care unit arrests and overall hospital mortality. J Hosp Med. 2015;10(6):352-357.

Clinical question: Can novel configured rapid response teams (RRTs) improve non-ICU cardiopulmonary arrest (CPA) and overall hospital mortality rate?

Background: RRTs are primarily executed in hospital settings to avert non-ICU CPA through early detection and intervention. Prevailing evidence has not shown consistent clear benefit of RRTs in this regard.

Study design: A parallel-controlled, before-after design.

Setting: Two urban university hospitals with approximately 500 medical/surgical beds.

Synopsis: Researchers compared annual non-ICU CPA rates from two university hospitals with newly configured RRTs (implemented in November 2007) from July 2005 through June 2011 and found a decline in the incidence of non-ICU CPA to 1.1 from 2.7 per 1000 discharges (P<0.0001) while comparing pre- (2005/2006 to 2006/2007) to post- RRT implementation (2007-2011), respectively. Post-implementation, the overall hospital mortality dropped to 1.74% from 2.12% (P<0.001). With year-over-year, the RRT activation was found to be inversely related to Code Blue activations (r=-0.68, P<0.001), while the case mix index coefficients were still high.

The study lacks internal validation and may carry bias by including just one pre-implementation year (2006) data. It demonstrates that the rounding of unit manager (charge nurse) on “at risk” patients might avert decompensation; however, there was no determination of their decision-making process, with regard to RRT activation. No comparison was done with other RRT configurations.

Bottom line: Novel configured RRTs may improve non-ICU CPA and overall hospital mortality rate.

Citation: Davis DP, Aguilar SA, Graham PG, et al. A novel configuration of a traditional rapid response team decreases non-intensive care unit arrests and overall hospital mortality. J Hosp Med. 2015;10(6):352-357.

State laws have played a big part in boosting the number of hospitals where specialized stroke care is available, a new study shows.

During the study, the increase in the number of hospitals certified as primary stroke centers was more than twice as high in states with stroke legislation as in states without similar laws.

At these hospitals, a dedicated stroke-focused program staffed by professionals with special training delivers emergency therapy rapidly and reliably.

All hospitals should be able to see patients with stroke, but PSC certification attests to quality of care, said lead author Dr. Ken Uchino of the Cleveland Clinic.

"It takes money and effort to organize quality care," he told Reuters Health by email. "Sometimes a hospital is so small that the facility does not expect many patients with stroke to arrive. Sometimes the resources to provide quality care are not available, such as radiology technicians on call to run a CT scanner 24 hours a day or a specialist physician in the community."

U.S. organizations first began certifying stroke centers in 2003. Some states developed their own certification programs, and many passed laws requiring ambulance personnel to take an acute stroke patient directly to a certified center, bypassing hospitals that are not certified.

These laws seem to have encouraged more hospitals to get certification, according to a paper online now in the journal Stroke.

Between 2009 and 2013, states with stroke legislation had a 16% increase in PSC certification, compared to a 6% increase in states without similar legislation.

"I think if a hospital administrator realizes that an ambulance might bypass his or her hospital because it is not stroke-certified, there is an incentive to organize stroke care in the hospital and have stroke center certification," Uchino said.

By 2013, about a third of short-term adult general hospitals with emergency departments in the U.S. were certified as primary stroke centers, he said. But growth rates have varied by state, and by 2013 there were still three states with only one certified center, he said.

Out of 4,640 general hospitals with emergency rooms in the country, 1,505 have been certified as primary stroke centers following action by state legislatures. But the proportion of stroke centers by state still varied from as low as 4% in Wyoming, which has no stroke legislation, to 100% in Delaware, which does have stroke laws.

"Massachusetts, Florida, and New Jersey, which passed stroke legislation in 2004, had 74% to 97% of the hospitals certified as stroke centers by 2013," Uchino said.

Larger, more urban hospitals in states with higher economic output are most likely to be certified as primary stroke centers, the researchers found.

Patients brought to a certified stroke center have a better chance of survival than those brought elsewhere, Uchino said.

Almost all large hospitals can and should be stroke centers, and small hospitals still need help to improve, he said.

"Small hospitals still can become stroke centers, but they had to be creative with how they pulled resources together," said Dr. Lee H. Schwamm of Massachusetts General Hospital and Harvard Medical School in Boston.

"Every community should have at least one" primary stroke center, Schwamm, who was not part of the new study, told Reuters Health by phone. "The real challenge is how do I ensure equitable access for people all over the country."

State laws have played a big part in boosting the number of hospitals where specialized stroke care is available, a new study shows.

During the study, the increase in the number of hospitals certified as primary stroke centers was more than twice as high in states with stroke legislation as in states without similar laws.

At these hospitals, a dedicated stroke-focused program staffed by professionals with special training delivers emergency therapy rapidly and reliably.

