Patient Care

Case

A 31-year-old male with a history of asthma is admitted with an asthma exacerbation. He has no regular outpatient provider. He denies tobacco use and reports that he is in a monogamous relationship with his girlfriend. On rounds, a medical student mentions that new HIV screening guidelines have been released recently and asks whether this patient should be screened for HIV.

Background

By the mid-2000s, approximately one to 1.2 million people in the United States were infected with HIV.¹ Approximately one quarter of these patients are estimated to be unaware of their HIV status, and this subgroup is believed responsible for a disproportionately higher percentage of new HIV infections each year.¹

While older HIV screening recommendations focused on screening patients who were deemed to be at high risk for HIV infection, there has been a paradigm change in recent years toward universal screening of all patients.^2,3 The ultimate goal is for earlier identification of infected patients, which will, in turn, lead to earlier treatment and better prevention efforts.

Universal screening has been supported by a number of different professional societies and screening guidelines.⁴

2013 Guideline

In 2013, the United States Preventive Services Task Force (USPSTF) issued new recommendations regarding HIV screening. Although the previous USPSTF guidelines (released in 2005) recommended screening patients who were believed to be at increased risk for contracting HIV, the 2013 guidelines now recommend screening all patients aged 15 to 65.⁴

Screening patients outside of this age range is recommended if the patient is deemed to be at increased risk for contracting HIV.⁴ The USPSTF provides criteria for identifying patients who are at increased risk of contracting HIV. These include:

• Men who have sex with men;
• People having unprotected vaginal or anal intercourse;
• People using injection drugs;
• People exchanging sex for drugs or money; and
• People requesting testing for other sexually transmitted diseases (STDs).⁴

Patients are also considered to be high risk if their sexual partners are infected with HIV, are bisexual, or use injection drugs.⁴

The shift toward universal HIV screening has been a trend for many years, because risk-based targeting of HIV screening will miss a significant number of HIV infections.² In fact, the 2013 recommendations bring the USPSTF guidelines into agreement with current CDC guidelines, which were released in 2006.²

The CDC, in its 2006 guidelines, recommended screening for all patients 13 to 64 years old unless HIV prevalence in the patient population has been found to be less than 0.1%, the minimum prevalence deemed necessary for HIV screening to be cost-effective.² The CDC guidelines also recommend HIV screening for all patients starting treatment for tuberculosis, patients being screened for STDs, and patients visiting STD clinics regardless of chief complaint.² They recommend that HIV screening be performed in an “opt-out” fashion, meaning that patients are informed that screening will be performed unless they decline.² Furthermore, they recommend against the need for a separate written consent form for HIV screening, as well as the prior requirement that pre-screening counseling be performed, because these requirements were felt to create potential time constraint barriers that prevented providers from screening patients.²

The CDC and the USPSTF are less conclusive with regard to frequency of rescreening for HIV infection. Both recommend rescreening patients considered high risk for HIV infection, but the interval for rescreening has not been concretely defined.^2,4 The guidelines urge providers to use clinical judgment in deciding when to rescreen for HIV infection.² For example, one reason for rescreening cited by the CDC would be the initiation of a new sexual relationship.²

In the 2013 guidelines, the USPSTF also recommends screening all pregnant women, including those presenting in labor without a known HIV status.⁴ This stance is supported by the American College of Gynecologists and Obstetricians.³ In high-risk patients with a negative screening test early in pregnancy, consideration should be given to repeat testing in the third trimester.³ Routinely screening pregnant women for HIV and starting appropriate therapy in positive patients has lowered the incidence of perinatal HIV transmission dramatically.²

Rationale

There are several reasons behind the shift to universal HIV screening, regardless of risk. First, providers often do not accurately identify patients’ HIV risk, often because patients are not aware of their actual risk or are uncomfortable discussing their high-risk behaviors with healthcare providers.² Using risk factors as a basis of screening will miss a significant number of HIV-positive patients.⁴

Additionally, screening all patients will result in the detection of HIV infection in a greater number of patients during the early asymptomatic phase, rather than when they later become symptomatic from HIV or AIDS.^2,4 Recent data has led the International Antiviral Society—USA Panel to issue updated recommendations advising initiation of antiretroviral therapy at all CD4 levels.⁵ Studies and observational data suggest that this could result in reduced AIDS complications and death rates.⁴

Early detection of HIV infection also has the potential of reducing spread of the virus.^2,4 It has been suggested that early initiation of antiretroviral therapy could reduce risk of transmission to noninfected partners by lowering viral load in the infected patient.² Knowledge of HIV status has also been shown to reduce high-risk behaviors.⁴

Moreover, by facilitating earlier detection of HIV, universal screening will allow for earlier and better counseling for infected patients.⁴ This has the potential to further alter behaviors and possibly reduce transmission of HIV and/or other sexually transmitted diseases.⁴ Additionally, routine screening of pregnant women allows for better detection of HIV-infected mothers.³ With appropriate interventions during pregnancy, including antiretroviral therapy, rates of mother-to-child transmission have decreased significantly.⁴

On the other hand, potential harms from HIV screening were considered during the USPSTF analysis, including risk of false positive test results, as well as the side effects of antiretroviral medications.⁴ Although there are known short-term and long-term side effects of antiretroviral medications, some of these side effects can be avoided by changing drug regimens.⁴ For many other side effects, the benefits appeared to outweigh the risks of these medications.⁴

Studies have also shown some potential side effects in infants exposed to antiretroviral medications, but the overall evidence is not strong.⁴ In the end, thorough analysis performed by the USPSTF resulted in the opinion that the benefits of HIV screening far outweigh the associated risks.⁴

Challenges for Hospitalists

Several potential drawbacks to universal HIV screening are relatively unique to hospitalists and other providers of hospital-based care.6 First, hospitalists must be prepared to counsel patients regarding their test results, particularly if patients are hospitalized for another issue. Second, hospitalists must be able to communicate these test results to primary care providers in a timely fashion, a challenge that is not unique to HIV testing.

The biggest concern for hospitalists is what to do with HIV test results that are still pending at the time of hospital discharge. Hospitalists will likely face this issue more as increasing numbers of patients are screened in a growing number of medical settings, including the ED and inpatient admissions. Hospitalists who plan to screen inpatients for HIV testing must ensure that these issues have been worked out prior to screening.

Back to the Case

Looking back to the initial case discussion, based on the 2006 CDC and 2013 USPSTF guidelines, this patient should be offered HIV screening if he has not been tested previously. Although the patient states that he is in a monogamous relationship and does not report any high-risk behaviors, patients often do not recognize the true risk associated with their behaviors and fail to accurately report them.² Additionally, patients often are embarrassed by high-risk behaviors and may not report them completely to providers.²

The patient has admitted that he does not seek medical care on a regular basis. This inpatient admission may be his only interaction with the medical field for some time, and thus his only opportunity to undergo screening. But, prior to screening the patient, the hospitalist must ensure that he or she will be able to counsel the patient regarding test results, will be able to communicate those results to the patient’s primary care physician, and will be able to handle pending results if the patient is discharged before the test results are returned.

Drs. Gwyn, Carbo and Li are hospitalists at Beth Israel Deaconess Medical Center in Boston.

References

1. Branson B. Current HIV epidemiology and revised recommendations for HIV testing in health-care settings. J Med Virol. 2007;79 Suppl 1:S6-S10.
2. Moyer VA; U.S. Preventive Services Task Force. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;159(1):51-60.
3. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17.
4. Clark J, Lampe MA, Jamieson DJ. Testing women for human immunodeficiency virus infection: who, when, and how? Clin Obstet Gynceol. 2008;51(3):507-517.
5. Thompson MA, Aberg JA, Hoy JF, et al. Antiretroviral treatment of adult HIV infection: 2012 recommendations of the International Antiviral Society–USA Panel. JAMA. 2012;308(4):387-402.
6. Arbelaez C, Wright EA, Losina E, et al. Emergency provider attitudes and barriers to universal HIV testing in the emergency department. J Emerg Med. 2012;42(1):7-14.

Case

A 31-year-old male with a history of asthma is admitted with an asthma exacerbation. He has no regular outpatient provider. He denies tobacco use and reports that he is in a monogamous relationship with his girlfriend. On rounds, a medical student mentions that new HIV screening guidelines have been released recently and asks whether this patient should be screened for HIV.

Background

By the mid-2000s, approximately one to 1.2 million people in the United States were infected with HIV.¹ Approximately one quarter of these patients are estimated to be unaware of their HIV status, and this subgroup is believed responsible for a disproportionately higher percentage of new HIV infections each year.¹

While older HIV screening recommendations focused on screening patients who were deemed to be at high risk for HIV infection, there has been a paradigm change in recent years toward universal screening of all patients.^2,3 The ultimate goal is for earlier identification of infected patients, which will, in turn, lead to earlier treatment and better prevention efforts.

