Alan Briones, MD

Emergency Department (ED) overcrowding has become an important problem in North American hospitals.13 A national survey identified the prolonged length of stay of admitted patients in the ED as the most frequent reason for overcrowding.4 This complex problem occurs when hospital inpatient census increases and prevents admitted patients from being assigned and transported to hospital beds in a timely manner.5 The practice of holding admitted patients in the ED, known as boarding, is typically defined as the length of stay (LOS) in ED beginning 2 hours after the time of admission to the time of transfer to the wards.

In a study of daily mean ED LOS, Rathlev et al.6 concluded that a 5% increase in hospital occupancy resulted in 14 hours of holding time for all patients in the ED, and an observational study found that when hospital occupancy exceeds a threshold of 90%, the ED LOS for admitted patients correspondingly increased.7 Thus, efforts to decrease overcrowding will need to address both ED and hospital throughput and LOS. Most importantly, overcrowding has important consequences on physician and patient satisfaction and the quality of patient care.811

Between 1995 and 2005, ED visits rose 20% from 96.5 million to 115.3 million visits annually, while the number of hospital EDs decreased from 4176 to 3795, making an overall 7% increase in ED utilization rate.12 Similarly, there was a 12% increase in the total inpatient admissions for all registered hospitals in the United States from 31 million in 1995 to 35.3 million in 2005.13 However, despite this increase in demand of ED utilization and inpatient admissions, there had been a steady decline in the supply of hospital beds, from 874,000 in 1995, to 805,000 in 2006.13 These factors have exacerbated the problem of ED overcrowding and boarding.

Not only does boarding entail additional consumption of space, resources, equipment, and manpower, it also potentially compromises patient safety. Typically, hospitalists and inpatient medical teams are engaged in providing care to patients in the wards, while ED physicians and nurses are busy taking care of newly‐arrived ED patients. Non‐ED physicians may have the false impression that their boarded patients, while in the ED, are receiving continuous care and so may decide to delay seeing these patients, which can jeopardize the quality and timeliness of care. Studies have shown that ED overcrowding may potentially lead to poor patient care and outcomes and increased risk for medical errors.1416 ED overcrowding potentially causes multiple effects, including prolonging patient pain and suffering, long patient waiting time, patient dissatisfaction, ambulance diversions, decreased physician productivity, and increased frustration among medical staff.15 In a report by the Joint Commission Accreditation of Healthcare Organizations,17 ED overcrowding was cited as a significant contributing factor in sentinel event cases of patient death or permanent injury due to delays in treatment. Boarding critically ill patients who are physiologically vulnerable and unstable can allow them to be subjected to treatment delays at a pivotal point when time‐sensitive interventions are necessary, ie, sepsis or cardiogenic shockthe golden hour in trauma.16 Medical errors are usually not caused by individual errors but by complex hospital systems; and ED overcrowding is a prime example of a system problem that creates a high‐risk environment for medical errors and threatens patient safety.18

Our hospital commonly has 5 to 15 boarders and often has 20 to 30 boarders at any time. Approximately 90% of these patients are admitted to the Medical Service. In response to this challenge, our institution has designated a full‐time hospitalist to manage boarded patients. The primary goal of this new role is to ensure patient safety and the delivery of high‐quality care while admitted patients are in the ED (Table 1).

Table 1.Responsibilities of the ED Hospitalist
Abbreviation: ED, emergency department.
1	Round on all patients admitted to the Department of Medicine located in the ED, including those on the Teaching and Nonteaching Services. Rounds focus on patient safety, such as ensuring vital home and hospital medications are administered and changes in stability are noted. All patient updates are documented in the ED electronic medical records (IBEX).
2	Identify admitted patients who may be downgraded from telemetry to nontelemetry status. Telemetry and cardiac beds are in high demand, and decreasing utilization facilitates obtaining the appropriate ward bed for ED patients.
3	Assess admitted patients for possible discharge. The patient's condition may have improved or results may indicate that admission is no longer required. The ED hospitalist communicates with the ED physician and wards teams, facilitates management, implements the discharge, and ensures adequate follow‐up.
4	Refer patients to an ED social worker as needed.
5	Facilitate referrals to other medical or surgical specialties if indicated.
6	Clarify the plan of care with the ED staff and facilitates ED communication with the ward team. Acts as a liaison and a resource for the ED physicians and nursing staff.
7	Supervise the triage duties of the medical admitting resident.
8	Provide medical consultation to ED physicians for patients not being admitted to the hospital or who are being admitted to other services (eg, surgery).