All hospitals should be able to see patients with stroke, but PSC certification attests to quality of care, said lead author Dr. Ken Uchino of the Cleveland Clinic.

"It takes money and effort to organize quality care," he told Reuters Health by email. "Sometimes a hospital is so small that the facility does not expect many patients with stroke to arrive. Sometimes the resources to provide quality care are not available, such as radiology technicians on call to run a CT scanner 24 hours a day or a specialist physician in the community."

U.S. organizations first began certifying stroke centers in 2003. Some states developed their own certification programs, and many passed laws requiring ambulance personnel to take an acute stroke patient directly to a certified center, bypassing hospitals that are not certified.

These laws seem to have encouraged more hospitals to get certification, according to a paper online now in the journal Stroke.

Between 2009 and 2013, states with stroke legislation had a 16% increase in PSC certification, compared to a 6% increase in states without similar legislation.

"I think if a hospital administrator realizes that an ambulance might bypass his or her hospital because it is not stroke-certified, there is an incentive to organize stroke care in the hospital and have stroke center certification," Uchino said.

By 2013, about a third of short-term adult general hospitals with emergency departments in the U.S. were certified as primary stroke centers, he said. But growth rates have varied by state, and by 2013 there were still three states with only one certified center, he said.

Out of 4,640 general hospitals with emergency rooms in the country, 1,505 have been certified as primary stroke centers following action by state legislatures. But the proportion of stroke centers by state still varied from as low as 4% in Wyoming, which has no stroke legislation, to 100% in Delaware, which does have stroke laws.

"Massachusetts, Florida, and New Jersey, which passed stroke legislation in 2004, had 74% to 97% of the hospitals certified as stroke centers by 2013," Uchino said.

Larger, more urban hospitals in states with higher economic output are most likely to be certified as primary stroke centers, the researchers found.

Patients brought to a certified stroke center have a better chance of survival than those brought elsewhere, Uchino said.

Almost all large hospitals can and should be stroke centers, and small hospitals still need help to improve, he said.

"Small hospitals still can become stroke centers, but they had to be creative with how they pulled resources together," said Dr. Lee H. Schwamm of Massachusetts General Hospital and Harvard Medical School in Boston.

"Every community should have at least one" primary stroke center, Schwamm, who was not part of the new study, told Reuters Health by phone. "The real challenge is how do I ensure equitable access for people all over the country."

State laws have played a big part in boosting the number of hospitals where specialized stroke care is available, a new study shows.

During the study, the increase in the number of hospitals certified as primary stroke centers was more than twice as high in states with stroke legislation as in states without similar laws.

At these hospitals, a dedicated stroke-focused program staffed by professionals with special training delivers emergency therapy rapidly and reliably.

All hospitals should be able to see patients with stroke, but PSC certification attests to quality of care, said lead author Dr. Ken Uchino of the Cleveland Clinic.

"It takes money and effort to organize quality care," he told Reuters Health by email. "Sometimes a hospital is so small that the facility does not expect many patients with stroke to arrive. Sometimes the resources to provide quality care are not available, such as radiology technicians on call to run a CT scanner 24 hours a day or a specialist physician in the community."

U.S. organizations first began certifying stroke centers in 2003. Some states developed their own certification programs, and many passed laws requiring ambulance personnel to take an acute stroke patient directly to a certified center, bypassing hospitals that are not certified.

These laws seem to have encouraged more hospitals to get certification, according to a paper online now in the journal Stroke.

Between 2009 and 2013, states with stroke legislation had a 16% increase in PSC certification, compared to a 6% increase in states without similar legislation.

"I think if a hospital administrator realizes that an ambulance might bypass his or her hospital because it is not stroke-certified, there is an incentive to organize stroke care in the hospital and have stroke center certification," Uchino said.

By 2013, about a third of short-term adult general hospitals with emergency departments in the U.S. were certified as primary stroke centers, he said. But growth rates have varied by state, and by 2013 there were still three states with only one certified center, he said.

Out of 4,640 general hospitals with emergency rooms in the country, 1,505 have been certified as primary stroke centers following action by state legislatures. But the proportion of stroke centers by state still varied from as low as 4% in Wyoming, which has no stroke legislation, to 100% in Delaware, which does have stroke laws.

"Massachusetts, Florida, and New Jersey, which passed stroke legislation in 2004, had 74% to 97% of the hospitals certified as stroke centers by 2013," Uchino said.

Larger, more urban hospitals in states with higher economic output are most likely to be certified as primary stroke centers, the researchers found.

Patients brought to a certified stroke center have a better chance of survival than those brought elsewhere, Uchino said.

Almost all large hospitals can and should be stroke centers, and small hospitals still need help to improve, he said.

"Small hospitals still can become stroke centers, but they had to be creative with how they pulled resources together," said Dr. Lee H. Schwamm of Massachusetts General Hospital and Harvard Medical School in Boston.

