Patient Care

Clinical question: What is the frequency and nature of undesirable events experienced by patients who “board” in the ED?

Background: Hospital crowding results in patients spending extended amounts of time—also known as “boarding”—in the ED as they wait for an inpatient bed. Prior studies have shown that longer ED boarding times are associated with adverse outcomes. Few studies have examined the nature and frequency of undesirable events that patients experience while boarding.

Study design: Retrospective chart review.

Setting: Urban academic medical center.

Synopsis: In this pilot study, authors reviewed the charts of patients who were treated in the ED and subsequently admitted to the hospital on three different days during the study period (n=151). More than a quarter (27.8%) of patients experienced an undesirable event, such as missing a scheduled medication, while they were boarding. Older patients, those with comorbid illnesses, and those who endured prolonged boarding times (greater than six hours) were more likely to experience an undesirable event. In addition, 3.3% of patients experienced such adverse events as suboptimal blood pressure control, hypotension, hypoxia, or arrhythmia.

This study was performed at a single center and lacks a comparison group (i.e., nonboarded patients). It is intended to serve as an exploratory study for future analysis of adverse events in boarded patients.

Bottom line: Undesirable events are common among boarded patients, although it is unknown whether they are more common than in nonboarded patients.

Citation: Liu SW, Thomas SH, Gordon JA, Hamedani AG, Weissman JS. A pilot study examining undesirable events among emergency-department boarded patients awaiting inpatient beds. Ann Emerg Med. 2009;54(3):381-385.

Clinical question: What is the frequency and nature of undesirable events experienced by patients who “board” in the ED?

Background: Hospital crowding results in patients spending extended amounts of time—also known as “boarding”—in the ED as they wait for an inpatient bed. Prior studies have shown that longer ED boarding times are associated with adverse outcomes. Few studies have examined the nature and frequency of undesirable events that patients experience while boarding.

Study design: Retrospective chart review.

Setting: Urban academic medical center.

Synopsis: In this pilot study, authors reviewed the charts of patients who were treated in the ED and subsequently admitted to the hospital on three different days during the study period (n=151). More than a quarter (27.8%) of patients experienced an undesirable event, such as missing a scheduled medication, while they were boarding. Older patients, those with comorbid illnesses, and those who endured prolonged boarding times (greater than six hours) were more likely to experience an undesirable event. In addition, 3.3% of patients experienced such adverse events as suboptimal blood pressure control, hypotension, hypoxia, or arrhythmia.

This study was performed at a single center and lacks a comparison group (i.e., nonboarded patients). It is intended to serve as an exploratory study for future analysis of adverse events in boarded patients.

Bottom line: Undesirable events are common among boarded patients, although it is unknown whether they are more common than in nonboarded patients.

Citation: Liu SW, Thomas SH, Gordon JA, Hamedani AG, Weissman JS. A pilot study examining undesirable events among emergency-department boarded patients awaiting inpatient beds. Ann Emerg Med. 2009;54(3):381-385.

Clinical question: What is the frequency and nature of undesirable events experienced by patients who “board” in the ED?

Background: Hospital crowding results in patients spending extended amounts of time—also known as “boarding”—in the ED as they wait for an inpatient bed. Prior studies have shown that longer ED boarding times are associated with adverse outcomes. Few studies have examined the nature and frequency of undesirable events that patients experience while boarding.

Study design: Retrospective chart review.

Setting: Urban academic medical center.

Synopsis: In this pilot study, authors reviewed the charts of patients who were treated in the ED and subsequently admitted to the hospital on three different days during the study period (n=151). More than a quarter (27.8%) of patients experienced an undesirable event, such as missing a scheduled medication, while they were boarding. Older patients, those with comorbid illnesses, and those who endured prolonged boarding times (greater than six hours) were more likely to experience an undesirable event. In addition, 3.3% of patients experienced such adverse events as suboptimal blood pressure control, hypotension, hypoxia, or arrhythmia.

This study was performed at a single center and lacks a comparison group (i.e., nonboarded patients). It is intended to serve as an exploratory study for future analysis of adverse events in boarded patients.

Bottom line: Undesirable events are common among boarded patients, although it is unknown whether they are more common than in nonboarded patients.

Citation: Liu SW, Thomas SH, Gordon JA, Hamedani AG, Weissman JS. A pilot study examining undesirable events among emergency-department boarded patients awaiting inpatient beds. Ann Emerg Med. 2009;54(3):381-385.

Clinical question: Does the reduction in work hours for residents affect mortality in medical and surgical ICUs?

Background: A reduction in work hours for residents was enforced in July 2003. Several prior studies using administrative or claims data did not show an association of the reduced work hours for residents with mortality in teaching hospitals when compared with nonteaching hospitals.

Study design: Observational retrospective registry cohort.

Setting: Twelve academic, 12 community, and 16 nonteaching hospitals in the U.S.

Synopsis: Data from 230,151 patients were extracted as post-hoc analysis from a voluntary clinical registry that uses a well-validated severity-of-illness scoring system. The exposure was defined as date of admission to ICU within two years before and after the reform. Hospitals were categorized as academic, community with residents, or nonteaching. Sophisticated statistical analyses were performed, including interaction terms for teaching status and time. To test the effect the reduced work hours had on mortality, the mortality trends of academic hospitals and community hospitals with residents were compared with the baseline trend of nonteaching hospitals. After risk adjustments, all hospitals had improved in-hospital and ICU mortality after the reform. None of the statistical improvements were significantly different.

Study limitations include the selection bias, as only highly motivated hospitals participating in the registry were included, and misclassification bias, as not all hospitals implemented the reform at the same time. Nevertheless, this study supports the consistent literature on the topic and adds a more robust assessment of severity of illness.

Bottom line: The restriction on resident duty hours does not appear to affect patient mortality.

Citation: Prasad M, Iwashyna TJ, Christie JD, et al. Effect of work-hours regulations on intensive care unit mortality in United States teaching hospitals. Crit Care Med. 2009;37(9):2564-2569.

Clinical question: Does the reduction in work hours for residents affect mortality in medical and surgical ICUs?

Background: A reduction in work hours for residents was enforced in July 2003. Several prior studies using administrative or claims data did not show an association of the reduced work hours for residents with mortality in teaching hospitals when compared with nonteaching hospitals.

Study design: Observational retrospective registry cohort.

Setting: Twelve academic, 12 community, and 16 nonteaching hospitals in the U.S.

Synopsis: Data from 230,151 patients were extracted as post-hoc analysis from a voluntary clinical registry that uses a well-validated severity-of-illness scoring system. The exposure was defined as date of admission to ICU within two years before and after the reform. Hospitals were categorized as academic, community with residents, or nonteaching. Sophisticated statistical analyses were performed, including interaction terms for teaching status and time. To test the effect the reduced work hours had on mortality, the mortality trends of academic hospitals and community hospitals with residents were compared with the baseline trend of nonteaching hospitals. After risk adjustments, all hospitals had improved in-hospital and ICU mortality after the reform. None of the statistical improvements were significantly different.

Study limitations include the selection bias, as only highly motivated hospitals participating in the registry were included, and misclassification bias, as not all hospitals implemented the reform at the same time. Nevertheless, this study supports the consistent literature on the topic and adds a more robust assessment of severity of illness.