Universal screening has been supported by a number of different professional societies and screening guidelines.⁴

2013 Guideline

In 2013, the United States Preventive Services Task Force (USPSTF) issued new recommendations regarding HIV screening. Although the previous USPSTF guidelines (released in 2005) recommended screening patients who were believed to be at increased risk for contracting HIV, the 2013 guidelines now recommend screening all patients aged 15 to 65.⁴

Screening patients outside of this age range is recommended if the patient is deemed to be at increased risk for contracting HIV.⁴ The USPSTF provides criteria for identifying patients who are at increased risk of contracting HIV. These include:

• Men who have sex with men;
• People having unprotected vaginal or anal intercourse;
• People using injection drugs;
• People exchanging sex for drugs or money; and
• People requesting testing for other sexually transmitted diseases (STDs).⁴

Patients are also considered to be high risk if their sexual partners are infected with HIV, are bisexual, or use injection drugs.⁴

The shift toward universal HIV screening has been a trend for many years, because risk-based targeting of HIV screening will miss a significant number of HIV infections.² In fact, the 2013 recommendations bring the USPSTF guidelines into agreement with current CDC guidelines, which were released in 2006.²

The CDC, in its 2006 guidelines, recommended screening for all patients 13 to 64 years old unless HIV prevalence in the patient population has been found to be less than 0.1%, the minimum prevalence deemed necessary for HIV screening to be cost-effective.² The CDC guidelines also recommend HIV screening for all patients starting treatment for tuberculosis, patients being screened for STDs, and patients visiting STD clinics regardless of chief complaint.² They recommend that HIV screening be performed in an “opt-out” fashion, meaning that patients are informed that screening will be performed unless they decline.² Furthermore, they recommend against the need for a separate written consent form for HIV screening, as well as the prior requirement that pre-screening counseling be performed, because these requirements were felt to create potential time constraint barriers that prevented providers from screening patients.²

The CDC and the USPSTF are less conclusive with regard to frequency of rescreening for HIV infection. Both recommend rescreening patients considered high risk for HIV infection, but the interval for rescreening has not been concretely defined.^2,4 The guidelines urge providers to use clinical judgment in deciding when to rescreen for HIV infection.² For example, one reason for rescreening cited by the CDC would be the initiation of a new sexual relationship.²

In the 2013 guidelines, the USPSTF also recommends screening all pregnant women, including those presenting in labor without a known HIV status.⁴ This stance is supported by the American College of Gynecologists and Obstetricians.³ In high-risk patients with a negative screening test early in pregnancy, consideration should be given to repeat testing in the third trimester.³ Routinely screening pregnant women for HIV and starting appropriate therapy in positive patients has lowered the incidence of perinatal HIV transmission dramatically.²

Rationale

There are several reasons behind the shift to universal HIV screening, regardless of risk. First, providers often do not accurately identify patients’ HIV risk, often because patients are not aware of their actual risk or are uncomfortable discussing their high-risk behaviors with healthcare providers.² Using risk factors as a basis of screening will miss a significant number of HIV-positive patients.⁴

Additionally, screening all patients will result in the detection of HIV infection in a greater number of patients during the early asymptomatic phase, rather than when they later become symptomatic from HIV or AIDS.^2,4 Recent data has led the International Antiviral Society—USA Panel to issue updated recommendations advising initiation of antiretroviral therapy at all CD4 levels.⁵ Studies and observational data suggest that this could result in reduced AIDS complications and death rates.⁴

Early detection of HIV infection also has the potential of reducing spread of the virus.^2,4 It has been suggested that early initiation of antiretroviral therapy could reduce risk of transmission to noninfected partners by lowering viral load in the infected patient.² Knowledge of HIV status has also been shown to reduce high-risk behaviors.⁴

Moreover, by facilitating earlier detection of HIV, universal screening will allow for earlier and better counseling for infected patients.⁴ This has the potential to further alter behaviors and possibly reduce transmission of HIV and/or other sexually transmitted diseases.⁴ Additionally, routine screening of pregnant women allows for better detection of HIV-infected mothers.³ With appropriate interventions during pregnancy, including antiretroviral therapy, rates of mother-to-child transmission have decreased significantly.⁴

On the other hand, potential harms from HIV screening were considered during the USPSTF analysis, including risk of false positive test results, as well as the side effects of antiretroviral medications.⁴ Although there are known short-term and long-term side effects of antiretroviral medications, some of these side effects can be avoided by changing drug regimens.⁴ For many other side effects, the benefits appeared to outweigh the risks of these medications.⁴

Studies have also shown some potential side effects in infants exposed to antiretroviral medications, but the overall evidence is not strong.⁴ In the end, thorough analysis performed by the USPSTF resulted in the opinion that the benefits of HIV screening far outweigh the associated risks.⁴

Challenges for Hospitalists

Several potential drawbacks to universal HIV screening are relatively unique to hospitalists and other providers of hospital-based care.6 First, hospitalists must be prepared to counsel patients regarding their test results, particularly if patients are hospitalized for another issue. Second, hospitalists must be able to communicate these test results to primary care providers in a timely fashion, a challenge that is not unique to HIV testing.

The biggest concern for hospitalists is what to do with HIV test results that are still pending at the time of hospital discharge. Hospitalists will likely face this issue more as increasing numbers of patients are screened in a growing number of medical settings, including the ED and inpatient admissions. Hospitalists who plan to screen inpatients for HIV testing must ensure that these issues have been worked out prior to screening.

Back to the Case

Looking back to the initial case discussion, based on the 2006 CDC and 2013 USPSTF guidelines, this patient should be offered HIV screening if he has not been tested previously. Although the patient states that he is in a monogamous relationship and does not report any high-risk behaviors, patients often do not recognize the true risk associated with their behaviors and fail to accurately report them.² Additionally, patients often are embarrassed by high-risk behaviors and may not report them completely to providers.²

The patient has admitted that he does not seek medical care on a regular basis. This inpatient admission may be his only interaction with the medical field for some time, and thus his only opportunity to undergo screening. But, prior to screening the patient, the hospitalist must ensure that he or she will be able to counsel the patient regarding test results, will be able to communicate those results to the patient’s primary care physician, and will be able to handle pending results if the patient is discharged before the test results are returned.

Drs. Gwyn, Carbo and Li are hospitalists at Beth Israel Deaconess Medical Center in Boston.

References

1. Branson B. Current HIV epidemiology and revised recommendations for HIV testing in health-care settings. J Med Virol. 2007;79 Suppl 1:S6-S10.
2. Moyer VA; U.S. Preventive Services Task Force. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;159(1):51-60.
3. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17.
4. Clark J, Lampe MA, Jamieson DJ. Testing women for human immunodeficiency virus infection: who, when, and how? Clin Obstet Gynceol. 2008;51(3):507-517.
5. Thompson MA, Aberg JA, Hoy JF, et al. Antiretroviral treatment of adult HIV infection: 2012 recommendations of the International Antiviral Society–USA Panel. JAMA. 2012;308(4):387-402.
6. Arbelaez C, Wright EA, Losina E, et al. Emergency provider attitudes and barriers to universal HIV testing in the emergency department. J Emerg Med. 2012;42(1):7-14.

Case

A 31-year-old male with a history of asthma is admitted with an asthma exacerbation. He has no regular outpatient provider. He denies tobacco use and reports that he is in a monogamous relationship with his girlfriend. On rounds, a medical student mentions that new HIV screening guidelines have been released recently and asks whether this patient should be screened for HIV.

Background

By the mid-2000s, approximately one to 1.2 million people in the United States were infected with HIV.¹ Approximately one quarter of these patients are estimated to be unaware of their HIV status, and this subgroup is believed responsible for a disproportionately higher percentage of new HIV infections each year.¹

While older HIV screening recommendations focused on screening patients who were deemed to be at high risk for HIV infection, there has been a paradigm change in recent years toward universal screening of all patients.^2,3 The ultimate goal is for earlier identification of infected patients, which will, in turn, lead to earlier treatment and better prevention efforts.

Universal screening has been supported by a number of different professional societies and screening guidelines.⁴

2013 Guideline

In 2013, the United States Preventive Services Task Force (USPSTF) issued new recommendations regarding HIV screening. Although the previous USPSTF guidelines (released in 2005) recommended screening patients who were believed to be at increased risk for contracting HIV, the 2013 guidelines now recommend screening all patients aged 15 to 65.⁴

Screening patients outside of this age range is recommended if the patient is deemed to be at increased risk for contracting HIV.⁴ The USPSTF provides criteria for identifying patients who are at increased risk of contracting HIV. These include:

• Men who have sex with men;
• People having unprotected vaginal or anal intercourse;
• People using injection drugs;
• People exchanging sex for drugs or money; and
• People requesting testing for other sexually transmitted diseases (STDs).⁴

Patients are also considered to be high risk if their sexual partners are infected with HIV, are bisexual, or use injection drugs.⁴

The shift toward universal HIV screening has been a trend for many years, because risk-based targeting of HIV screening will miss a significant number of HIV infections.² In fact, the 2013 recommendations bring the USPSTF guidelines into agreement with current CDC guidelines, which were released in 2006.²

The CDC, in its 2006 guidelines, recommended screening for all patients 13 to 64 years old unless HIV prevalence in the patient population has been found to be less than 0.1%, the minimum prevalence deemed necessary for HIV screening to be cost-effective.² The CDC guidelines also recommend HIV screening for all patients starting treatment for tuberculosis, patients being screened for STDs, and patients visiting STD clinics regardless of chief complaint.² They recommend that HIV screening be performed in an “opt-out” fashion, meaning that patients are informed that screening will be performed unless they decline.² Furthermore, they recommend against the need for a separate written consent form for HIV screening, as well as the prior requirement that pre-screening counseling be performed, because these requirements were felt to create potential time constraint barriers that prevented providers from screening patients.²