"Every community should have at least one" primary stroke center, Schwamm, who was not part of the new study, told Reuters Health by phone. "The real challenge is how do I ensure equitable access for people all over the country."

The newly developed Pediatric All-Cause Harm Measurement Tool (PACHMT) improved detection of harms in pediatric inpatients in a recent pilot study.

Using the tool, researchers found a rate of 40 harms per 100 patients admitted, and at least one harm in nearly a quarter of the children in the study. Close to half of the events were potentially or definitely preventable.

"Safety is measured inconsistently in health care, and the only way to make progress to improving these rates of harm is to understand how our patients are impacted by the care they receive," says Dr. David C. Stockwell, of George Washington University and Children's National Medical Center in Washington, D.C. "Therefore, we would like to see wider adoption of active surveillance of safety events with an approach like the PACHMT.

“While not replacing voluntarily reported events, it would greatly augment the understanding of all-cause harm." TH

—Reuters Health

The newly developed Pediatric All-Cause Harm Measurement Tool (PACHMT) improved detection of harms in pediatric inpatients in a recent pilot study.

Using the tool, researchers found a rate of 40 harms per 100 patients admitted, and at least one harm in nearly a quarter of the children in the study. Close to half of the events were potentially or definitely preventable.

"Safety is measured inconsistently in health care, and the only way to make progress to improving these rates of harm is to understand how our patients are impacted by the care they receive," says Dr. David C. Stockwell, of George Washington University and Children's National Medical Center in Washington, D.C. "Therefore, we would like to see wider adoption of active surveillance of safety events with an approach like the PACHMT.

“While not replacing voluntarily reported events, it would greatly augment the understanding of all-cause harm." TH

—Reuters Health

The newly developed Pediatric All-Cause Harm Measurement Tool (PACHMT) improved detection of harms in pediatric inpatients in a recent pilot study.

Using the tool, researchers found a rate of 40 harms per 100 patients admitted, and at least one harm in nearly a quarter of the children in the study. Close to half of the events were potentially or definitely preventable.

"Safety is measured inconsistently in health care, and the only way to make progress to improving these rates of harm is to understand how our patients are impacted by the care they receive," says Dr. David C. Stockwell, of George Washington University and Children's National Medical Center in Washington, D.C. "Therefore, we would like to see wider adoption of active surveillance of safety events with an approach like the PACHMT.

“While not replacing voluntarily reported events, it would greatly augment the understanding of all-cause harm." TH

—Reuters Health

The Wells score is only slightly better than a coin toss for predicting deep vein thrombosis (DVT) in hospitalized patients, researchers have found.

"The Wells score risk stratification is not sufficient to rule out DVT or influence management decisions in the inpatient setting," Dr. Patricia C. Silveira from Brigham and Women’s Hospital in Boston says.

Although the Wells score has been validated in outpatient and ED settings, it has not been studied in hospitalized patients in a large prospective trial, Dr. Silveira and her colleagues note in JAMA Internal Medicine, online May 18.

The team evaluated the utility of the tool for risk stratification of inpatients with suspected DVT in a prospective study that included more than 1,100 patients. About one in eight were found on lower-extremity venous duplex ultrasound studies (LEUS) to have proximal DVT and 9.2% to have distal DVT.

The incidence of proximal DVT in the low, moderate, and high Wells pretest probability groups was 5.9%, 9.5%, and 16.4%, respectively, a much narrower range than was previously reported for outpatients (3.0%, 16.6%, and 74.6%).

The AUC for the discriminatory accuracy of the Wells score for risk of proximal DVT identified on LEUS was only 0.6 (a coin toss would yield a predicted AUC of 0.5), the researchers found.

Results were even less informative for distal DVT, where low, moderate, and high pretest probability groups had DVT incidences of 7.4%, 9.1%, and 9.7%, respectively.

"Physician should use their clinical judgment to order lower extremity ultrasound studies for hospitalized patients with suspected DVT," Dr. Silveira concludes. "A new clinical decision rule might be useful to determine a patient's pre-test probability of DVT in the inpatient setting."

Dr. Erika Leemann Price from San Francisco Veterans Affairs Medical Center in California, who coauthored an invited commentary on the new report, told Reuters Health by email, "In the inpatient setting, the Wells score for DVT doesn't do a good job of telling us who has a DVT and who doesn't. Inpatients are different from outpatients in that they are at greater risk for DVT overall, but they also have multiple other comorbidities that can mimic the signs and symptoms of DVT.

"We don't currently have a validated clinical prediction model for DVT in the inpatient setting, although there is clearly a need for one that includes factors more predictive of VTE (venous thromboembolism) specifically in inpatients," Dr. Price says. "For now, if you are worried that your hospitalized patient may have a DVT, skip the Wells score and get an ultrasound." TH

—Reuters Health

The Wells score is only slightly better than a coin toss for predicting deep vein thrombosis (DVT) in hospitalized patients, researchers have found.