Bottom line: The restriction on resident duty hours does not appear to affect patient mortality.

Citation: Prasad M, Iwashyna TJ, Christie JD, et al. Effect of work-hours regulations on intensive care unit mortality in United States teaching hospitals. Crit Care Med. 2009;37(9):2564-2569.

Clinical question: Does the reduction in work hours for residents affect mortality in medical and surgical ICUs?

Background: A reduction in work hours for residents was enforced in July 2003. Several prior studies using administrative or claims data did not show an association of the reduced work hours for residents with mortality in teaching hospitals when compared with nonteaching hospitals.

Study design: Observational retrospective registry cohort.

Setting: Twelve academic, 12 community, and 16 nonteaching hospitals in the U.S.

Synopsis: Data from 230,151 patients were extracted as post-hoc analysis from a voluntary clinical registry that uses a well-validated severity-of-illness scoring system. The exposure was defined as date of admission to ICU within two years before and after the reform. Hospitals were categorized as academic, community with residents, or nonteaching. Sophisticated statistical analyses were performed, including interaction terms for teaching status and time. To test the effect the reduced work hours had on mortality, the mortality trends of academic hospitals and community hospitals with residents were compared with the baseline trend of nonteaching hospitals. After risk adjustments, all hospitals had improved in-hospital and ICU mortality after the reform. None of the statistical improvements were significantly different.

Study limitations include the selection bias, as only highly motivated hospitals participating in the registry were included, and misclassification bias, as not all hospitals implemented the reform at the same time. Nevertheless, this study supports the consistent literature on the topic and adds a more robust assessment of severity of illness.

Bottom line: The restriction on resident duty hours does not appear to affect patient mortality.

Citation: Prasad M, Iwashyna TJ, Christie JD, et al. Effect of work-hours regulations on intensive care unit mortality in United States teaching hospitals. Crit Care Med. 2009;37(9):2564-2569.

EDITOR’S NOTE: First in a series of reviews of the “Hospital Medicine: Current Concepts” series by members of Team Hospitalist.

According to the Advisory Board projections of inpatient service line volume through 2017, most service lines will experience a decrease. Those that are projected to increase include neurosurgery, vascular surgery, orthopedic surgery, and general surgery. It seems clear that the need for hospital medicine to engage in the care of the surgical patient is sure to grow.

That makes the publication of this book so prescient. As one in a series titled Hospital Medicine: Current Concepts, edited by Scott Flanders, MD, MHM, and Sanjay Saint, MD, MPH, this is a valuable contribution to hospitalist leaders, policymakers, and anyone routinely caring for the peri-operative patient.

Part one focuses on systems of care. The authors articulate the essential elements of developing a consultation service, a clinic, and a co-management program. Eric Siegal, MD, FHM, authors the second chapter, clearly delineating the important differences between a co-management program and a consultation program. He provides the reader with pearls as well as potential pitfalls.

The first eight chapters of this book will have a long shelf life; they deliver sound advice on quality and practice management in the peri-operative arena. Identifying elements of a successful program, engaging key stakeholders, and managing medications are all skills a hospitalist needs and will not change anytime soon. Anyone planning to build a consultation or co-management service will be well served by the guidance in part one.

The next three parts explore the assessment and management of various risks, post-operative care, and post-operative conditions. Although written by a veritable who’s who of hospital medicine and peri-operative medicine giants, some parts of these sections fall prey to the rapidly changing world of clinical care. For example, Chapter 9 provides a great review of the history of developing cardiac risk assessment tools for the patient undergoing noncardiac surgery. The chapter also reviews strategies to mitigate risk; however, it falls short by failing to discuss the Gupta risk score, which was developed over 200,000 cases, compared with about 4,000 for the revised cardiac risk index. That omission is likely a result of publication timing. Although the chapter does not call out the recent implications of scientific misconduct related to the Dutch peri-operative beta blocker trials, the authors’ conclusions on the use of beta blockers remains appropriate and could have been more timely if it had included a recent meta-analysis omitting the Dutch data.

Similarly, Chapter 10 provides an excellent review of the etiology and burden of peri-operative pulmonary complications. Relatively recent literature that updates previous guidelines, indicating the benefits of respiratory muscle training, is included; however, the recently completed IMPROVE trial was likely published too late for inclusion in this chapter. Thus the benefits of a low tidal volume/lung protective strategy in those at intermediate to high risk could be missed. Still, the clinical foundation provided by the chapters in parts two through four fill the void most of us experienced in training—namely, not learning how to care for the peri-operative patient.

Special sections on the bariatric and neurosurgical patient will be welcomed by those of us never trained in the care of such conditions.

Key Takeaways

As hospitalists become increasingly important in the care of surgical patients, this book will provide an excellent foundation for critical peri-operative concepts and tools.

The authors include specific recommendations that will help in the management of almost every surgical patient encountered. For example, the anticoagulation and glycemic control strategies are well written, as well as easy to understand and apply.

If you are a hospitalist group leader, this is a must read that will help define quality, scope of practice, and practice management issues we all struggle with.

Dr. Fitterman is vice chair of hospital medicine in the department of medicine North Shore-LIJ Health System and assistant professor of medicine at Hofstra North Shore-LIJ School of Medicine.

EDITOR’S NOTE: First in a series of reviews of the “Hospital Medicine: Current Concepts” series by members of Team Hospitalist.

According to the Advisory Board projections of inpatient service line volume through 2017, most service lines will experience a decrease. Those that are projected to increase include neurosurgery, vascular surgery, orthopedic surgery, and general surgery. It seems clear that the need for hospital medicine to engage in the care of the surgical patient is sure to grow.

That makes the publication of this book so prescient. As one in a series titled Hospital Medicine: Current Concepts, edited by Scott Flanders, MD, MHM, and Sanjay Saint, MD, MPH, this is a valuable contribution to hospitalist leaders, policymakers, and anyone routinely caring for the peri-operative patient.

Part one focuses on systems of care. The authors articulate the essential elements of developing a consultation service, a clinic, and a co-management program. Eric Siegal, MD, FHM, authors the second chapter, clearly delineating the important differences between a co-management program and a consultation program. He provides the reader with pearls as well as potential pitfalls.

The first eight chapters of this book will have a long shelf life; they deliver sound advice on quality and practice management in the peri-operative arena. Identifying elements of a successful program, engaging key stakeholders, and managing medications are all skills a hospitalist needs and will not change anytime soon. Anyone planning to build a consultation or co-management service will be well served by the guidance in part one.

The next three parts explore the assessment and management of various risks, post-operative care, and post-operative conditions. Although written by a veritable who’s who of hospital medicine and peri-operative medicine giants, some parts of these sections fall prey to the rapidly changing world of clinical care. For example, Chapter 9 provides a great review of the history of developing cardiac risk assessment tools for the patient undergoing noncardiac surgery. The chapter also reviews strategies to mitigate risk; however, it falls short by failing to discuss the Gupta risk score, which was developed over 200,000 cases, compared with about 4,000 for the revised cardiac risk index. That omission is likely a result of publication timing. Although the chapter does not call out the recent implications of scientific misconduct related to the Dutch peri-operative beta blocker trials, the authors’ conclusions on the use of beta blockers remains appropriate and could have been more timely if it had included a recent meta-analysis omitting the Dutch data.