The CDC and the USPSTF are less conclusive with regard to frequency of rescreening for HIV infection. Both recommend rescreening patients considered high risk for HIV infection, but the interval for rescreening has not been concretely defined.^2,4 The guidelines urge providers to use clinical judgment in deciding when to rescreen for HIV infection.² For example, one reason for rescreening cited by the CDC would be the initiation of a new sexual relationship.²

In the 2013 guidelines, the USPSTF also recommends screening all pregnant women, including those presenting in labor without a known HIV status.⁴ This stance is supported by the American College of Gynecologists and Obstetricians.³ In high-risk patients with a negative screening test early in pregnancy, consideration should be given to repeat testing in the third trimester.³ Routinely screening pregnant women for HIV and starting appropriate therapy in positive patients has lowered the incidence of perinatal HIV transmission dramatically.²

Rationale

There are several reasons behind the shift to universal HIV screening, regardless of risk. First, providers often do not accurately identify patients’ HIV risk, often because patients are not aware of their actual risk or are uncomfortable discussing their high-risk behaviors with healthcare providers.² Using risk factors as a basis of screening will miss a significant number of HIV-positive patients.⁴

Additionally, screening all patients will result in the detection of HIV infection in a greater number of patients during the early asymptomatic phase, rather than when they later become symptomatic from HIV or AIDS.^2,4 Recent data has led the International Antiviral Society—USA Panel to issue updated recommendations advising initiation of antiretroviral therapy at all CD4 levels.⁵ Studies and observational data suggest that this could result in reduced AIDS complications and death rates.⁴

Early detection of HIV infection also has the potential of reducing spread of the virus.^2,4 It has been suggested that early initiation of antiretroviral therapy could reduce risk of transmission to noninfected partners by lowering viral load in the infected patient.² Knowledge of HIV status has also been shown to reduce high-risk behaviors.⁴

Moreover, by facilitating earlier detection of HIV, universal screening will allow for earlier and better counseling for infected patients.⁴ This has the potential to further alter behaviors and possibly reduce transmission of HIV and/or other sexually transmitted diseases.⁴ Additionally, routine screening of pregnant women allows for better detection of HIV-infected mothers.³ With appropriate interventions during pregnancy, including antiretroviral therapy, rates of mother-to-child transmission have decreased significantly.⁴

On the other hand, potential harms from HIV screening were considered during the USPSTF analysis, including risk of false positive test results, as well as the side effects of antiretroviral medications.⁴ Although there are known short-term and long-term side effects of antiretroviral medications, some of these side effects can be avoided by changing drug regimens.⁴ For many other side effects, the benefits appeared to outweigh the risks of these medications.⁴

Studies have also shown some potential side effects in infants exposed to antiretroviral medications, but the overall evidence is not strong.⁴ In the end, thorough analysis performed by the USPSTF resulted in the opinion that the benefits of HIV screening far outweigh the associated risks.⁴

Challenges for Hospitalists

Several potential drawbacks to universal HIV screening are relatively unique to hospitalists and other providers of hospital-based care.6 First, hospitalists must be prepared to counsel patients regarding their test results, particularly if patients are hospitalized for another issue. Second, hospitalists must be able to communicate these test results to primary care providers in a timely fashion, a challenge that is not unique to HIV testing.

The biggest concern for hospitalists is what to do with HIV test results that are still pending at the time of hospital discharge. Hospitalists will likely face this issue more as increasing numbers of patients are screened in a growing number of medical settings, including the ED and inpatient admissions. Hospitalists who plan to screen inpatients for HIV testing must ensure that these issues have been worked out prior to screening.

Back to the Case

Looking back to the initial case discussion, based on the 2006 CDC and 2013 USPSTF guidelines, this patient should be offered HIV screening if he has not been tested previously. Although the patient states that he is in a monogamous relationship and does not report any high-risk behaviors, patients often do not recognize the true risk associated with their behaviors and fail to accurately report them.² Additionally, patients often are embarrassed by high-risk behaviors and may not report them completely to providers.²

The patient has admitted that he does not seek medical care on a regular basis. This inpatient admission may be his only interaction with the medical field for some time, and thus his only opportunity to undergo screening. But, prior to screening the patient, the hospitalist must ensure that he or she will be able to counsel the patient regarding test results, will be able to communicate those results to the patient’s primary care physician, and will be able to handle pending results if the patient is discharged before the test results are returned.

Drs. Gwyn, Carbo and Li are hospitalists at Beth Israel Deaconess Medical Center in Boston.

References

1. Branson B. Current HIV epidemiology and revised recommendations for HIV testing in health-care settings. J Med Virol. 2007;79 Suppl 1:S6-S10.
2. Moyer VA; U.S. Preventive Services Task Force. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;159(1):51-60.
3. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17.
4. Clark J, Lampe MA, Jamieson DJ. Testing women for human immunodeficiency virus infection: who, when, and how? Clin Obstet Gynceol. 2008;51(3):507-517.
5. Thompson MA, Aberg JA, Hoy JF, et al. Antiretroviral treatment of adult HIV infection: 2012 recommendations of the International Antiviral Society–USA Panel. JAMA. 2012;308(4):387-402.
6. Arbelaez C, Wright EA, Losina E, et al. Emergency provider attitudes and barriers to universal HIV testing in the emergency department. J Emerg Med. 2012;42(1):7-14.

As the hysteria about Ebola spreads, hospitalists who have been running most of the country’s ICUs will find themselves at the forefront of treating these patients when more of them present at our different hospitals. It is now time for America to come into the age of Ebola and treat Ebola patients in Ebola centers, in specific prefabricated buildings designed for this specific pestilence. It has been done successfully in Africa—specifically, Nigeria.

Our hospitals in North America are not designed to handle the kind of elaborate decontamination protocols that we now know Ebola requires; we lack the isolation chambers for staff decontamination and the rapid throughput for hazardous material that guarantee minimal environmental exposure before incineration that we are told is required for Ebola waste.

One thing that is clear from the Dallas, Texas Presbyterian Hospital fiasco is not only that the staff was not really prepared to receive its first Ebola patient, despite the false sense of security it was lulled into by numerous drills and reenactments, but also that this lack of preparedness was not solely a staffing or staff-related issue. Ebola was being treated as if it were MRSA, TB, or C. diff. Ebola is none of those. The stories of equipment failure and the pileup of contaminated waste should have come as no surprise. This is a situation like no other. And, not surprisingly, the hospital administration was caught unaware. It could have happened with almost any other hospital.

In Nigeria, where the infection was successfully contained, an Ebola unit was erected in just two weeks. It had a patients’ unit, decontamination unit, and an outside incineration unit. The patients also had to go through elaborate head to toe decontamination before they were released back into the community. I suggest that we look into building such units in a few major cities in this country. It needn’t take more than a few days to erect such prefabricated units in fairly isolated areas with temporary outside incineration units attached for disposal of medical waste.

This effort would afford healthcare workers the ability to don full hazmat gear, including boots, and, after contact with Ebola patients at the end of the day, to go into decontamination chambers, wade with boots through chlorinated pools to reduce contamination, and rinse gloved hands in chlorinated water before commencing ‘directly observed’ degowning. This protocol cannot be effectively performed in our regular U.S. hospitals the way they’re designed now.

The sooner we get on board with this, the better. Ebola is like no other infection we have encountered before in the U.S.

–Ngozi Achebe, MD

Hospitalist, Sunnyside (Wash.) Community Hospital

As the hysteria about Ebola spreads, hospitalists who have been running most of the country’s ICUs will find themselves at the forefront of treating these patients when more of them present at our different hospitals. It is now time for America to come into the age of Ebola and treat Ebola patients in Ebola centers, in specific prefabricated buildings designed for this specific pestilence. It has been done successfully in Africa—specifically, Nigeria.

Our hospitals in North America are not designed to handle the kind of elaborate decontamination protocols that we now know Ebola requires; we lack the isolation chambers for staff decontamination and the rapid throughput for hazardous material that guarantee minimal environmental exposure before incineration that we are told is required for Ebola waste.

One thing that is clear from the Dallas, Texas Presbyterian Hospital fiasco is not only that the staff was not really prepared to receive its first Ebola patient, despite the false sense of security it was lulled into by numerous drills and reenactments, but also that this lack of preparedness was not solely a staffing or staff-related issue. Ebola was being treated as if it were MRSA, TB, or C. diff. Ebola is none of those. The stories of equipment failure and the pileup of contaminated waste should have come as no surprise. This is a situation like no other. And, not surprisingly, the hospital administration was caught unaware. It could have happened with almost any other hospital.

In Nigeria, where the infection was successfully contained, an Ebola unit was erected in just two weeks. It had a patients’ unit, decontamination unit, and an outside incineration unit. The patients also had to go through elaborate head to toe decontamination before they were released back into the community. I suggest that we look into building such units in a few major cities in this country. It needn’t take more than a few days to erect such prefabricated units in fairly isolated areas with temporary outside incineration units attached for disposal of medical waste.