The objectives of the study were to determine: (1) the impact on quality of care by assessing laboratory results acted upon and medication follow‐up by the ED hospitalist, and (2) the impact on throughput by assessing the number of ED discharges and telemetry downgrades.

Methods

Setting

The Mount Sinai Medical Center is a tertiary‐care 1121‐bed acute care teaching hospital located in New York City. The hospital borders East Harlem and the Upper East Side of Manhattan. The Medical Service is composed of a Teaching Service, composed of house staff and attendings, and a non‐Teaching Service, composed of nurse practitioners, physician assistants, and attendings. Hospitalists and private attendings may have patients on either the Teaching or the non‐Teaching Service. In 2007, there were 56,541 patients admitted for a total of 332,368 days. The mean LOS for medical inpatients was 5.89 days. The total ED visit was 79,500 with a total inpatient and critical care admissions of 24,522. The mean and median LOS for all ED patients were 623 minutes and 493 minutes, respectively. There were 11,488 patients who qualified as boarders, averaging 31.5 boarders per 24 hours; with a mean and median LOS per boarder of 288 minutes and 198 minutes, respectively. The ED LOS for admitted patients ranged from 2 minutes to 4074 minutes (2.83 days).

Admission Process

Once an ED attending physician decides that a patient is to be admitted, the patient is placed on a computerized list in the ED's electronic medical record (IBEX software). The Medical Admitting Resident (MAR) evaluates and triages admitted patients, and assigns and gives a verbal report to the appropriate Medicine Service (ie, Teaching, non‐Teaching, cardiac telemetry unit, intensive care, etc.). The Admitting Office searches for and assigns the appropriate unit and bed for the patient. A hospitalist or resident physician performs the patient's initial assessment and evaluation in the ED, and admission orders are placed in the inpatient computerized order entry system (TDS). When the bed is ready, the ED nurse gives a verbal report to the floor nurse, and the patient is transported to the ward.

Responsibilities

The specific responsibilities of the ED hospitalist are listed in Table 1. The primary role is to round on patients admitted to the Medicine Service who are located in the ED. This encompasses a wide array of patients and services, including patients assigned to a hospitalist service attending or who have a private attending, patients admitted to the Teaching or non‐Teaching Service, patients admitted to the intensive care unit, and patients admitted to a general medicine or specialty service (eg, telemetry, oncology, human immunodeficiency virus [HIV]). Rounding includes review of the ED's electronic medical record as well as direct examination of patients. The hospitalist focuses on patients with longer ED LOS and on aspects of care that may lapse while patients remain in the ED for prolonged periods. At our institution, the follow‐up of subsequent tests, laboratory values, and medications for ED boarders is the responsibility of the primary inpatient team, though the ED physicians act on urgent and critical results and continue to deliver all emergency care. Through rounding, the ED hospitalist is able to identify abnormal results in a timely manner, alert the ED physician and primary inpatient team, and address abnormalities. Specific examples of laboratory results acted upon include hypokalemia, hyperglycemia, and elevated cardiac enzymes. The ED hospitalist is also able to determine whether any outpatient medications have not yet been administered (eg, antihypertensives, immune suppressants) and ensure that subsequent doses of medications initiated in the ED (eg, antibiotics) are administered during the appropriate timeframe.

Communication is emphasized, as contact with ED physicians, ward physicians, and often the outpatient primary care physician is required when any change in management is considered. The ED hospitalist also provides the capability of rapid response to changes in patient status (eg, a new complaint or fever). In addition, the hospitalist is available to consult on medical patients who may not require admission and on nonmedical patients for whom an internal medicine consult may be beneficial (eg, preoperative optimization of a surgical patient). The ED hospitalist documents the evaluation in the IBEX system. Bills were submitted for visits in which patients were discharged as these encounters are comprehensive, but not for other encounters.

Data Collection

The ED hospitalist role began March 10, 2008 and is a 10‐hour shift (8 _AM to 6 _PM) on weekdays. The study period was from March 10, 2008 through June 30, 2008. The study was approved by the hospital's institutional review board.