Similarly, Chapter 10 provides an excellent review of the etiology and burden of peri-operative pulmonary complications. Relatively recent literature that updates previous guidelines, indicating the benefits of respiratory muscle training, is included; however, the recently completed IMPROVE trial was likely published too late for inclusion in this chapter. Thus the benefits of a low tidal volume/lung protective strategy in those at intermediate to high risk could be missed. Still, the clinical foundation provided by the chapters in parts two through four fill the void most of us experienced in training—namely, not learning how to care for the peri-operative patient.

Special sections on the bariatric and neurosurgical patient will be welcomed by those of us never trained in the care of such conditions.

Key Takeaways

As hospitalists become increasingly important in the care of surgical patients, this book will provide an excellent foundation for critical peri-operative concepts and tools.

The authors include specific recommendations that will help in the management of almost every surgical patient encountered. For example, the anticoagulation and glycemic control strategies are well written, as well as easy to understand and apply.

If you are a hospitalist group leader, this is a must read that will help define quality, scope of practice, and practice management issues we all struggle with.

Dr. Fitterman is vice chair of hospital medicine in the department of medicine North Shore-LIJ Health System and assistant professor of medicine at Hofstra North Shore-LIJ School of Medicine.

EDITOR’S NOTE: First in a series of reviews of the “Hospital Medicine: Current Concepts” series by members of Team Hospitalist.

According to the Advisory Board projections of inpatient service line volume through 2017, most service lines will experience a decrease. Those that are projected to increase include neurosurgery, vascular surgery, orthopedic surgery, and general surgery. It seems clear that the need for hospital medicine to engage in the care of the surgical patient is sure to grow.

That makes the publication of this book so prescient. As one in a series titled Hospital Medicine: Current Concepts, edited by Scott Flanders, MD, MHM, and Sanjay Saint, MD, MPH, this is a valuable contribution to hospitalist leaders, policymakers, and anyone routinely caring for the peri-operative patient.

Part one focuses on systems of care. The authors articulate the essential elements of developing a consultation service, a clinic, and a co-management program. Eric Siegal, MD, FHM, authors the second chapter, clearly delineating the important differences between a co-management program and a consultation program. He provides the reader with pearls as well as potential pitfalls.

The first eight chapters of this book will have a long shelf life; they deliver sound advice on quality and practice management in the peri-operative arena. Identifying elements of a successful program, engaging key stakeholders, and managing medications are all skills a hospitalist needs and will not change anytime soon. Anyone planning to build a consultation or co-management service will be well served by the guidance in part one.

The next three parts explore the assessment and management of various risks, post-operative care, and post-operative conditions. Although written by a veritable who’s who of hospital medicine and peri-operative medicine giants, some parts of these sections fall prey to the rapidly changing world of clinical care. For example, Chapter 9 provides a great review of the history of developing cardiac risk assessment tools for the patient undergoing noncardiac surgery. The chapter also reviews strategies to mitigate risk; however, it falls short by failing to discuss the Gupta risk score, which was developed over 200,000 cases, compared with about 4,000 for the revised cardiac risk index. That omission is likely a result of publication timing. Although the chapter does not call out the recent implications of scientific misconduct related to the Dutch peri-operative beta blocker trials, the authors’ conclusions on the use of beta blockers remains appropriate and could have been more timely if it had included a recent meta-analysis omitting the Dutch data.

Similarly, Chapter 10 provides an excellent review of the etiology and burden of peri-operative pulmonary complications. Relatively recent literature that updates previous guidelines, indicating the benefits of respiratory muscle training, is included; however, the recently completed IMPROVE trial was likely published too late for inclusion in this chapter. Thus the benefits of a low tidal volume/lung protective strategy in those at intermediate to high risk could be missed. Still, the clinical foundation provided by the chapters in parts two through four fill the void most of us experienced in training—namely, not learning how to care for the peri-operative patient.

Special sections on the bariatric and neurosurgical patient will be welcomed by those of us never trained in the care of such conditions.

Key Takeaways

As hospitalists become increasingly important in the care of surgical patients, this book will provide an excellent foundation for critical peri-operative concepts and tools.

The authors include specific recommendations that will help in the management of almost every surgical patient encountered. For example, the anticoagulation and glycemic control strategies are well written, as well as easy to understand and apply.

If you are a hospitalist group leader, this is a must read that will help define quality, scope of practice, and practice management issues we all struggle with.

Dr. Fitterman is vice chair of hospital medicine in the department of medicine North Shore-LIJ Health System and assistant professor of medicine at Hofstra North Shore-LIJ School of Medicine.

Engaging patients more effectively in their own treatment is becoming a growing focus for hospitals and hospitalists. The Wall Street Journal earlier this year described how hospitals are scoring patients on their “activation”—how engaged they are likely to be in their ongoing care and recovery—with measurement tools such as the Patient Activation Measure (www.insigniahealth.com/solutions/patient-activation-measure)—in order to customize their care through special coaching or other interventions.⁴ Information Week Healthcare notes that more hospitals are putting patient experience officers in the C-suite to help them learn how to treat patients more like valued customers.⁵

One of the country’s first chief experience officers (CXOs), James Merlino, MD, CXO for Cleveland Clinic, heads a department that hosts the annual Patient Experience Summit, which was held in Cleveland in May with co-sponsorship by the Society for Hospital Medicine and the American Hospital Association. It’s one thing to talk about how important patient experience is, Dr. Merlino told Information Week Healthcare. “But it’s another to hold people accountable for it.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Nagasako EM, Reidhead M, Waterman B, Dunagan WC. Adding socioeconomic data to hospital readmissions calculations may produce more useful results. Health Affair. 2014;33(5):786-791.
2. Hu J, Gonsahn MD, Nerenz DR. Socioeconomic status and readmissions: Evidence from an urban teaching hospital. Health Affair. 2014;33(5):778-785.
3. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–282.
4. Landro L. How doctors rate patients. The Wall Street Journal. March 31, 2014. Available at: http://online.wsj.com/news/articles/SB10001424052702304432604579473301109907412. Accessed July 31, 2014.
5. Diana A. Hospitals elevate patient satisfaction to the C-suite. Information Week Healthcare. March 24, 2014. Available at: http://www.informationweek.com/healthcare/leadership/ hospitals-elevate-patient-satisfaction-to-the-c-suite/d/d-id/1127860. Accessed July 31, 2014.
6. The Press Association. London trust now testing seriously ill patients for HIV. Nursing Times. May 8, 2014. Available at: http://www.nursingtimes.net/confirmation?rtn=%252fbarts-to-rollout-routine-hiv-testing-for-intensive-care-patients%252f5070642.article. Accessed July 31, 2014.
7. Pallin DJ, Espinola JA, Camargo CA Jr. US population aging and demand for inpatient services. J Hosp Med. 2014;9(3):193-196.