This effort would afford healthcare workers the ability to don full hazmat gear, including boots, and, after contact with Ebola patients at the end of the day, to go into decontamination chambers, wade with boots through chlorinated pools to reduce contamination, and rinse gloved hands in chlorinated water before commencing ‘directly observed’ degowning. This protocol cannot be effectively performed in our regular U.S. hospitals the way they’re designed now.

The sooner we get on board with this, the better. Ebola is like no other infection we have encountered before in the U.S.

–Ngozi Achebe, MD

Hospitalist, Sunnyside (Wash.) Community Hospital

As the hysteria about Ebola spreads, hospitalists who have been running most of the country’s ICUs will find themselves at the forefront of treating these patients when more of them present at our different hospitals. It is now time for America to come into the age of Ebola and treat Ebola patients in Ebola centers, in specific prefabricated buildings designed for this specific pestilence. It has been done successfully in Africa—specifically, Nigeria.

Our hospitals in North America are not designed to handle the kind of elaborate decontamination protocols that we now know Ebola requires; we lack the isolation chambers for staff decontamination and the rapid throughput for hazardous material that guarantee minimal environmental exposure before incineration that we are told is required for Ebola waste.

One thing that is clear from the Dallas, Texas Presbyterian Hospital fiasco is not only that the staff was not really prepared to receive its first Ebola patient, despite the false sense of security it was lulled into by numerous drills and reenactments, but also that this lack of preparedness was not solely a staffing or staff-related issue. Ebola was being treated as if it were MRSA, TB, or C. diff. Ebola is none of those. The stories of equipment failure and the pileup of contaminated waste should have come as no surprise. This is a situation like no other. And, not surprisingly, the hospital administration was caught unaware. It could have happened with almost any other hospital.

In Nigeria, where the infection was successfully contained, an Ebola unit was erected in just two weeks. It had a patients’ unit, decontamination unit, and an outside incineration unit. The patients also had to go through elaborate head to toe decontamination before they were released back into the community. I suggest that we look into building such units in a few major cities in this country. It needn’t take more than a few days to erect such prefabricated units in fairly isolated areas with temporary outside incineration units attached for disposal of medical waste.

This effort would afford healthcare workers the ability to don full hazmat gear, including boots, and, after contact with Ebola patients at the end of the day, to go into decontamination chambers, wade with boots through chlorinated pools to reduce contamination, and rinse gloved hands in chlorinated water before commencing ‘directly observed’ degowning. This protocol cannot be effectively performed in our regular U.S. hospitals the way they’re designed now.

The sooner we get on board with this, the better. Ebola is like no other infection we have encountered before in the U.S.

–Ngozi Achebe, MD

Hospitalist, Sunnyside (Wash.) Community Hospital

Insurers’ use of certain criteria to separate hospital stays into inpatient or observation status remains widespread. Observation status ensures provider reimbursement for hospitalizations deemed necessary by clinical judgment but not qualifying as inpatient care. Admission under observation status impacts the patient’s financial burden, as well, with observation admissions typically associated with increased out-of-pocket costs.

Although hospitals have always faced decreased reimbursement for observation admissions (compared to inpatient admissions), new penalties attached to readmission for patients discharged from an inpatient stay raise the potential to impact hospitalist practice by incentivizing increased use of observation status for hospitalizations in order to avoid readmission penalties.

Have readmission penalties associated with inpatient admissions actually led to increased use of observation status by hospitalist groups?

SHM’s 2014 State of Hospital Medicine report provides insight into this question. In groups serving adults only, observation discharges accounted for 16.1% of all discharges (see Figure 1). If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

In groups serving adults only, observation discharges accounted for 16.1% of all discharges. If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

–Dr. Smith

The question of determining whether to bill episodes as inpatient or observation status was asked in the 2012 survey, as well, though by a different methodology: 20% of admissions were billed as observation status by hospitalist practices seeing adults only. Even with some observation admissions in 2012 being converted to inpatient status later in the hospital stay (a factor accounted for in the 2014 survey by changing the wording of the survey so that it asks about status at discharge), not much overall change in hospitalist group practice can be appreciated.

Does the overall observation status use rate tell the whole story?

When 2012 and 2014 survey data are separated by academic status, a clear change in practice over time can be seen. Academic HMGs experienced an increase in use of observation status, from 15.3% of admissions in 2012 to 19.4% of discharges in 2014 (or 22.8% in 2014, if same-day hospital stay responses are added to the observation data). In comparison, nonacademic hospitalist practices reported a decrease in observation status utilization, from 20.4% of admissions in 2012 to 15.6% of discharges in 2014 (or 19.2%, accounting for same-day discharges as observation status).

Academic HMGs, which frequently rely on housestaff for the finer points of patient care documentation, must consequently rely on documentation largely written by providers with less experience and incentive to optimize documentation for billing, compared to experienced hospitalists. It’s plausible to speculate that the benefits associated with compensation for inpatient status for hospitals, compared to the risks of financial penalty associated with billing under inpatient status, could be different for academic than for nonacademic hospitalist groups, due to the differences in the quality of documentation between the two practice types, and that academic HMGs, or the hospitals they work with, see the risks associated with inpatient status billing as high enough to change billing practices. Nonacademic hospitalist groups, on the other hand, may rely on the experience of their retained hospitalists to document justification for inpatient status more effectively, and may thus maximize the financial benefit of inpatient status utilization sufficiently to overcome associated financial risks.

In an ever-changing reimbursement and political advocacy landscape, future SHM surveys will be pivotal in assessing what happens with trends surrounding use of observation status for episodes of hospital care.

Dr. Smith is a hospitalist and assistant professor at Northwestern University in Chicago, Ill., and a member of SHM’s Practice Analysis Committee.

Insurers’ use of certain criteria to separate hospital stays into inpatient or observation status remains widespread. Observation status ensures provider reimbursement for hospitalizations deemed necessary by clinical judgment but not qualifying as inpatient care. Admission under observation status impacts the patient’s financial burden, as well, with observation admissions typically associated with increased out-of-pocket costs.

Although hospitals have always faced decreased reimbursement for observation admissions (compared to inpatient admissions), new penalties attached to readmission for patients discharged from an inpatient stay raise the potential to impact hospitalist practice by incentivizing increased use of observation status for hospitalizations in order to avoid readmission penalties.

Have readmission penalties associated with inpatient admissions actually led to increased use of observation status by hospitalist groups?

SHM’s 2014 State of Hospital Medicine report provides insight into this question. In groups serving adults only, observation discharges accounted for 16.1% of all discharges (see Figure 1). If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

In groups serving adults only, observation discharges accounted for 16.1% of all discharges. If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

–Dr. Smith

The question of determining whether to bill episodes as inpatient or observation status was asked in the 2012 survey, as well, though by a different methodology: 20% of admissions were billed as observation status by hospitalist practices seeing adults only. Even with some observation admissions in 2012 being converted to inpatient status later in the hospital stay (a factor accounted for in the 2014 survey by changing the wording of the survey so that it asks about status at discharge), not much overall change in hospitalist group practice can be appreciated.

Does the overall observation status use rate tell the whole story?

When 2012 and 2014 survey data are separated by academic status, a clear change in practice over time can be seen. Academic HMGs experienced an increase in use of observation status, from 15.3% of admissions in 2012 to 19.4% of discharges in 2014 (or 22.8% in 2014, if same-day hospital stay responses are added to the observation data). In comparison, nonacademic hospitalist practices reported a decrease in observation status utilization, from 20.4% of admissions in 2012 to 15.6% of discharges in 2014 (or 19.2%, accounting for same-day discharges as observation status).

Academic HMGs, which frequently rely on housestaff for the finer points of patient care documentation, must consequently rely on documentation largely written by providers with less experience and incentive to optimize documentation for billing, compared to experienced hospitalists. It’s plausible to speculate that the benefits associated with compensation for inpatient status for hospitals, compared to the risks of financial penalty associated with billing under inpatient status, could be different for academic than for nonacademic hospitalist groups, due to the differences in the quality of documentation between the two practice types, and that academic HMGs, or the hospitals they work with, see the risks associated with inpatient status billing as high enough to change billing practices. Nonacademic hospitalist groups, on the other hand, may rely on the experience of their retained hospitalists to document justification for inpatient status more effectively, and may thus maximize the financial benefit of inpatient status utilization sufficiently to overcome associated financial risks.

In an ever-changing reimbursement and political advocacy landscape, future SHM surveys will be pivotal in assessing what happens with trends surrounding use of observation status for episodes of hospital care.

Dr. Smith is a hospitalist and assistant professor at Northwestern University in Chicago, Ill., and a member of SHM’s Practice Analysis Committee.

Insurers’ use of certain criteria to separate hospital stays into inpatient or observation status remains widespread. Observation status ensures provider reimbursement for hospitalizations deemed necessary by clinical judgment but not qualifying as inpatient care. Admission under observation status impacts the patient’s financial burden, as well, with observation admissions typically associated with increased out-of-pocket costs.