"The Wells score risk stratification is not sufficient to rule out DVT or influence management decisions in the inpatient setting," Dr. Patricia C. Silveira from Brigham and Women’s Hospital in Boston says.

Although the Wells score has been validated in outpatient and ED settings, it has not been studied in hospitalized patients in a large prospective trial, Dr. Silveira and her colleagues note in JAMA Internal Medicine, online May 18.

The team evaluated the utility of the tool for risk stratification of inpatients with suspected DVT in a prospective study that included more than 1,100 patients. About one in eight were found on lower-extremity venous duplex ultrasound studies (LEUS) to have proximal DVT and 9.2% to have distal DVT.

The incidence of proximal DVT in the low, moderate, and high Wells pretest probability groups was 5.9%, 9.5%, and 16.4%, respectively, a much narrower range than was previously reported for outpatients (3.0%, 16.6%, and 74.6%).

The AUC for the discriminatory accuracy of the Wells score for risk of proximal DVT identified on LEUS was only 0.6 (a coin toss would yield a predicted AUC of 0.5), the researchers found.

Results were even less informative for distal DVT, where low, moderate, and high pretest probability groups had DVT incidences of 7.4%, 9.1%, and 9.7%, respectively.

"Physician should use their clinical judgment to order lower extremity ultrasound studies for hospitalized patients with suspected DVT," Dr. Silveira concludes. "A new clinical decision rule might be useful to determine a patient's pre-test probability of DVT in the inpatient setting."

Dr. Erika Leemann Price from San Francisco Veterans Affairs Medical Center in California, who coauthored an invited commentary on the new report, told Reuters Health by email, "In the inpatient setting, the Wells score for DVT doesn't do a good job of telling us who has a DVT and who doesn't. Inpatients are different from outpatients in that they are at greater risk for DVT overall, but they also have multiple other comorbidities that can mimic the signs and symptoms of DVT.

"We don't currently have a validated clinical prediction model for DVT in the inpatient setting, although there is clearly a need for one that includes factors more predictive of VTE (venous thromboembolism) specifically in inpatients," Dr. Price says. "For now, if you are worried that your hospitalized patient may have a DVT, skip the Wells score and get an ultrasound." TH

—Reuters Health

The Wells score is only slightly better than a coin toss for predicting deep vein thrombosis (DVT) in hospitalized patients, researchers have found.

"The Wells score risk stratification is not sufficient to rule out DVT or influence management decisions in the inpatient setting," Dr. Patricia C. Silveira from Brigham and Women’s Hospital in Boston says.

Although the Wells score has been validated in outpatient and ED settings, it has not been studied in hospitalized patients in a large prospective trial, Dr. Silveira and her colleagues note in JAMA Internal Medicine, online May 18.

The team evaluated the utility of the tool for risk stratification of inpatients with suspected DVT in a prospective study that included more than 1,100 patients. About one in eight were found on lower-extremity venous duplex ultrasound studies (LEUS) to have proximal DVT and 9.2% to have distal DVT.

The incidence of proximal DVT in the low, moderate, and high Wells pretest probability groups was 5.9%, 9.5%, and 16.4%, respectively, a much narrower range than was previously reported for outpatients (3.0%, 16.6%, and 74.6%).

The AUC for the discriminatory accuracy of the Wells score for risk of proximal DVT identified on LEUS was only 0.6 (a coin toss would yield a predicted AUC of 0.5), the researchers found.

Results were even less informative for distal DVT, where low, moderate, and high pretest probability groups had DVT incidences of 7.4%, 9.1%, and 9.7%, respectively.

"Physician should use their clinical judgment to order lower extremity ultrasound studies for hospitalized patients with suspected DVT," Dr. Silveira concludes. "A new clinical decision rule might be useful to determine a patient's pre-test probability of DVT in the inpatient setting."

Dr. Erika Leemann Price from San Francisco Veterans Affairs Medical Center in California, who coauthored an invited commentary on the new report, told Reuters Health by email, "In the inpatient setting, the Wells score for DVT doesn't do a good job of telling us who has a DVT and who doesn't. Inpatients are different from outpatients in that they are at greater risk for DVT overall, but they also have multiple other comorbidities that can mimic the signs and symptoms of DVT.

"We don't currently have a validated clinical prediction model for DVT in the inpatient setting, although there is clearly a need for one that includes factors more predictive of VTE (venous thromboembolism) specifically in inpatients," Dr. Price says. "For now, if you are worried that your hospitalized patient may have a DVT, skip the Wells score and get an ultrasound." TH

—Reuters Health

It only takes one idea to help change the face of medicine and, recently, Forbes posted an article outlining a small startup pharmacy that could change the way we get our medication. Manchester, N.H.-based Pill Pack takes the whole mail-order pharmacy to a new level.