Engaging patients more effectively in their own treatment is becoming a growing focus for hospitals and hospitalists. The Wall Street Journal earlier this year described how hospitals are scoring patients on their “activation”—how engaged they are likely to be in their ongoing care and recovery—with measurement tools such as the Patient Activation Measure (www.insigniahealth.com/solutions/patient-activation-measure)—in order to customize their care through special coaching or other interventions.⁴ Information Week Healthcare notes that more hospitals are putting patient experience officers in the C-suite to help them learn how to treat patients more like valued customers.⁵

One of the country’s first chief experience officers (CXOs), James Merlino, MD, CXO for Cleveland Clinic, heads a department that hosts the annual Patient Experience Summit, which was held in Cleveland in May with co-sponsorship by the Society for Hospital Medicine and the American Hospital Association. It’s one thing to talk about how important patient experience is, Dr. Merlino told Information Week Healthcare. “But it’s another to hold people accountable for it.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Nagasako EM, Reidhead M, Waterman B, Dunagan WC. Adding socioeconomic data to hospital readmissions calculations may produce more useful results. Health Affair. 2014;33(5):786-791.
2. Hu J, Gonsahn MD, Nerenz DR. Socioeconomic status and readmissions: Evidence from an urban teaching hospital. Health Affair. 2014;33(5):778-785.
3. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–282.
4. Landro L. How doctors rate patients. The Wall Street Journal. March 31, 2014. Available at: http://online.wsj.com/news/articles/SB10001424052702304432604579473301109907412. Accessed July 31, 2014.
5. Diana A. Hospitals elevate patient satisfaction to the C-suite. Information Week Healthcare. March 24, 2014. Available at: http://www.informationweek.com/healthcare/leadership/ hospitals-elevate-patient-satisfaction-to-the-c-suite/d/d-id/1127860. Accessed July 31, 2014.
6. The Press Association. London trust now testing seriously ill patients for HIV. Nursing Times. May 8, 2014. Available at: http://www.nursingtimes.net/confirmation?rtn=%252fbarts-to-rollout-routine-hiv-testing-for-intensive-care-patients%252f5070642.article. Accessed July 31, 2014.
7. Pallin DJ, Espinola JA, Camargo CA Jr. US population aging and demand for inpatient services. J Hosp Med. 2014;9(3):193-196.

Engaging patients more effectively in their own treatment is becoming a growing focus for hospitals and hospitalists. The Wall Street Journal earlier this year described how hospitals are scoring patients on their “activation”—how engaged they are likely to be in their ongoing care and recovery—with measurement tools such as the Patient Activation Measure (www.insigniahealth.com/solutions/patient-activation-measure)—in order to customize their care through special coaching or other interventions.⁴ Information Week Healthcare notes that more hospitals are putting patient experience officers in the C-suite to help them learn how to treat patients more like valued customers.⁵

One of the country’s first chief experience officers (CXOs), James Merlino, MD, CXO for Cleveland Clinic, heads a department that hosts the annual Patient Experience Summit, which was held in Cleveland in May with co-sponsorship by the Society for Hospital Medicine and the American Hospital Association. It’s one thing to talk about how important patient experience is, Dr. Merlino told Information Week Healthcare. “But it’s another to hold people accountable for it.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Nagasako EM, Reidhead M, Waterman B, Dunagan WC. Adding socioeconomic data to hospital readmissions calculations may produce more useful results. Health Affair. 2014;33(5):786-791.
2. Hu J, Gonsahn MD, Nerenz DR. Socioeconomic status and readmissions: Evidence from an urban teaching hospital. Health Affair. 2014;33(5):778-785.
3. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–282.
4. Landro L. How doctors rate patients. The Wall Street Journal. March 31, 2014. Available at: http://online.wsj.com/news/articles/SB10001424052702304432604579473301109907412. Accessed July 31, 2014.
5. Diana A. Hospitals elevate patient satisfaction to the C-suite. Information Week Healthcare. March 24, 2014. Available at: http://www.informationweek.com/healthcare/leadership/ hospitals-elevate-patient-satisfaction-to-the-c-suite/d/d-id/1127860. Accessed July 31, 2014.
6. The Press Association. London trust now testing seriously ill patients for HIV. Nursing Times. May 8, 2014. Available at: http://www.nursingtimes.net/confirmation?rtn=%252fbarts-to-rollout-routine-hiv-testing-for-intensive-care-patients%252f5070642.article. Accessed July 31, 2014.
7. Pallin DJ, Espinola JA, Camargo CA Jr. US population aging and demand for inpatient services. J Hosp Med. 2014;9(3):193-196.

Clinical question: Is once-weekly intravenous dalbavancin as effective as conventional therapy for the treatment of acute bacterial skin infections?

Background: Acute bacterial skin infections are common and often require hospitalization for intravenous antibiotic administration. Treatment covering gram-positive bacteria usually is indicated. Dalbavancin is effective against gram-positives, including MRSA. Its long half-life makes it an attractive alternative to other commonly used antibiotics, which require more frequent dosing.

Study design: Phase 3, double-blinded RCT.

Setting: Multiple international centers.

Synopsis: Researchers randomized 1,312 patients with acute bacterial skin and skin-structure infections with signs of systemic infection requiring intravenous antibiotics to receive dalbavancin on days one and eight, with placebo on other days, or several doses of vancomycin with an option to switch to oral linezolid. The primary endpoint was cessation of spread of erythema and temperature of ≤37.6°C at 48-72 hours. Secondary endpoints included a decrease in lesion area of ≥20% at 48-72 hours and clinical success at end of therapy (determined by clinical and historical features).

Results of the primary endpoint were similar with dalbavancin and vancomycin-linezolid groups (79.7% and 79.8%, respectively) and were within 10 percentage points of noninferiority. The secondary endpoints were similar between both groups.

Limitations of the study were the early primary endpoint, lack of noninferiority analysis of the secondary endpoints, and cost-effective analysis.

Bottom line: Once-weekly dalbavancin appears to be similarly efficacious to intravenous vancomycin in the treatment of acute bacterial skin infections in terms of outcomes within 48-72 hours of therapy and might provide an alternative to continued inpatient hospitalization for intravenous antibiotics in stable patients.

Citation: Boucher HW, Wilcox M, Talbot GH, Puttagunta S, Das AF, Dunne MW. Once-weekly dalbavancin versus daily conventional therapy for skin infection. N Engl J Med. 2014;370(23):2169-2179.

Clinical question: Is once-weekly intravenous dalbavancin as effective as conventional therapy for the treatment of acute bacterial skin infections?

Background: Acute bacterial skin infections are common and often require hospitalization for intravenous antibiotic administration. Treatment covering gram-positive bacteria usually is indicated. Dalbavancin is effective against gram-positives, including MRSA. Its long half-life makes it an attractive alternative to other commonly used antibiotics, which require more frequent dosing.

Study design: Phase 3, double-blinded RCT.

Setting: Multiple international centers.

Synopsis: Researchers randomized 1,312 patients with acute bacterial skin and skin-structure infections with signs of systemic infection requiring intravenous antibiotics to receive dalbavancin on days one and eight, with placebo on other days, or several doses of vancomycin with an option to switch to oral linezolid. The primary endpoint was cessation of spread of erythema and temperature of ≤37.6°C at 48-72 hours. Secondary endpoints included a decrease in lesion area of ≥20% at 48-72 hours and clinical success at end of therapy (determined by clinical and historical features).

Results of the primary endpoint were similar with dalbavancin and vancomycin-linezolid groups (79.7% and 79.8%, respectively) and were within 10 percentage points of noninferiority. The secondary endpoints were similar between both groups.