Although hospitals have always faced decreased reimbursement for observation admissions (compared to inpatient admissions), new penalties attached to readmission for patients discharged from an inpatient stay raise the potential to impact hospitalist practice by incentivizing increased use of observation status for hospitalizations in order to avoid readmission penalties.

Have readmission penalties associated with inpatient admissions actually led to increased use of observation status by hospitalist groups?

SHM’s 2014 State of Hospital Medicine report provides insight into this question. In groups serving adults only, observation discharges accounted for 16.1% of all discharges (see Figure 1). If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

In groups serving adults only, observation discharges accounted for 16.1% of all discharges. If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

–Dr. Smith

The question of determining whether to bill episodes as inpatient or observation status was asked in the 2012 survey, as well, though by a different methodology: 20% of admissions were billed as observation status by hospitalist practices seeing adults only. Even with some observation admissions in 2012 being converted to inpatient status later in the hospital stay (a factor accounted for in the 2014 survey by changing the wording of the survey so that it asks about status at discharge), not much overall change in hospitalist group practice can be appreciated.

Does the overall observation status use rate tell the whole story?

When 2012 and 2014 survey data are separated by academic status, a clear change in practice over time can be seen. Academic HMGs experienced an increase in use of observation status, from 15.3% of admissions in 2012 to 19.4% of discharges in 2014 (or 22.8% in 2014, if same-day hospital stay responses are added to the observation data). In comparison, nonacademic hospitalist practices reported a decrease in observation status utilization, from 20.4% of admissions in 2012 to 15.6% of discharges in 2014 (or 19.2%, accounting for same-day discharges as observation status).

Academic HMGs, which frequently rely on housestaff for the finer points of patient care documentation, must consequently rely on documentation largely written by providers with less experience and incentive to optimize documentation for billing, compared to experienced hospitalists. It’s plausible to speculate that the benefits associated with compensation for inpatient status for hospitals, compared to the risks of financial penalty associated with billing under inpatient status, could be different for academic than for nonacademic hospitalist groups, due to the differences in the quality of documentation between the two practice types, and that academic HMGs, or the hospitals they work with, see the risks associated with inpatient status billing as high enough to change billing practices. Nonacademic hospitalist groups, on the other hand, may rely on the experience of their retained hospitalists to document justification for inpatient status more effectively, and may thus maximize the financial benefit of inpatient status utilization sufficiently to overcome associated financial risks.

In an ever-changing reimbursement and political advocacy landscape, future SHM surveys will be pivotal in assessing what happens with trends surrounding use of observation status for episodes of hospital care.

Dr. Smith is a hospitalist and assistant professor at Northwestern University in Chicago, Ill., and a member of SHM’s Practice Analysis Committee.

Clinical question: How are medical consultants used for hospitalized surgical patients, and how does this vary among regions and hospitals in the U.S.?

Background: Reimbursement for surgical procedures is moving toward bundled payments, making it increasingly important to understand the use of resources in order to improve efficiency and quality of care.

Study design: Observational, retrospective, cohort study.

Setting: Fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) at U.S. acute care hospitals.

Synopsis: Using the Medicare Provider Analysis and Review (MEDPAR) File, the Carrier File, and the 2007 American Hospital Association’s annual survey, researchers evaluated a sample of 91,684 colectomy patients at 930 hospitals and 339,319 THR patients at 1,589 hospitals between the ages of 65 and 99 who were enrolled in Medicare parts A and B between 2007 and 2010. Sixty-nine percent of colectomy patients saw a consultant (50% medicine and 56% specialists). Sixty-three percent of THR patients saw a consultant (53% medicine and 24% specialists).

Patient factors for consults included older age, comorbidities, and nonelective admission. Hospital factors for consults included Midwest location, nonteaching, for-profit status, and hospital size. Greater use of consultants was associated with higher rates of post-operative complications.

Additional research on the association between mortality after complications (including type and timing) and number of consultants may help to improve future efficiency and outcomes. Creating a consensus about the use of medical consultants in healthy patients would also be beneficial.

Limitations of the study include a lack of detail on consult indications, unknown effect of pre-operative outpatient medical consults, major differences in median visits by site and surgery type, and the sole use of administrative claims data.

Bottom line: With the procedural fee for service changing to bundled payments, guidelines may be necessary for appropriate use of consultants, to improve both efficiency and quality of care provided by hospitals.

Citation: Chen LM, Wilk AS, Thumma JR, Birkmeyer JD, Banerjee M. Use of medical consultants for hospitalized surgical patients: an observational cohort study. JAMA Intern Med. 2014;174(9):1470-1477.

Clinical question: How are medical consultants used for hospitalized surgical patients, and how does this vary among regions and hospitals in the U.S.?

Background: Reimbursement for surgical procedures is moving toward bundled payments, making it increasingly important to understand the use of resources in order to improve efficiency and quality of care.

Study design: Observational, retrospective, cohort study.

Setting: Fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) at U.S. acute care hospitals.

Synopsis: Using the Medicare Provider Analysis and Review (MEDPAR) File, the Carrier File, and the 2007 American Hospital Association’s annual survey, researchers evaluated a sample of 91,684 colectomy patients at 930 hospitals and 339,319 THR patients at 1,589 hospitals between the ages of 65 and 99 who were enrolled in Medicare parts A and B between 2007 and 2010. Sixty-nine percent of colectomy patients saw a consultant (50% medicine and 56% specialists). Sixty-three percent of THR patients saw a consultant (53% medicine and 24% specialists).

Patient factors for consults included older age, comorbidities, and nonelective admission. Hospital factors for consults included Midwest location, nonteaching, for-profit status, and hospital size. Greater use of consultants was associated with higher rates of post-operative complications.

Additional research on the association between mortality after complications (including type and timing) and number of consultants may help to improve future efficiency and outcomes. Creating a consensus about the use of medical consultants in healthy patients would also be beneficial.

Limitations of the study include a lack of detail on consult indications, unknown effect of pre-operative outpatient medical consults, major differences in median visits by site and surgery type, and the sole use of administrative claims data.

Bottom line: With the procedural fee for service changing to bundled payments, guidelines may be necessary for appropriate use of consultants, to improve both efficiency and quality of care provided by hospitals.

Citation: Chen LM, Wilk AS, Thumma JR, Birkmeyer JD, Banerjee M. Use of medical consultants for hospitalized surgical patients: an observational cohort study. JAMA Intern Med. 2014;174(9):1470-1477.

Clinical question: How are medical consultants used for hospitalized surgical patients, and how does this vary among regions and hospitals in the U.S.?

Background: Reimbursement for surgical procedures is moving toward bundled payments, making it increasingly important to understand the use of resources in order to improve efficiency and quality of care.

Study design: Observational, retrospective, cohort study.

Setting: Fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) at U.S. acute care hospitals.

Synopsis: Using the Medicare Provider Analysis and Review (MEDPAR) File, the Carrier File, and the 2007 American Hospital Association’s annual survey, researchers evaluated a sample of 91,684 colectomy patients at 930 hospitals and 339,319 THR patients at 1,589 hospitals between the ages of 65 and 99 who were enrolled in Medicare parts A and B between 2007 and 2010. Sixty-nine percent of colectomy patients saw a consultant (50% medicine and 56% specialists). Sixty-three percent of THR patients saw a consultant (53% medicine and 24% specialists).

Patient factors for consults included older age, comorbidities, and nonelective admission. Hospital factors for consults included Midwest location, nonteaching, for-profit status, and hospital size. Greater use of consultants was associated with higher rates of post-operative complications.

Additional research on the association between mortality after complications (including type and timing) and number of consultants may help to improve future efficiency and outcomes. Creating a consensus about the use of medical consultants in healthy patients would also be beneficial.

Limitations of the study include a lack of detail on consult indications, unknown effect of pre-operative outpatient medical consults, major differences in median visits by site and surgery type, and the sole use of administrative claims data.

Bottom line: With the procedural fee for service changing to bundled payments, guidelines may be necessary for appropriate use of consultants, to improve both efficiency and quality of care provided by hospitals.

Citation: Chen LM, Wilk AS, Thumma JR, Birkmeyer JD, Banerjee M. Use of medical consultants for hospitalized surgical patients: an observational cohort study. JAMA Intern Med. 2014;174(9):1470-1477.

Clinical question: Is there any difference between different resuscitative fluids (crystalloids or colloids) on mortality in critically ill sepsis patients?

Background: Fluid resuscitation, in addition to antibiotics and source control, is a cornerstone of initial management of sepsis. Resuscitation with crystalloids compared with colloids for critically ill patients has been evaluated in large randomized, controlled trials and meta-analyses; however, whether any of these fluid properties translates into a survival advantage, particularly regarding the optimal fluid for resuscitation in critically ill sepsis patients, remains unclear.

Study design: Systematic review, network meta-analysis (NMA).

Setting: Database search in MEDLINE, Embase, ACP Journal Club, Cumulative Index to Nursing and Allied Health Literature (CINAHL), HealthSTAR, the Allied and Complementary Medicine Database (AMED), and the Cochrane Central Register of Controlled Trials (CENTRAL).