Medication management can be a major issue for seniors and their caregivers. Seniors are at risk for such problems as overmedication and drug interactions, if medications are not properly managed.

An UpToDate article says that a survey for adults aged 57-85 shows:

• At least one prescription medication was used by 81%;
• Five or more prescription medications were used by 29% of the overall survey population and by 36% of people aged 75 to 85 years; and
• 46% of prescription users also took at least one over-the-counter medication.

Hospitalists see it every day; the readmit because prescribed medication isn’t taken correctly. Possibly, Pill Pack might be one step in the right direction. TH

Lisa Courtney is director of operations at Baptist Health Systems in Birmingham, Ala., and a member of Team Hospitalist.

It only takes one idea to help change the face of medicine and, recently, Forbes posted an article outlining a small startup pharmacy that could change the way we get our medication. Manchester, N.H.-based Pill Pack takes the whole mail-order pharmacy to a new level.

Medication management can be a major issue for seniors and their caregivers. Seniors are at risk for such problems as overmedication and drug interactions, if medications are not properly managed.

An UpToDate article says that a survey for adults aged 57-85 shows:

• At least one prescription medication was used by 81%;
• Five or more prescription medications were used by 29% of the overall survey population and by 36% of people aged 75 to 85 years; and
• 46% of prescription users also took at least one over-the-counter medication.

Hospitalists see it every day; the readmit because prescribed medication isn’t taken correctly. Possibly, Pill Pack might be one step in the right direction. TH

Lisa Courtney is director of operations at Baptist Health Systems in Birmingham, Ala., and a member of Team Hospitalist.

It only takes one idea to help change the face of medicine and, recently, Forbes posted an article outlining a small startup pharmacy that could change the way we get our medication. Manchester, N.H.-based Pill Pack takes the whole mail-order pharmacy to a new level.

Medication management can be a major issue for seniors and their caregivers. Seniors are at risk for such problems as overmedication and drug interactions, if medications are not properly managed.

An UpToDate article says that a survey for adults aged 57-85 shows:

• At least one prescription medication was used by 81%;
• Five or more prescription medications were used by 29% of the overall survey population and by 36% of people aged 75 to 85 years; and
• 46% of prescription users also took at least one over-the-counter medication.

Hospitalists see it every day; the readmit because prescribed medication isn’t taken correctly. Possibly, Pill Pack might be one step in the right direction. TH

Lisa Courtney is director of operations at Baptist Health Systems in Birmingham, Ala., and a member of Team Hospitalist.

Clinical question: Does inclusion of two or more SIRS criteria in the definition of severe sepsis accurately identify patients with higher mortality risk, as compared with patients with infection and organ failure but with fewer than two SIRS criteria?

Background: SIRS describes dysregulation of the inflammatory response to illness. The current definition of severe sepsis includes evidence of infection, organ failure, and two or more SIRS criteria. This study sought to test the validity of inclusion of two or more SIRS criteria in the definition of severe sepsis to differentiate patients at higher mortality risk.

Study design: 14-year, retrospective study.

Setting: One hundred seventy-two ICUs in Australia and New Zealand.

Synopsis: Investigators evaluated 109,663 patients; 87.9% had SIRS-positive severe sepsis, and 12.1% had SIRS-negative severe sepsis. Patients with SIRS-positive sepsis were younger, more ill with higher mortality, and more likely to have community-acquired infections. Both groups had decreased mortality over the 14-year study period; SIRS-positive patients decreased to 18.3% from 36.1%; SIRS-negative patients decreased to 8.5% from 27.7%.

Being SIRS-positive independently increased the risk of death by 26%; however, modeling showed a linear relationship between mortality and presence of SIRS criteria with each additional criteria, from zero to four, increasing mortality by 13%. There was no transitional increase in risk of mortality using two criteria as a cut-off.

Limiting the severe sepsis definition to two or more SIRS criteria missed one of eight patients admitted to ICU with organ failure and infection alone. SIRS-negative severe sepsis patients had significant mortality but showed similarities to SIRS-positive severe sepsis patients, suggesting they are separate phenotypes of the same condition.

Bottom line: This study challenges the sensitivity, face validity, and construct validity of the two-criteria SIRS cutoff. Redefining severe sepsis to include a lower number of SIRS criteria may diagnose more patients with organ failure and infection.

Citation: Kaukonen KM, Bailey M, Pilcher D, Cooper DJ, Bellomo R. Systemic inflammatory response syndrome criteria in defining severe sepsis. N Engl J Med. 2015;372:1629-1638.

Clinical question: Does inclusion of two or more SIRS criteria in the definition of severe sepsis accurately identify patients with higher mortality risk, as compared with patients with infection and organ failure but with fewer than two SIRS criteria?