Limitations of the study were the early primary endpoint, lack of noninferiority analysis of the secondary endpoints, and cost-effective analysis.

Bottom line: Once-weekly dalbavancin appears to be similarly efficacious to intravenous vancomycin in the treatment of acute bacterial skin infections in terms of outcomes within 48-72 hours of therapy and might provide an alternative to continued inpatient hospitalization for intravenous antibiotics in stable patients.

Citation: Boucher HW, Wilcox M, Talbot GH, Puttagunta S, Das AF, Dunne MW. Once-weekly dalbavancin versus daily conventional therapy for skin infection. N Engl J Med. 2014;370(23):2169-2179.

Clinical question: Is once-weekly intravenous dalbavancin as effective as conventional therapy for the treatment of acute bacterial skin infections?

Background: Acute bacterial skin infections are common and often require hospitalization for intravenous antibiotic administration. Treatment covering gram-positive bacteria usually is indicated. Dalbavancin is effective against gram-positives, including MRSA. Its long half-life makes it an attractive alternative to other commonly used antibiotics, which require more frequent dosing.

Study design: Phase 3, double-blinded RCT.

Setting: Multiple international centers.

Synopsis: Researchers randomized 1,312 patients with acute bacterial skin and skin-structure infections with signs of systemic infection requiring intravenous antibiotics to receive dalbavancin on days one and eight, with placebo on other days, or several doses of vancomycin with an option to switch to oral linezolid. The primary endpoint was cessation of spread of erythema and temperature of ≤37.6°C at 48-72 hours. Secondary endpoints included a decrease in lesion area of ≥20% at 48-72 hours and clinical success at end of therapy (determined by clinical and historical features).

Results of the primary endpoint were similar with dalbavancin and vancomycin-linezolid groups (79.7% and 79.8%, respectively) and were within 10 percentage points of noninferiority. The secondary endpoints were similar between both groups.

Limitations of the study were the early primary endpoint, lack of noninferiority analysis of the secondary endpoints, and cost-effective analysis.

Bottom line: Once-weekly dalbavancin appears to be similarly efficacious to intravenous vancomycin in the treatment of acute bacterial skin infections in terms of outcomes within 48-72 hours of therapy and might provide an alternative to continued inpatient hospitalization for intravenous antibiotics in stable patients.

Citation: Boucher HW, Wilcox M, Talbot GH, Puttagunta S, Das AF, Dunne MW. Once-weekly dalbavancin versus daily conventional therapy for skin infection. N Engl J Med. 2014;370(23):2169-2179.

Clinical question: What is the effect of continuous positive airway pressure (CPAP) or supplemental oxygen on ambulatory blood pressures and markers of cardiovascular risk when combined with sleep hygiene education in patients with obstructive sleep apnea (OSA) and coronary artery disease or cardiac risk factors?

Background: OSA is considered a risk factor for the development of hypertension. One meta-analysis showed reduction of mean arterial pressure (MAP) with CPAP therapy, but randomized controlled data on blood pressure reduction with treatment of OSA is lacking.

Study design: Randomized, parallel-group trial.

Setting: Four outpatient cardiology practices.

Synopsis: Patients ages 45-75 with OSA were randomized to receive nocturnal CPAP and healthy lifestyle and sleep education (HLSE), nocturnal oxygen therapy and HSLE, or HSLE alone. The primary outcome was 24-hour MAP. Secondary outcomes included fasting blood glucose, lipid panel, insulin level, erythrocyte sedimentation rate, C-reactive protein (CRP), and N-terminal pro-brain naturetic peptide.

Participants had high rates of diabetes, hypertension, and coronary artery disease. At 12 weeks, the CPAP arm experienced greater reductions in 24-hour MAP compared to both the nocturnal oxygen and HSLE arms (-2.8 mmHg [P=0.02] and -2.4 mmHg [P=0.04], respectively). No significant decrease in MAP was identified in the nocturnal oxygen arm when compared to the HSLE arm. The only significant difference in secondary outcomes was a decrease in CRP in the CPAP arm when compared to the HSLE arm, the clinical significance of which is unclear.

Bottom line: CPAP therapy with sleep hygiene education appears superior to nocturnal oxygen therapy with sleep hygiene education and sleep hygiene education alone in decreasing 24-hour MAP in patients with OSA and coronary artery disease or cardiac risk factors.

Citation: Gottlieb DJ, Punjabi NM, Mehra R, et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med. 2014;370(24):2276-2285.

Clinical question: What is the effect of continuous positive airway pressure (CPAP) or supplemental oxygen on ambulatory blood pressures and markers of cardiovascular risk when combined with sleep hygiene education in patients with obstructive sleep apnea (OSA) and coronary artery disease or cardiac risk factors?

Background: OSA is considered a risk factor for the development of hypertension. One meta-analysis showed reduction of mean arterial pressure (MAP) with CPAP therapy, but randomized controlled data on blood pressure reduction with treatment of OSA is lacking.

Study design: Randomized, parallel-group trial.

Setting: Four outpatient cardiology practices.

Synopsis: Patients ages 45-75 with OSA were randomized to receive nocturnal CPAP and healthy lifestyle and sleep education (HLSE), nocturnal oxygen therapy and HSLE, or HSLE alone. The primary outcome was 24-hour MAP. Secondary outcomes included fasting blood glucose, lipid panel, insulin level, erythrocyte sedimentation rate, C-reactive protein (CRP), and N-terminal pro-brain naturetic peptide.

Participants had high rates of diabetes, hypertension, and coronary artery disease. At 12 weeks, the CPAP arm experienced greater reductions in 24-hour MAP compared to both the nocturnal oxygen and HSLE arms (-2.8 mmHg [P=0.02] and -2.4 mmHg [P=0.04], respectively). No significant decrease in MAP was identified in the nocturnal oxygen arm when compared to the HSLE arm. The only significant difference in secondary outcomes was a decrease in CRP in the CPAP arm when compared to the HSLE arm, the clinical significance of which is unclear.

Bottom line: CPAP therapy with sleep hygiene education appears superior to nocturnal oxygen therapy with sleep hygiene education and sleep hygiene education alone in decreasing 24-hour MAP in patients with OSA and coronary artery disease or cardiac risk factors.

Citation: Gottlieb DJ, Punjabi NM, Mehra R, et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med. 2014;370(24):2276-2285.

Clinical question: What is the effect of continuous positive airway pressure (CPAP) or supplemental oxygen on ambulatory blood pressures and markers of cardiovascular risk when combined with sleep hygiene education in patients with obstructive sleep apnea (OSA) and coronary artery disease or cardiac risk factors?

Background: OSA is considered a risk factor for the development of hypertension. One meta-analysis showed reduction of mean arterial pressure (MAP) with CPAP therapy, but randomized controlled data on blood pressure reduction with treatment of OSA is lacking.

Study design: Randomized, parallel-group trial.

Setting: Four outpatient cardiology practices.

Synopsis: Patients ages 45-75 with OSA were randomized to receive nocturnal CPAP and healthy lifestyle and sleep education (HLSE), nocturnal oxygen therapy and HSLE, or HSLE alone. The primary outcome was 24-hour MAP. Secondary outcomes included fasting blood glucose, lipid panel, insulin level, erythrocyte sedimentation rate, C-reactive protein (CRP), and N-terminal pro-brain naturetic peptide.