Synopsis: Of 9,875 records that involved adult (aged ≥16 years) critically ill patients with severe sepsis or septic shock who required fluid resuscitation, with no restrictions on language or publication date, 14 randomized controlled trials were considered eligible. Interventions studied included any fluid or fluid strategy used for resuscitation compared with another fluid or fluid strategy. The endpoint was 90-day mortality or, if not available, 30-day intensive care unit or hospital mortality, whichever was longest. The analysis classified fluids as crystalloids or colloids. The relevant analyses were a four-node NMA (crystalloids vs. albumin vs. HES [hydroxyethyl starch] vs. gelatin) and a six-node NMA (crystalloids vs. albumin vs. HES vs. gelatin, with crystalloids divided into balanced or unbalanced and HES divided into low or high molecular weight), and a conventional fixed-effects meta-analytic comparison of crystalloids vs. colloids.

In the four-node analysis, the results suggested higher mortality with starches (vs. crystalloids) and lower mortality with albumin (vs. crystalloids and starches). In the six-node analysis, the results suggested that albumin is superior to saline and low molecular weight starch, and balanced crystalloids are superior to saline and starch (both high and low molecular weight).

These results highlight potentially important differences in mortality among solutions; it suggests an advantage of balanced crystalloids versus saline and low or high molecular weight starch, with similar mortality results for balanced crystalloids and albumin. These differences were not detectable using a standard meta-analytic approach directly comparing “any crystalloids vs. any colloids.” Biological rationale is consistent with the findings of lower mortality with balanced crystalloid solutions than with saline, as it mimics the homeostatic composition of body fluids to a greater extent than unbalanced fluids.

These results raise concerns about using unbalanced crystalloids in the acute resuscitation of patients with sepsis.

Bottom line: Among patients with sepsis, resuscitation with balanced crystalloids or albumin is associated with reduced mortality compared to other fluids.

Citation: Rochwerg B, Alhazzani W, Sindi A, et al. Fluids in Sepsis and Septic Shock Group. Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Ann Intern Med. 2014;161(5):347-355.

Clinical question: Is there any difference between different resuscitative fluids (crystalloids or colloids) on mortality in critically ill sepsis patients?

Background: Fluid resuscitation, in addition to antibiotics and source control, is a cornerstone of initial management of sepsis. Resuscitation with crystalloids compared with colloids for critically ill patients has been evaluated in large randomized, controlled trials and meta-analyses; however, whether any of these fluid properties translates into a survival advantage, particularly regarding the optimal fluid for resuscitation in critically ill sepsis patients, remains unclear.

Study design: Systematic review, network meta-analysis (NMA).

Setting: Database search in MEDLINE, Embase, ACP Journal Club, Cumulative Index to Nursing and Allied Health Literature (CINAHL), HealthSTAR, the Allied and Complementary Medicine Database (AMED), and the Cochrane Central Register of Controlled Trials (CENTRAL).

Synopsis: Of 9,875 records that involved adult (aged ≥16 years) critically ill patients with severe sepsis or septic shock who required fluid resuscitation, with no restrictions on language or publication date, 14 randomized controlled trials were considered eligible. Interventions studied included any fluid or fluid strategy used for resuscitation compared with another fluid or fluid strategy. The endpoint was 90-day mortality or, if not available, 30-day intensive care unit or hospital mortality, whichever was longest. The analysis classified fluids as crystalloids or colloids. The relevant analyses were a four-node NMA (crystalloids vs. albumin vs. HES [hydroxyethyl starch] vs. gelatin) and a six-node NMA (crystalloids vs. albumin vs. HES vs. gelatin, with crystalloids divided into balanced or unbalanced and HES divided into low or high molecular weight), and a conventional fixed-effects meta-analytic comparison of crystalloids vs. colloids.

In the four-node analysis, the results suggested higher mortality with starches (vs. crystalloids) and lower mortality with albumin (vs. crystalloids and starches). In the six-node analysis, the results suggested that albumin is superior to saline and low molecular weight starch, and balanced crystalloids are superior to saline and starch (both high and low molecular weight).

These results highlight potentially important differences in mortality among solutions; it suggests an advantage of balanced crystalloids versus saline and low or high molecular weight starch, with similar mortality results for balanced crystalloids and albumin. These differences were not detectable using a standard meta-analytic approach directly comparing “any crystalloids vs. any colloids.” Biological rationale is consistent with the findings of lower mortality with balanced crystalloid solutions than with saline, as it mimics the homeostatic composition of body fluids to a greater extent than unbalanced fluids.

These results raise concerns about using unbalanced crystalloids in the acute resuscitation of patients with sepsis.

Bottom line: Among patients with sepsis, resuscitation with balanced crystalloids or albumin is associated with reduced mortality compared to other fluids.

Citation: Rochwerg B, Alhazzani W, Sindi A, et al. Fluids in Sepsis and Septic Shock Group. Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Ann Intern Med. 2014;161(5):347-355.

Clinical question: Is there any difference between different resuscitative fluids (crystalloids or colloids) on mortality in critically ill sepsis patients?

Background: Fluid resuscitation, in addition to antibiotics and source control, is a cornerstone of initial management of sepsis. Resuscitation with crystalloids compared with colloids for critically ill patients has been evaluated in large randomized, controlled trials and meta-analyses; however, whether any of these fluid properties translates into a survival advantage, particularly regarding the optimal fluid for resuscitation in critically ill sepsis patients, remains unclear.

Study design: Systematic review, network meta-analysis (NMA).

Setting: Database search in MEDLINE, Embase, ACP Journal Club, Cumulative Index to Nursing and Allied Health Literature (CINAHL), HealthSTAR, the Allied and Complementary Medicine Database (AMED), and the Cochrane Central Register of Controlled Trials (CENTRAL).

Synopsis: Of 9,875 records that involved adult (aged ≥16 years) critically ill patients with severe sepsis or septic shock who required fluid resuscitation, with no restrictions on language or publication date, 14 randomized controlled trials were considered eligible. Interventions studied included any fluid or fluid strategy used for resuscitation compared with another fluid or fluid strategy. The endpoint was 90-day mortality or, if not available, 30-day intensive care unit or hospital mortality, whichever was longest. The analysis classified fluids as crystalloids or colloids. The relevant analyses were a four-node NMA (crystalloids vs. albumin vs. HES [hydroxyethyl starch] vs. gelatin) and a six-node NMA (crystalloids vs. albumin vs. HES vs. gelatin, with crystalloids divided into balanced or unbalanced and HES divided into low or high molecular weight), and a conventional fixed-effects meta-analytic comparison of crystalloids vs. colloids.

In the four-node analysis, the results suggested higher mortality with starches (vs. crystalloids) and lower mortality with albumin (vs. crystalloids and starches). In the six-node analysis, the results suggested that albumin is superior to saline and low molecular weight starch, and balanced crystalloids are superior to saline and starch (both high and low molecular weight).

These results highlight potentially important differences in mortality among solutions; it suggests an advantage of balanced crystalloids versus saline and low or high molecular weight starch, with similar mortality results for balanced crystalloids and albumin. These differences were not detectable using a standard meta-analytic approach directly comparing “any crystalloids vs. any colloids.” Biological rationale is consistent with the findings of lower mortality with balanced crystalloid solutions than with saline, as it mimics the homeostatic composition of body fluids to a greater extent than unbalanced fluids.

These results raise concerns about using unbalanced crystalloids in the acute resuscitation of patients with sepsis.

Bottom line: Among patients with sepsis, resuscitation with balanced crystalloids or albumin is associated with reduced mortality compared to other fluids.

Citation: Rochwerg B, Alhazzani W, Sindi A, et al. Fluids in Sepsis and Septic Shock Group. Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Ann Intern Med. 2014;161(5):347-355.

Clinical question: What are the risk factors for mortality and functional decline following hip fracture among nursing home residents?

Background: Little is known about the survival and functional outcomes of nursing home residents who sustain hip fracture. Previous studies on hip fracture have either excluded nursing home residents or have been limited by small sample size.

Study design: Retrospective cohort study.

Setting: Fee-for-service Medicare beneficiaries.

Synopsis: This retrospective study of 60,111 patients residing in nursing homes who were hospitalized for hip fracture between 2005 and 2010 found that 36.2% died within six months. Within this cohort, 53.5% of the patients who did not have total dependence prior to the hip fracture either died or became totally disabled within six months.

Specifically, patients older than 90 years (vs. those younger than 75 years: RR 1.42; P<0.001), with severe cognitive impairment (vs. intact cognition: RR 1.66, P<0.001), and receiving nonoperative management (vs. internal fixation: RR 1.48, P<0.001) had a higher combined risk of death or new total dependence in locomotion within six months of the hip fracture.

The findings suggest there is substantial mortality and functional decline following hip fracture among residents in nursing homes. A profound decrease in activities of daily living across the spectrum was observed. Interestingly, patients who underwent nonoperative treatment, even after risk adjustment, were more likely to have adverse outcomes, suggesting surgery should be considered, if consistent with the patient’s overall goal of care.

Bottom line: Significant mortality and functional decline occurs following hip fracture among nursing home patients. Patients with severe cognitive impairment, older age (more than 90 years), and receiving nonoperative treatment are more likely to die or develop complete dependence in locomotion.