Background: SIRS describes dysregulation of the inflammatory response to illness. The current definition of severe sepsis includes evidence of infection, organ failure, and two or more SIRS criteria. This study sought to test the validity of inclusion of two or more SIRS criteria in the definition of severe sepsis to differentiate patients at higher mortality risk.

Study design: 14-year, retrospective study.

Setting: One hundred seventy-two ICUs in Australia and New Zealand.

Synopsis: Investigators evaluated 109,663 patients; 87.9% had SIRS-positive severe sepsis, and 12.1% had SIRS-negative severe sepsis. Patients with SIRS-positive sepsis were younger, more ill with higher mortality, and more likely to have community-acquired infections. Both groups had decreased mortality over the 14-year study period; SIRS-positive patients decreased to 18.3% from 36.1%; SIRS-negative patients decreased to 8.5% from 27.7%.

Being SIRS-positive independently increased the risk of death by 26%; however, modeling showed a linear relationship between mortality and presence of SIRS criteria with each additional criteria, from zero to four, increasing mortality by 13%. There was no transitional increase in risk of mortality using two criteria as a cut-off.

Limiting the severe sepsis definition to two or more SIRS criteria missed one of eight patients admitted to ICU with organ failure and infection alone. SIRS-negative severe sepsis patients had significant mortality but showed similarities to SIRS-positive severe sepsis patients, suggesting they are separate phenotypes of the same condition.

Bottom line: This study challenges the sensitivity, face validity, and construct validity of the two-criteria SIRS cutoff. Redefining severe sepsis to include a lower number of SIRS criteria may diagnose more patients with organ failure and infection.

Citation: Kaukonen KM, Bailey M, Pilcher D, Cooper DJ, Bellomo R. Systemic inflammatory response syndrome criteria in defining severe sepsis. N Engl J Med. 2015;372:1629-1638.

Clinical question: Does inclusion of two or more SIRS criteria in the definition of severe sepsis accurately identify patients with higher mortality risk, as compared with patients with infection and organ failure but with fewer than two SIRS criteria?

Background: SIRS describes dysregulation of the inflammatory response to illness. The current definition of severe sepsis includes evidence of infection, organ failure, and two or more SIRS criteria. This study sought to test the validity of inclusion of two or more SIRS criteria in the definition of severe sepsis to differentiate patients at higher mortality risk.

Study design: 14-year, retrospective study.

Setting: One hundred seventy-two ICUs in Australia and New Zealand.

Synopsis: Investigators evaluated 109,663 patients; 87.9% had SIRS-positive severe sepsis, and 12.1% had SIRS-negative severe sepsis. Patients with SIRS-positive sepsis were younger, more ill with higher mortality, and more likely to have community-acquired infections. Both groups had decreased mortality over the 14-year study period; SIRS-positive patients decreased to 18.3% from 36.1%; SIRS-negative patients decreased to 8.5% from 27.7%.

Being SIRS-positive independently increased the risk of death by 26%; however, modeling showed a linear relationship between mortality and presence of SIRS criteria with each additional criteria, from zero to four, increasing mortality by 13%. There was no transitional increase in risk of mortality using two criteria as a cut-off.

Limiting the severe sepsis definition to two or more SIRS criteria missed one of eight patients admitted to ICU with organ failure and infection alone. SIRS-negative severe sepsis patients had significant mortality but showed similarities to SIRS-positive severe sepsis patients, suggesting they are separate phenotypes of the same condition.

Bottom line: This study challenges the sensitivity, face validity, and construct validity of the two-criteria SIRS cutoff. Redefining severe sepsis to include a lower number of SIRS criteria may diagnose more patients with organ failure and infection.

Citation: Kaukonen KM, Bailey M, Pilcher D, Cooper DJ, Bellomo R. Systemic inflammatory response syndrome criteria in defining severe sepsis. N Engl J Med. 2015;372:1629-1638.

Clinical question: Does trimethoprim-sulfamethoxazole (TMP-SMX) increase the risk of sudden death in older patients taking spironolactone?

Background: TMP-SMX increases the risk of hyperkalemia when used with spironolactone; however, previous studies have not examined whether the drug interaction is associated with an increased risk of sudden cardiac death, a predictable consequence of hyperkalemia.

Study design: Population-based, nested, case-control study.

Setting: Ontario, Canada.

Synopsis: Investigators identified 11,968 patients aged 66 years or older who suffered sudden death between 1994 and 2011 while receiving spironolactone; for 328 of these patients, death occurred within 14 days of antibiotic exposure. The rate of sudden death in patients receiving TMP-SMX was compared to the rate of sudden death in patients who instead received other study antibiotics.