Participants had high rates of diabetes, hypertension, and coronary artery disease. At 12 weeks, the CPAP arm experienced greater reductions in 24-hour MAP compared to both the nocturnal oxygen and HSLE arms (-2.8 mmHg [P=0.02] and -2.4 mmHg [P=0.04], respectively). No significant decrease in MAP was identified in the nocturnal oxygen arm when compared to the HSLE arm. The only significant difference in secondary outcomes was a decrease in CRP in the CPAP arm when compared to the HSLE arm, the clinical significance of which is unclear.

Bottom line: CPAP therapy with sleep hygiene education appears superior to nocturnal oxygen therapy with sleep hygiene education and sleep hygiene education alone in decreasing 24-hour MAP in patients with OSA and coronary artery disease or cardiac risk factors.

Citation: Gottlieb DJ, Punjabi NM, Mehra R, et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med. 2014;370(24):2276-2285.

Clinical question: Is greater lactate clearance following resuscitation from cardiac arrest associated with lower mortality and better neurologic outcomes?

Background: Recommendations from the International Liaison Committee on Resuscitation for monitoring serial lactate levels in post-resuscitation patients are based primarily on extrapolation from other conditions such as sepsis. Two single-retrospective analyses found effective lactate clearance was associated with decreased mortality. This association had not previously been validated in a multicenter, prospective study.

Study design: Multicenter, prospective, observational study.

Setting: Four urban, tertiary-care teaching hospitals.

Synopsis: Absolute lactate levels and the differences in the percent lactate change over 24 hours were compared in 100 patients who suffered out-of-hospital cardiac arrest. Ninety-seven percent received therapeutic hypothermia, and overall survival was 46%. Survivors and patients with a good neurologic outcome had lower lactate levels at zero hours (4.1 vs. 7.3), 12 hours (2.2 vs. 6.0), and 24 hours (1.6 vs. 4.4) compared with nonsurvivors and patients with bad neurologic outcomes.

The percent lactate decreased was greater in survivors and in those with good neurologic outcomes (odds ratio, 2.2; 95% confidence interval, 1.1–4.4).

Nonsurvivors or those with poor neurologic outcomes were less likely to have received bystander CPR, to have suffered a witnessed arrest, or to have had a shockable rhythm at presentation. Superior lactate clearance in survivors and those with good neurologic outcomes suggests a potential role in developing markers of effective resuscitation.

Bottom line: Lower lactate levels and more effective clearance of lactate in patients following cardiac arrest are associated with improved survival and good neurologic outcome.

Citation: Donnino MW, Andersen LW, Giberson T, et al. Initial lactate and lactate change in post-cardiac arrest: a multicenter validation study. Crit Care Med. 2014;42(8):1804-1811.

Clinical question: Is greater lactate clearance following resuscitation from cardiac arrest associated with lower mortality and better neurologic outcomes?

Background: Recommendations from the International Liaison Committee on Resuscitation for monitoring serial lactate levels in post-resuscitation patients are based primarily on extrapolation from other conditions such as sepsis. Two single-retrospective analyses found effective lactate clearance was associated with decreased mortality. This association had not previously been validated in a multicenter, prospective study.

Study design: Multicenter, prospective, observational study.

Setting: Four urban, tertiary-care teaching hospitals.

Synopsis: Absolute lactate levels and the differences in the percent lactate change over 24 hours were compared in 100 patients who suffered out-of-hospital cardiac arrest. Ninety-seven percent received therapeutic hypothermia, and overall survival was 46%. Survivors and patients with a good neurologic outcome had lower lactate levels at zero hours (4.1 vs. 7.3), 12 hours (2.2 vs. 6.0), and 24 hours (1.6 vs. 4.4) compared with nonsurvivors and patients with bad neurologic outcomes.

The percent lactate decreased was greater in survivors and in those with good neurologic outcomes (odds ratio, 2.2; 95% confidence interval, 1.1–4.4).

Nonsurvivors or those with poor neurologic outcomes were less likely to have received bystander CPR, to have suffered a witnessed arrest, or to have had a shockable rhythm at presentation. Superior lactate clearance in survivors and those with good neurologic outcomes suggests a potential role in developing markers of effective resuscitation.

Bottom line: Lower lactate levels and more effective clearance of lactate in patients following cardiac arrest are associated with improved survival and good neurologic outcome.

Citation: Donnino MW, Andersen LW, Giberson T, et al. Initial lactate and lactate change in post-cardiac arrest: a multicenter validation study. Crit Care Med. 2014;42(8):1804-1811.

Clinical question: Is greater lactate clearance following resuscitation from cardiac arrest associated with lower mortality and better neurologic outcomes?

Background: Recommendations from the International Liaison Committee on Resuscitation for monitoring serial lactate levels in post-resuscitation patients are based primarily on extrapolation from other conditions such as sepsis. Two single-retrospective analyses found effective lactate clearance was associated with decreased mortality. This association had not previously been validated in a multicenter, prospective study.

Study design: Multicenter, prospective, observational study.

Setting: Four urban, tertiary-care teaching hospitals.

Synopsis: Absolute lactate levels and the differences in the percent lactate change over 24 hours were compared in 100 patients who suffered out-of-hospital cardiac arrest. Ninety-seven percent received therapeutic hypothermia, and overall survival was 46%. Survivors and patients with a good neurologic outcome had lower lactate levels at zero hours (4.1 vs. 7.3), 12 hours (2.2 vs. 6.0), and 24 hours (1.6 vs. 4.4) compared with nonsurvivors and patients with bad neurologic outcomes.

The percent lactate decreased was greater in survivors and in those with good neurologic outcomes (odds ratio, 2.2; 95% confidence interval, 1.1–4.4).

Nonsurvivors or those with poor neurologic outcomes were less likely to have received bystander CPR, to have suffered a witnessed arrest, or to have had a shockable rhythm at presentation. Superior lactate clearance in survivors and those with good neurologic outcomes suggests a potential role in developing markers of effective resuscitation.

Bottom line: Lower lactate levels and more effective clearance of lactate in patients following cardiac arrest are associated with improved survival and good neurologic outcome.

Citation: Donnino MW, Andersen LW, Giberson T, et al. Initial lactate and lactate change in post-cardiac arrest: a multicenter validation study. Crit Care Med. 2014;42(8):1804-1811.

Clinical question: Is earlier administration of epinephrine in patients with cardiac arrest due to nonshockable rhythms associated with increased return of spontaneous circulation, survival, and neurologically intact survival?

Background: About 200,000 hospitalized patients in the U.S. have a cardiac arrest, commonly due to nonshockable rhythms. Cardiopulmonary resuscitation has been the only efficacious intervention. There are no well-controlled trials of the use of epinephrine on survival and neurological outcomes.

Study design: Prospective cohort from a large multicenter registry of in-hospital cardiac arrests.

Setting: Data from 570 hospitals from 2000 to 2009.

Synopsis: Authors included 25,095 adults from 570 hospitals who had cardiac arrests in hospital with asystole or pulseless electrical activity as the initial rhythm. Time to first administration of epinephrine was recorded and then separated into quartiles, and odds ratios were evaluated using one to three minutes as the reference group. Outcomes of survival to hospital discharge (10%), return of spontaneous circulation (47%), and survival to hospital discharge with favorable neurologic status (7%) were assessed.