Citation: Neuman MD, Silber JH, Magaziner JS, Passarella MA, Mehta S, Werner RM. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med. 2014;174(8):1273-1280.

Clinical question: What are the risk factors for mortality and functional decline following hip fracture among nursing home residents?

Background: Little is known about the survival and functional outcomes of nursing home residents who sustain hip fracture. Previous studies on hip fracture have either excluded nursing home residents or have been limited by small sample size.

Study design: Retrospective cohort study.

Setting: Fee-for-service Medicare beneficiaries.

Synopsis: This retrospective study of 60,111 patients residing in nursing homes who were hospitalized for hip fracture between 2005 and 2010 found that 36.2% died within six months. Within this cohort, 53.5% of the patients who did not have total dependence prior to the hip fracture either died or became totally disabled within six months.

Specifically, patients older than 90 years (vs. those younger than 75 years: RR 1.42; P<0.001), with severe cognitive impairment (vs. intact cognition: RR 1.66, P<0.001), and receiving nonoperative management (vs. internal fixation: RR 1.48, P<0.001) had a higher combined risk of death or new total dependence in locomotion within six months of the hip fracture.

The findings suggest there is substantial mortality and functional decline following hip fracture among residents in nursing homes. A profound decrease in activities of daily living across the spectrum was observed. Interestingly, patients who underwent nonoperative treatment, even after risk adjustment, were more likely to have adverse outcomes, suggesting surgery should be considered, if consistent with the patient’s overall goal of care.

Bottom line: Significant mortality and functional decline occurs following hip fracture among nursing home patients. Patients with severe cognitive impairment, older age (more than 90 years), and receiving nonoperative treatment are more likely to die or develop complete dependence in locomotion.

Citation: Neuman MD, Silber JH, Magaziner JS, Passarella MA, Mehta S, Werner RM. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med. 2014;174(8):1273-1280.

Clinical question: What are the risk factors for mortality and functional decline following hip fracture among nursing home residents?

Background: Little is known about the survival and functional outcomes of nursing home residents who sustain hip fracture. Previous studies on hip fracture have either excluded nursing home residents or have been limited by small sample size.

Study design: Retrospective cohort study.

Setting: Fee-for-service Medicare beneficiaries.

Synopsis: This retrospective study of 60,111 patients residing in nursing homes who were hospitalized for hip fracture between 2005 and 2010 found that 36.2% died within six months. Within this cohort, 53.5% of the patients who did not have total dependence prior to the hip fracture either died or became totally disabled within six months.

Specifically, patients older than 90 years (vs. those younger than 75 years: RR 1.42; P<0.001), with severe cognitive impairment (vs. intact cognition: RR 1.66, P<0.001), and receiving nonoperative management (vs. internal fixation: RR 1.48, P<0.001) had a higher combined risk of death or new total dependence in locomotion within six months of the hip fracture.

The findings suggest there is substantial mortality and functional decline following hip fracture among residents in nursing homes. A profound decrease in activities of daily living across the spectrum was observed. Interestingly, patients who underwent nonoperative treatment, even after risk adjustment, were more likely to have adverse outcomes, suggesting surgery should be considered, if consistent with the patient’s overall goal of care.

Bottom line: Significant mortality and functional decline occurs following hip fracture among nursing home patients. Patients with severe cognitive impairment, older age (more than 90 years), and receiving nonoperative treatment are more likely to die or develop complete dependence in locomotion.

Citation: Neuman MD, Silber JH, Magaziner JS, Passarella MA, Mehta S, Werner RM. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med. 2014;174(8):1273-1280.

Clinical question: What is the long-term effectiveness of a standardized pneumonia prevention program among surgical noncritical inpatients?

Background: Few studies have focused on the prevention of post-operative pneumonia in non-mechanically ventilated patients. The current study describes the effectiveness of an intervention designed to reduce post-operative pneumonia among noncritical patients who did not require mechanical ventilation.

Study design: Retrospective, cohort study.

Setting: University-affiliated VA hospital involving all noncardiac surgical patients.

Synopsis: A standardized pneumonia prevention program was implemented in 2007 in noncritical care settings for noncardiac surgery patients. Post-operative pneumonia rates were compared to pre-intervention and to American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) benchmarks. Rates of post-operative pneumonia following the intervention dropped from 0.78% to 0.44%, a 43% decrease (P=0.01). Both pre- and post-intervention rates were significantly better than those reported in the ACS-NSQIP database (2.56%).

It was proposed that widespread implementation of the program could lead to a 43% reduction of pneumonia cases in the ACS-NSQIP population, which would translate into a cost savings of more than $280 million.

Bottom line: A sustained reduction of post-operative pneumonia among noncritical surgical patients can be achieved by a standardized pneumonia prevention program, which may lead to improved outcomes and substantial cost savings.

Citation: Kazaure HS, Martin M, Yoon JK, Wren SM. Long-term results of a postoperative pneumonia prevention program for the inpatient surgical ward. JAMA Surg. 2014;149(9):914-918.

Clinical question: What is the long-term effectiveness of a standardized pneumonia prevention program among surgical noncritical inpatients?

Background: Few studies have focused on the prevention of post-operative pneumonia in non-mechanically ventilated patients. The current study describes the effectiveness of an intervention designed to reduce post-operative pneumonia among noncritical patients who did not require mechanical ventilation.

Study design: Retrospective, cohort study.

Setting: University-affiliated VA hospital involving all noncardiac surgical patients.

Synopsis: A standardized pneumonia prevention program was implemented in 2007 in noncritical care settings for noncardiac surgery patients. Post-operative pneumonia rates were compared to pre-intervention and to American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) benchmarks. Rates of post-operative pneumonia following the intervention dropped from 0.78% to 0.44%, a 43% decrease (P=0.01). Both pre- and post-intervention rates were significantly better than those reported in the ACS-NSQIP database (2.56%).

It was proposed that widespread implementation of the program could lead to a 43% reduction of pneumonia cases in the ACS-NSQIP population, which would translate into a cost savings of more than $280 million.

Bottom line: A sustained reduction of post-operative pneumonia among noncritical surgical patients can be achieved by a standardized pneumonia prevention program, which may lead to improved outcomes and substantial cost savings.

Citation: Kazaure HS, Martin M, Yoon JK, Wren SM. Long-term results of a postoperative pneumonia prevention program for the inpatient surgical ward. JAMA Surg. 2014;149(9):914-918.

Clinical question: What is the long-term effectiveness of a standardized pneumonia prevention program among surgical noncritical inpatients?

Background: Few studies have focused on the prevention of post-operative pneumonia in non-mechanically ventilated patients. The current study describes the effectiveness of an intervention designed to reduce post-operative pneumonia among noncritical patients who did not require mechanical ventilation.

Study design: Retrospective, cohort study.

Setting: University-affiliated VA hospital involving all noncardiac surgical patients.

Synopsis: A standardized pneumonia prevention program was implemented in 2007 in noncritical care settings for noncardiac surgery patients. Post-operative pneumonia rates were compared to pre-intervention and to American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) benchmarks. Rates of post-operative pneumonia following the intervention dropped from 0.78% to 0.44%, a 43% decrease (P=0.01). Both pre- and post-intervention rates were significantly better than those reported in the ACS-NSQIP database (2.56%).

It was proposed that widespread implementation of the program could lead to a 43% reduction of pneumonia cases in the ACS-NSQIP population, which would translate into a cost savings of more than $280 million.

Bottom line: A sustained reduction of post-operative pneumonia among noncritical surgical patients can be achieved by a standardized pneumonia prevention program, which may lead to improved outcomes and substantial cost savings.

Citation: Kazaure HS, Martin M, Yoon JK, Wren SM. Long-term results of a postoperative pneumonia prevention program for the inpatient surgical ward. JAMA Surg. 2014;149(9):914-918.

Clinical question: What are rates of venous thromboembolism (VTE) and bleeding among adult patients receiving aspirin versus anticoagulants after major lower extremity orthopedic surgery?

Background: VTE is common after hip fracture surgery and elective total knee/hip arthroplasty. National guidelines recommend pharmacologic thromboprophylaxis but leave clinicians to select the specific agents. The efficiency and safety of aspirin in these patient populations, compared to other anticoagulants, has been a source of great controversy.

Study design: Meta-analysis.

Setting: Eight randomized trials in the U.S., Spain, Sweden, and Canada.

Synopsis: The trials included 1,408 subjects; aspirin was compared with other anticoagulants for VTE prevention and bleeding after major lower extremity orthopedic surgery. The primary outcome was the rate of proximal deep vein thrombosis (DVT). The different classes of anticoagulants included warfarin, heparin, low molecular weight heparin (LMWH), and danaparoid. Treatment duration was seven to 21 days with clinical follow-up extended up to six months.

Overall rates of DVT did not differ statistically between aspirin and anticoagulants (10.4% vs. 9.2%); however, the balance of risk versus benefit of aspirin compared to anticoagulation differed according to type of surgery; there was a nonsignificant trend favoring anticoagulation for VTE prevention following hip fracture repair, but no difference was found for knee/hip arthroplasty. The risk of bleeding was lower with aspirin than with anticoagulants following hip fracture repair (3.1% vs. 10%) and knee/hip arthroplasty (3.9% vs. 7.8%).