Compared with amoxicillin, TMP-SMX was associated with a more than twofold increase in the risk of sudden death (OR 2.46, 95%; CI 1.55-3.90). The absolute rate of death of patients taking spironolactone who were prescribed TMP-SMX was 0.74%, compared to 0.35% in patients prescribed amoxicillin.

Because TMP-SMX and spironolactone are common medications, the likelihood of co-prescription leading to drug interaction is high. Although the study does not establish causality, it suggests that alternate antibiotics should be used in elderly patients on spironolactone when possible.

Bottom line: TMP-SMX increases the risk of sudden death in older patients taking spironolactone.

Citation: Antoniou T, Hollands S, Macdonald EM, Gomes T, Mamdani MM, Juurlink DN. Trimethoprim-sulfamethoxazole and risk of sudden death among patients taking spironolactone. CMAJ. 2015;187(4):E138-E143

Clinical question: Does trimethoprim-sulfamethoxazole (TMP-SMX) increase the risk of sudden death in older patients taking spironolactone?

Background: TMP-SMX increases the risk of hyperkalemia when used with spironolactone; however, previous studies have not examined whether the drug interaction is associated with an increased risk of sudden cardiac death, a predictable consequence of hyperkalemia.

Study design: Population-based, nested, case-control study.

Setting: Ontario, Canada.

Synopsis: Investigators identified 11,968 patients aged 66 years or older who suffered sudden death between 1994 and 2011 while receiving spironolactone; for 328 of these patients, death occurred within 14 days of antibiotic exposure. The rate of sudden death in patients receiving TMP-SMX was compared to the rate of sudden death in patients who instead received other study antibiotics.

Compared with amoxicillin, TMP-SMX was associated with a more than twofold increase in the risk of sudden death (OR 2.46, 95%; CI 1.55-3.90). The absolute rate of death of patients taking spironolactone who were prescribed TMP-SMX was 0.74%, compared to 0.35% in patients prescribed amoxicillin.

Because TMP-SMX and spironolactone are common medications, the likelihood of co-prescription leading to drug interaction is high. Although the study does not establish causality, it suggests that alternate antibiotics should be used in elderly patients on spironolactone when possible.

Bottom line: TMP-SMX increases the risk of sudden death in older patients taking spironolactone.

Citation: Antoniou T, Hollands S, Macdonald EM, Gomes T, Mamdani MM, Juurlink DN. Trimethoprim-sulfamethoxazole and risk of sudden death among patients taking spironolactone. CMAJ. 2015;187(4):E138-E143

Clinical question: Does trimethoprim-sulfamethoxazole (TMP-SMX) increase the risk of sudden death in older patients taking spironolactone?

Background: TMP-SMX increases the risk of hyperkalemia when used with spironolactone; however, previous studies have not examined whether the drug interaction is associated with an increased risk of sudden cardiac death, a predictable consequence of hyperkalemia.

Study design: Population-based, nested, case-control study.

Setting: Ontario, Canada.

Synopsis: Investigators identified 11,968 patients aged 66 years or older who suffered sudden death between 1994 and 2011 while receiving spironolactone; for 328 of these patients, death occurred within 14 days of antibiotic exposure. The rate of sudden death in patients receiving TMP-SMX was compared to the rate of sudden death in patients who instead received other study antibiotics.

Compared with amoxicillin, TMP-SMX was associated with a more than twofold increase in the risk of sudden death (OR 2.46, 95%; CI 1.55-3.90). The absolute rate of death of patients taking spironolactone who were prescribed TMP-SMX was 0.74%, compared to 0.35% in patients prescribed amoxicillin.

Because TMP-SMX and spironolactone are common medications, the likelihood of co-prescription leading to drug interaction is high. Although the study does not establish causality, it suggests that alternate antibiotics should be used in elderly patients on spironolactone when possible.

Bottom line: TMP-SMX increases the risk of sudden death in older patients taking spironolactone.

Citation: Antoniou T, Hollands S, Macdonald EM, Gomes T, Mamdani MM, Juurlink DN. Trimethoprim-sulfamethoxazole and risk of sudden death among patients taking spironolactone. CMAJ. 2015;187(4):E138-E143

Clinical question: What was the effect of the Centers for Medicare and Medicaid Services’ (CMS) nonpayment for hospital-acquired conditions?

Background: In 2008, CMS implemented the Hospital-Acquired Conditions (HAC) initiative, denying incremental payment to hospitals for complications of hospital care, including central-line associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), hospital-acquired pressure ulcers, and injurious patient falls.

Study design: Quasi-experimental data review, pre-post comparison of outcomes.

Setting: Nearly 1,400 U.S. hospitals contributing data to the National Database of Nursing Quality Indicators (NDNQI).

Synopsis: Using time points before and after implementation of the CMS initiative, the authors found that the rates of CLABSIs and CAUTIs dropped significantly after implementation (11% reduction of CLABSIs, 10% reduction of CAUTIs). The rates of pressure ulcers and falls did not change significantly.