Survival to discharge decreased as the time to administration of the first dose of epinephrine increased. Of those patients receiving epinephrine in one minute, 12% survived. This dropped to 7% for those first receiving epinephrine after seven minutes. Return of spontaneous circulation and survival to discharge with favorable neurologic status showed a similar stepwise decrease with longer times to first administration of epinephrine.

Bottom line: Earlier administration of epinephrine to patients with cardiac arrest due to nonshockable rhythms is associated with improved survival to discharge, return of spontaneous circulation, and neurologically intact survival.

Citation: Donnino MW, Salciccioli JD, Howell MD, et al. Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: restrospective analysis of large in-hospital data registry. BMJ. 2014;348:g3028.

Clinical question: Is earlier administration of epinephrine in patients with cardiac arrest due to nonshockable rhythms associated with increased return of spontaneous circulation, survival, and neurologically intact survival?

Background: About 200,000 hospitalized patients in the U.S. have a cardiac arrest, commonly due to nonshockable rhythms. Cardiopulmonary resuscitation has been the only efficacious intervention. There are no well-controlled trials of the use of epinephrine on survival and neurological outcomes.

Study design: Prospective cohort from a large multicenter registry of in-hospital cardiac arrests.

Setting: Data from 570 hospitals from 2000 to 2009.

Synopsis: Authors included 25,095 adults from 570 hospitals who had cardiac arrests in hospital with asystole or pulseless electrical activity as the initial rhythm. Time to first administration of epinephrine was recorded and then separated into quartiles, and odds ratios were evaluated using one to three minutes as the reference group. Outcomes of survival to hospital discharge (10%), return of spontaneous circulation (47%), and survival to hospital discharge with favorable neurologic status (7%) were assessed.

Survival to discharge decreased as the time to administration of the first dose of epinephrine increased. Of those patients receiving epinephrine in one minute, 12% survived. This dropped to 7% for those first receiving epinephrine after seven minutes. Return of spontaneous circulation and survival to discharge with favorable neurologic status showed a similar stepwise decrease with longer times to first administration of epinephrine.

Bottom line: Earlier administration of epinephrine to patients with cardiac arrest due to nonshockable rhythms is associated with improved survival to discharge, return of spontaneous circulation, and neurologically intact survival.

Citation: Donnino MW, Salciccioli JD, Howell MD, et al. Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: restrospective analysis of large in-hospital data registry. BMJ. 2014;348:g3028.

Clinical question: Is earlier administration of epinephrine in patients with cardiac arrest due to nonshockable rhythms associated with increased return of spontaneous circulation, survival, and neurologically intact survival?

Background: About 200,000 hospitalized patients in the U.S. have a cardiac arrest, commonly due to nonshockable rhythms. Cardiopulmonary resuscitation has been the only efficacious intervention. There are no well-controlled trials of the use of epinephrine on survival and neurological outcomes.

Study design: Prospective cohort from a large multicenter registry of in-hospital cardiac arrests.

Setting: Data from 570 hospitals from 2000 to 2009.

Synopsis: Authors included 25,095 adults from 570 hospitals who had cardiac arrests in hospital with asystole or pulseless electrical activity as the initial rhythm. Time to first administration of epinephrine was recorded and then separated into quartiles, and odds ratios were evaluated using one to three minutes as the reference group. Outcomes of survival to hospital discharge (10%), return of spontaneous circulation (47%), and survival to hospital discharge with favorable neurologic status (7%) were assessed.

Survival to discharge decreased as the time to administration of the first dose of epinephrine increased. Of those patients receiving epinephrine in one minute, 12% survived. This dropped to 7% for those first receiving epinephrine after seven minutes. Return of spontaneous circulation and survival to discharge with favorable neurologic status showed a similar stepwise decrease with longer times to first administration of epinephrine.

Bottom line: Earlier administration of epinephrine to patients with cardiac arrest due to nonshockable rhythms is associated with improved survival to discharge, return of spontaneous circulation, and neurologically intact survival.

Citation: Donnino MW, Salciccioli JD, Howell MD, et al. Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: restrospective analysis of large in-hospital data registry. BMJ. 2014;348:g3028.

Clinical question: Is there a more accurate way to predict adverse post-operative outcomes in geriatric patients undergoing elective surgery?

Background: More than half of all operations in the U.S. involve geriatric patients. Most tools hospitalists use to predict post-operative outcomes are focused on cardiovascular events and do not account for frailty. Common in geriatric patients, frailty is thought to influence post-operative outcomes.

Study design: Prospective cohort study.

Setting: A 1,000-bed academic hospital in Seoul, South Korea.

Synopsis: A cohort of 275 elderly patients (>64 years old) who were scheduled for elective intermediate or high-risk surgery underwent a pre-operative comprehensive geriatric assessment (CGA) that included measures of frailty. This cohort was then followed for mortality, major post-operative complications (pneumonia, urinary infection, pulmonary embolism, and unplanned transfer to intensive care), length of stay, and transfer to a nursing home. Post-operative complications, transfer to a nursing facility, and one-year mortality were associated with a derived scoring tool that included the Charlson Comorbidity Index, activities of daily living (ADL), instrumental activities of daily living (IADL), dementia, risk for delirium, mid-arm circumference, and a mini-nutritional assessment.

This tool was more accurate at predicting one-year mortality than the American Society of Anesthesiologists (ASA) classification.

Bottom line: This study establishes that measures of frailty predict post-operative outcomes in geriatric patients undergoing elective surgery; however, the authors’ tool depends on CGA, which is time-consuming, cumbersome, and depends on indices not familiar to many hospitalists.

Citation: Kim SW, Han HS, Jung HW, et al. Multidimensional frailty scores for the prediction of postoperative mortality risk. JAMA Surg. 2014;149(7):633-640.

Clinical question: Is there a more accurate way to predict adverse post-operative outcomes in geriatric patients undergoing elective surgery?

Background: More than half of all operations in the U.S. involve geriatric patients. Most tools hospitalists use to predict post-operative outcomes are focused on cardiovascular events and do not account for frailty. Common in geriatric patients, frailty is thought to influence post-operative outcomes.

Study design: Prospective cohort study.

Setting: A 1,000-bed academic hospital in Seoul, South Korea.

Synopsis: A cohort of 275 elderly patients (>64 years old) who were scheduled for elective intermediate or high-risk surgery underwent a pre-operative comprehensive geriatric assessment (CGA) that included measures of frailty. This cohort was then followed for mortality, major post-operative complications (pneumonia, urinary infection, pulmonary embolism, and unplanned transfer to intensive care), length of stay, and transfer to a nursing home. Post-operative complications, transfer to a nursing facility, and one-year mortality were associated with a derived scoring tool that included the Charlson Comorbidity Index, activities of daily living (ADL), instrumental activities of daily living (IADL), dementia, risk for delirium, mid-arm circumference, and a mini-nutritional assessment.

This tool was more accurate at predicting one-year mortality than the American Society of Anesthesiologists (ASA) classification.