Rates of pulmonary embolism were too low in all the groups to provide reliable estimates.

Bottom line: Aspirin may be associated with higher risk of VTE following hip fracture repair compared to anticoagulants, although bleeding rates were substantially lower. Aspirin was similarly effective compared to anticoagulants for VTE prevention after knee/hip arthroplasty and may be associated with lower bleeding risk.

Citation: Drescher FS, Sirovich BE, Lee A, Morrison DH, Chiang WH, Larson RJ. Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis. J Hosp Med. 2014;9(9):579-585.

Clinical question: What are rates of venous thromboembolism (VTE) and bleeding among adult patients receiving aspirin versus anticoagulants after major lower extremity orthopedic surgery?

Background: VTE is common after hip fracture surgery and elective total knee/hip arthroplasty. National guidelines recommend pharmacologic thromboprophylaxis but leave clinicians to select the specific agents. The efficiency and safety of aspirin in these patient populations, compared to other anticoagulants, has been a source of great controversy.

Study design: Meta-analysis.

Setting: Eight randomized trials in the U.S., Spain, Sweden, and Canada.

Synopsis: The trials included 1,408 subjects; aspirin was compared with other anticoagulants for VTE prevention and bleeding after major lower extremity orthopedic surgery. The primary outcome was the rate of proximal deep vein thrombosis (DVT). The different classes of anticoagulants included warfarin, heparin, low molecular weight heparin (LMWH), and danaparoid. Treatment duration was seven to 21 days with clinical follow-up extended up to six months.

Overall rates of DVT did not differ statistically between aspirin and anticoagulants (10.4% vs. 9.2%); however, the balance of risk versus benefit of aspirin compared to anticoagulation differed according to type of surgery; there was a nonsignificant trend favoring anticoagulation for VTE prevention following hip fracture repair, but no difference was found for knee/hip arthroplasty. The risk of bleeding was lower with aspirin than with anticoagulants following hip fracture repair (3.1% vs. 10%) and knee/hip arthroplasty (3.9% vs. 7.8%).

Rates of pulmonary embolism were too low in all the groups to provide reliable estimates.

Bottom line: Aspirin may be associated with higher risk of VTE following hip fracture repair compared to anticoagulants, although bleeding rates were substantially lower. Aspirin was similarly effective compared to anticoagulants for VTE prevention after knee/hip arthroplasty and may be associated with lower bleeding risk.

Citation: Drescher FS, Sirovich BE, Lee A, Morrison DH, Chiang WH, Larson RJ. Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis. J Hosp Med. 2014;9(9):579-585.

Clinical question: What are rates of venous thromboembolism (VTE) and bleeding among adult patients receiving aspirin versus anticoagulants after major lower extremity orthopedic surgery?

Background: VTE is common after hip fracture surgery and elective total knee/hip arthroplasty. National guidelines recommend pharmacologic thromboprophylaxis but leave clinicians to select the specific agents. The efficiency and safety of aspirin in these patient populations, compared to other anticoagulants, has been a source of great controversy.

Study design: Meta-analysis.

Setting: Eight randomized trials in the U.S., Spain, Sweden, and Canada.

Synopsis: The trials included 1,408 subjects; aspirin was compared with other anticoagulants for VTE prevention and bleeding after major lower extremity orthopedic surgery. The primary outcome was the rate of proximal deep vein thrombosis (DVT). The different classes of anticoagulants included warfarin, heparin, low molecular weight heparin (LMWH), and danaparoid. Treatment duration was seven to 21 days with clinical follow-up extended up to six months.

Overall rates of DVT did not differ statistically between aspirin and anticoagulants (10.4% vs. 9.2%); however, the balance of risk versus benefit of aspirin compared to anticoagulation differed according to type of surgery; there was a nonsignificant trend favoring anticoagulation for VTE prevention following hip fracture repair, but no difference was found for knee/hip arthroplasty. The risk of bleeding was lower with aspirin than with anticoagulants following hip fracture repair (3.1% vs. 10%) and knee/hip arthroplasty (3.9% vs. 7.8%).

Rates of pulmonary embolism were too low in all the groups to provide reliable estimates.

Bottom line: Aspirin may be associated with higher risk of VTE following hip fracture repair compared to anticoagulants, although bleeding rates were substantially lower. Aspirin was similarly effective compared to anticoagulants for VTE prevention after knee/hip arthroplasty and may be associated with lower bleeding risk.

Citation: Drescher FS, Sirovich BE, Lee A, Morrison DH, Chiang WH, Larson RJ. Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis. J Hosp Med. 2014;9(9):579-585.

Clinical question: What is the benefit associated with a depletive fluid management strategy on ventilator-associated complication (VAC) and ventilator-associated pneumonia (VAP) during weaning from mechanical ventilation?

Background: VAP is common in the ICU. Pulmonary edema predisposes patients to pneumonia by altering the alveolar microenvironment through enhancement of bacterial colonization and infectivity and a decrease in host bactericidal capacities. A fluid management strategy aimed at lowering lung fluid balance may prove useful in reducing both VAC and VAP.

Study design: Randomized controlled trial.

Setting: Nine ICUs in Europe and South America, between May 2007 and July 2009.

Synopsis: Data from the B-type Natriuretic Peptide for the Management of Weaning (BMW) trial was used to compare the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid management group and the usual care group during the 14 days following randomization. The trial enrolled 304 randomized patients, 152 in each group.

Compared with usual care, the interventional strategy was associated with a higher proportion of patients receiving diuretics, in higher doses, resulting in a significantly more negative fluid balance during weaning and a shorter duration of mechanical ventilation. VAC (as defined by worsening oxygenation) occurred in 13.2% of patients during the 14 days following randomization: 17.8% in the usual care group and 8.6% in the interventional group. VAP occurred in 13.5% during the 14 days following randomization: 17.8% in the usual care group and 9.2% in the interventional group.

Bottom line: A biomarker-driven, depletive fluid strategy decreases the cumulative incidence of VAC and VAP.

Citation: Mekontso Dessap A, Katsahian S, Roche-Campo F, et al. Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management. Chest. 2014;146(1):58-65.

Clinical question: What is the benefit associated with a depletive fluid management strategy on ventilator-associated complication (VAC) and ventilator-associated pneumonia (VAP) during weaning from mechanical ventilation?

Background: VAP is common in the ICU. Pulmonary edema predisposes patients to pneumonia by altering the alveolar microenvironment through enhancement of bacterial colonization and infectivity and a decrease in host bactericidal capacities. A fluid management strategy aimed at lowering lung fluid balance may prove useful in reducing both VAC and VAP.

Study design: Randomized controlled trial.

Setting: Nine ICUs in Europe and South America, between May 2007 and July 2009.

Synopsis: Data from the B-type Natriuretic Peptide for the Management of Weaning (BMW) trial was used to compare the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid management group and the usual care group during the 14 days following randomization. The trial enrolled 304 randomized patients, 152 in each group.

Compared with usual care, the interventional strategy was associated with a higher proportion of patients receiving diuretics, in higher doses, resulting in a significantly more negative fluid balance during weaning and a shorter duration of mechanical ventilation. VAC (as defined by worsening oxygenation) occurred in 13.2% of patients during the 14 days following randomization: 17.8% in the usual care group and 8.6% in the interventional group. VAP occurred in 13.5% during the 14 days following randomization: 17.8% in the usual care group and 9.2% in the interventional group.

Bottom line: A biomarker-driven, depletive fluid strategy decreases the cumulative incidence of VAC and VAP.

Citation: Mekontso Dessap A, Katsahian S, Roche-Campo F, et al. Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management. Chest. 2014;146(1):58-65.

Clinical question: What is the benefit associated with a depletive fluid management strategy on ventilator-associated complication (VAC) and ventilator-associated pneumonia (VAP) during weaning from mechanical ventilation?

Background: VAP is common in the ICU. Pulmonary edema predisposes patients to pneumonia by altering the alveolar microenvironment through enhancement of bacterial colonization and infectivity and a decrease in host bactericidal capacities. A fluid management strategy aimed at lowering lung fluid balance may prove useful in reducing both VAC and VAP.

Study design: Randomized controlled trial.

Setting: Nine ICUs in Europe and South America, between May 2007 and July 2009.

Synopsis: Data from the B-type Natriuretic Peptide for the Management of Weaning (BMW) trial was used to compare the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid management group and the usual care group during the 14 days following randomization. The trial enrolled 304 randomized patients, 152 in each group.

Compared with usual care, the interventional strategy was associated with a higher proportion of patients receiving diuretics, in higher doses, resulting in a significantly more negative fluid balance during weaning and a shorter duration of mechanical ventilation. VAC (as defined by worsening oxygenation) occurred in 13.2% of patients during the 14 days following randomization: 17.8% in the usual care group and 8.6% in the interventional group. VAP occurred in 13.5% during the 14 days following randomization: 17.8% in the usual care group and 9.2% in the interventional group.

Bottom line: A biomarker-driven, depletive fluid strategy decreases the cumulative incidence of VAC and VAP.

Citation: Mekontso Dessap A, Katsahian S, Roche-Campo F, et al. Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management. Chest. 2014;146(1):58-65.