Findings differ from an earlier study, which found the HAC initiative did not lead to a reduction in the rates of CLABSIs or CAUTIs. The authors point out that the databases used were different, as was the time frame of data collection.

The authors hypothesize that the reason CLABSI and CAUTI rates decreased while fall and pressure ulcer rates were unchanged was better evidence supporting infection prevention practices for the former. An accompanying editorial argues that the differential outcomes may have been due to increased challenges in implementing practices for the latter measures rather than differential evidence.

Limitations of the study include characteristics of hospitals reporting to the NDNQI and accuracy of data capture by individual reporting hospitals. Changes over time may also be attributed to factors other than the HAC initiative.

Bottom line: Nonpayment for HACs may have led to decreases in rates of CLABSIs and CAUTIs, but rates of pressure ulcers and falls remained unchanged.

Citation: Waters TM, Daniels MJ, Bazzoli GJ, et al. Effect of Medicare’s nonpayment for hospital-acquired conditions. JAMA Intern Med. 2015;175(3):347-354.

Clinical question: What was the effect of the Centers for Medicare and Medicaid Services’ (CMS) nonpayment for hospital-acquired conditions?

Background: In 2008, CMS implemented the Hospital-Acquired Conditions (HAC) initiative, denying incremental payment to hospitals for complications of hospital care, including central-line associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), hospital-acquired pressure ulcers, and injurious patient falls.

Study design: Quasi-experimental data review, pre-post comparison of outcomes.

Setting: Nearly 1,400 U.S. hospitals contributing data to the National Database of Nursing Quality Indicators (NDNQI).

Synopsis: Using time points before and after implementation of the CMS initiative, the authors found that the rates of CLABSIs and CAUTIs dropped significantly after implementation (11% reduction of CLABSIs, 10% reduction of CAUTIs). The rates of pressure ulcers and falls did not change significantly.

Findings differ from an earlier study, which found the HAC initiative did not lead to a reduction in the rates of CLABSIs or CAUTIs. The authors point out that the databases used were different, as was the time frame of data collection.

The authors hypothesize that the reason CLABSI and CAUTI rates decreased while fall and pressure ulcer rates were unchanged was better evidence supporting infection prevention practices for the former. An accompanying editorial argues that the differential outcomes may have been due to increased challenges in implementing practices for the latter measures rather than differential evidence.

Limitations of the study include characteristics of hospitals reporting to the NDNQI and accuracy of data capture by individual reporting hospitals. Changes over time may also be attributed to factors other than the HAC initiative.

Bottom line: Nonpayment for HACs may have led to decreases in rates of CLABSIs and CAUTIs, but rates of pressure ulcers and falls remained unchanged.

Citation: Waters TM, Daniels MJ, Bazzoli GJ, et al. Effect of Medicare’s nonpayment for hospital-acquired conditions. JAMA Intern Med. 2015;175(3):347-354.

Clinical question: What was the effect of the Centers for Medicare and Medicaid Services’ (CMS) nonpayment for hospital-acquired conditions?

Background: In 2008, CMS implemented the Hospital-Acquired Conditions (HAC) initiative, denying incremental payment to hospitals for complications of hospital care, including central-line associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), hospital-acquired pressure ulcers, and injurious patient falls.

Study design: Quasi-experimental data review, pre-post comparison of outcomes.

Setting: Nearly 1,400 U.S. hospitals contributing data to the National Database of Nursing Quality Indicators (NDNQI).

Synopsis: Using time points before and after implementation of the CMS initiative, the authors found that the rates of CLABSIs and CAUTIs dropped significantly after implementation (11% reduction of CLABSIs, 10% reduction of CAUTIs). The rates of pressure ulcers and falls did not change significantly.

Findings differ from an earlier study, which found the HAC initiative did not lead to a reduction in the rates of CLABSIs or CAUTIs. The authors point out that the databases used were different, as was the time frame of data collection.

The authors hypothesize that the reason CLABSI and CAUTI rates decreased while fall and pressure ulcer rates were unchanged was better evidence supporting infection prevention practices for the former. An accompanying editorial argues that the differential outcomes may have been due to increased challenges in implementing practices for the latter measures rather than differential evidence.

Limitations of the study include characteristics of hospitals reporting to the NDNQI and accuracy of data capture by individual reporting hospitals. Changes over time may also be attributed to factors other than the HAC initiative.

Bottom line: Nonpayment for HACs may have led to decreases in rates of CLABSIs and CAUTIs, but rates of pressure ulcers and falls remained unchanged.

Citation: Waters TM, Daniels MJ, Bazzoli GJ, et al. Effect of Medicare’s nonpayment for hospital-acquired conditions. JAMA Intern Med. 2015;175(3):347-354.