Bottom line: This study establishes that measures of frailty predict post-operative outcomes in geriatric patients undergoing elective surgery; however, the authors’ tool depends on CGA, which is time-consuming, cumbersome, and depends on indices not familiar to many hospitalists.

Citation: Kim SW, Han HS, Jung HW, et al. Multidimensional frailty scores for the prediction of postoperative mortality risk. JAMA Surg. 2014;149(7):633-640.

Clinical question: Is there a more accurate way to predict adverse post-operative outcomes in geriatric patients undergoing elective surgery?

Background: More than half of all operations in the U.S. involve geriatric patients. Most tools hospitalists use to predict post-operative outcomes are focused on cardiovascular events and do not account for frailty. Common in geriatric patients, frailty is thought to influence post-operative outcomes.

Study design: Prospective cohort study.

Setting: A 1,000-bed academic hospital in Seoul, South Korea.

Synopsis: A cohort of 275 elderly patients (>64 years old) who were scheduled for elective intermediate or high-risk surgery underwent a pre-operative comprehensive geriatric assessment (CGA) that included measures of frailty. This cohort was then followed for mortality, major post-operative complications (pneumonia, urinary infection, pulmonary embolism, and unplanned transfer to intensive care), length of stay, and transfer to a nursing home. Post-operative complications, transfer to a nursing facility, and one-year mortality were associated with a derived scoring tool that included the Charlson Comorbidity Index, activities of daily living (ADL), instrumental activities of daily living (IADL), dementia, risk for delirium, mid-arm circumference, and a mini-nutritional assessment.

This tool was more accurate at predicting one-year mortality than the American Society of Anesthesiologists (ASA) classification.

Bottom line: This study establishes that measures of frailty predict post-operative outcomes in geriatric patients undergoing elective surgery; however, the authors’ tool depends on CGA, which is time-consuming, cumbersome, and depends on indices not familiar to many hospitalists.

Citation: Kim SW, Han HS, Jung HW, et al. Multidimensional frailty scores for the prediction of postoperative mortality risk. JAMA Surg. 2014;149(7):633-640.

Clinical question: Should angiotension-converting enzyme inhibitors or angiotension receptor blockers (ACEI/ARB) be held the morning of elective joint replacement?

Background: In patients taking ACEI/ARB, the decision regarding whether or not to give these medications on the day of surgery is controversial. UptoDate recommends holding ACEI/ARB the day of surgery; American College of Physicians Guidelines and SHM Consult Medicine recommend giving these drugs on the day of surgery.

Study design: Retrospective cohort (case control) study.

Setting: A large academic hospital in Pennsylvania.

Synopsis: Researchers studied adults undergoing elective spinal fusion, total knee replacement, or total hip replacement, and compared outcomes in 323 patients who were taking an ACEI/ARB (study group) to outcomes in the 579 patients who were not taking an ACEI/ARB (control group) before surgery. It was assumed—but not studied—that the ACEI/ARB was continued the morning of surgery in all patients in the study group, because that was the standard practice at this hospital.

Compared to the control group, the study group had more post-induction hypotension (12.2% vs. 6.7%) and more post-operative acute kidney injury (5.76% vs. 3.28%). Patients who developed acute kidney injury had longer length of stay (5.76 vs. 3.28 days) but no difference in two-year mortality.

Patients in the study group had higher baseline creatinine, were older, were more likely to be taking a diuretic, and were more likely to have diabetes, heart failure, and coronary artery disease. The authors used multiple logistic regression to adjust for these differences. Anesthesia and intra-operative fluid management were not standardized or compared.

Bottom line: ACEI/ARB administration on the morning of elective major orthopedic surgery is likely associated with a higher risk of intra-operative hypotension and acute kidney injury.

Citation: Nielson E, Hennrikus E, Lehman E, Mets B. Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery. J Hosp Med. 2014;9(5):283-288.

Clinical question: Should angiotension-converting enzyme inhibitors or angiotension receptor blockers (ACEI/ARB) be held the morning of elective joint replacement?

Background: In patients taking ACEI/ARB, the decision regarding whether or not to give these medications on the day of surgery is controversial. UptoDate recommends holding ACEI/ARB the day of surgery; American College of Physicians Guidelines and SHM Consult Medicine recommend giving these drugs on the day of surgery.

Study design: Retrospective cohort (case control) study.

Setting: A large academic hospital in Pennsylvania.

Synopsis: Researchers studied adults undergoing elective spinal fusion, total knee replacement, or total hip replacement, and compared outcomes in 323 patients who were taking an ACEI/ARB (study group) to outcomes in the 579 patients who were not taking an ACEI/ARB (control group) before surgery. It was assumed—but not studied—that the ACEI/ARB was continued the morning of surgery in all patients in the study group, because that was the standard practice at this hospital.

Compared to the control group, the study group had more post-induction hypotension (12.2% vs. 6.7%) and more post-operative acute kidney injury (5.76% vs. 3.28%). Patients who developed acute kidney injury had longer length of stay (5.76 vs. 3.28 days) but no difference in two-year mortality.

Patients in the study group had higher baseline creatinine, were older, were more likely to be taking a diuretic, and were more likely to have diabetes, heart failure, and coronary artery disease. The authors used multiple logistic regression to adjust for these differences. Anesthesia and intra-operative fluid management were not standardized or compared.

Bottom line: ACEI/ARB administration on the morning of elective major orthopedic surgery is likely associated with a higher risk of intra-operative hypotension and acute kidney injury.

Citation: Nielson E, Hennrikus E, Lehman E, Mets B. Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery. J Hosp Med. 2014;9(5):283-288.

Clinical question: Should angiotension-converting enzyme inhibitors or angiotension receptor blockers (ACEI/ARB) be held the morning of elective joint replacement?

Background: In patients taking ACEI/ARB, the decision regarding whether or not to give these medications on the day of surgery is controversial. UptoDate recommends holding ACEI/ARB the day of surgery; American College of Physicians Guidelines and SHM Consult Medicine recommend giving these drugs on the day of surgery.

Study design: Retrospective cohort (case control) study.

Setting: A large academic hospital in Pennsylvania.

Synopsis: Researchers studied adults undergoing elective spinal fusion, total knee replacement, or total hip replacement, and compared outcomes in 323 patients who were taking an ACEI/ARB (study group) to outcomes in the 579 patients who were not taking an ACEI/ARB (control group) before surgery. It was assumed—but not studied—that the ACEI/ARB was continued the morning of surgery in all patients in the study group, because that was the standard practice at this hospital.

Compared to the control group, the study group had more post-induction hypotension (12.2% vs. 6.7%) and more post-operative acute kidney injury (5.76% vs. 3.28%). Patients who developed acute kidney injury had longer length of stay (5.76 vs. 3.28 days) but no difference in two-year mortality.

Patients in the study group had higher baseline creatinine, were older, were more likely to be taking a diuretic, and were more likely to have diabetes, heart failure, and coronary artery disease. The authors used multiple logistic regression to adjust for these differences. Anesthesia and intra-operative fluid management were not standardized or compared.

Bottom line: ACEI/ARB administration on the morning of elective major orthopedic surgery is likely associated with a higher risk of intra-operative hypotension and acute kidney injury.

Citation: Nielson E, Hennrikus E, Lehman E, Mets B. Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery. J Hosp Med. 2014;9(5):283-288.