Data were collected on aspects of care that could have been impacted by the ED hospitalist, including medication and laboratory orders, ED discharges, ED admissions avoided, and telemetry downgrades. Discharges from ED refers to boarded admitted patients in the ED, who by the judgment of the ED hospitalist were ready for discharge. Admissions avoided refers to patients who the ED physician planned to admit but had not yet been admitted, and whose admission was avoided through the recommendations made by the ED hospitalist. The ED LOS was defined as the duration of time from when the patient was admitted to the Medicine Service to the time the patient was transferred to a medical ward. Telemetry downgrades were defined as patients assigned to the cardiac telemetry unit who the hospitalist determined required only telemetry on a general medical unit or did not require telemetry, or patients assigned to telemetry on a general medicine unit who the hospitalist determined no longer required telemetry.

Results were expressed as percentages of patients admitted to a Medicine Service and percentage of patients evaluated by the ED hospitalist, as indicated. 95% confidence intervals (CI) were calculated.

Results

During the study period, there were 4363 patients admitted to the Medicine Service and 3555 patients who qualified as boarders (mean of 29 boarders per 24 hours). The mean boarding time of admitted patients was 440 minutes. A total of 634 patients (17.8% of all boarded patients) were evaluated by the ED hospitalist. The mean daily number of patients seen by the ED hospitalist was 8.0.

The key elements of the delivery of care by the ED hospitalist are summarized in Table 2.

Table 2.Elements of Care Delivered by the ED Hospitalist to ED Boarders
Elements	Boarders (n = 3555) [n (%)]	Patients Intervened on (n = 634) [n (%)]
Abbreviation: ED, emergency department. * Forty‐four patients improved and 2 left against medical advice.
Laboratory results acted upon	472 (13.2)	472 (74.5)
Medication follow‐up	506 (14.2)	506 (79.8)
Discharges from the ED*	46 (1.3)	46 (7.3)
Admissions avoided	6 (0.2)	6 (0.95)
Telemetry downgrades	61 (1.8)	61 (9.6)

The care of boarded patients included follow‐up of laboratory tests for 74.5% (95% CI, 71‐78%) and medication orders for 79.8% (95% CI, 77‐83%) of patients. A total of 46 patients were discharged by the ED hospitalist (0.6 discharges/day) and telemetry was discontinued for 61 patients (0.8 downgrades/day). The discharge rate was 7.3% (95% CI, 5‐10%) and telemetry downgrade rate was 9.6% (95% CI, 8‐12%) of those patients assessed by the ED hospitalist. Expressed as a percentage of the total ED boarders (n = 3555), the combined discharge rate and the admissions avoided rate was 1.5%.

Table 3 shows the discharge diagnoses made from the ED. Chest pain was the most common diagnosis, followed by syncope, pneumonia, and chronic obstructive pulmonary disease (COPD).

Table 3.Diagnoses of Patients Discharged from the ED by the ED Hospitalist
Diagnoses	Patients (n = 46) [n (%)]
Abbreviations: COPD, chronic obstructive pulmonary disease; ED, emergency department.
Chest pain	12 (26)
Syncope/dizziness	7 (15)
Pneumonia	4 (9)
COPD	4 (9)
Congestive heart failure	3 (7)
Gastroenteritis	3 (7)
Dermatitis/rash	3 (7)
Alcohol abuse	3 (7)
Abdominal pain	3 (7)
End stage renal disease	2 (4)
Vaginal bleeding	1 (2)
Fall	1 (2)
Asthma	1 (2)

Discussion

Our hospital has successfully implemented an innovative strategy utilizing a hospitalist to help provide seamless care to medical patients located in the ED. Other solutions at our hospital had previously been implemented, but had not adequately addressed the problem, including: (1) protocols to monitor length of stay patterns and deviations, (2) discharge planning activities, (3) organized computerized bed tracking, (4) improvement in the timeliness of ancillary services, (5) daily bed briefing among nurse managers, and (6) 24‐hour presence of a MAR to facilitate triage in the ED.

The current study demonstrates the potential for substantial impact on patient care. The substantial number of the assessed boarder patients for whom laboratory tests (74.5%) and medications (79.8%) were ordered by the ED hospitalists suggests that the quality and timeliness of care was enhanced by this initiative. In addition, the considerable number of patients discharged from the ED and downgraded from telemetry (1.5% and 1.8% of all boarder patients, respectively) suggests that an ED hospitalist may have a meaningful impact on bed utilization and thus decrease ED overcrowding. In 2007, there were 11,488 who qualified as boarders; our data suggest that an ED hospitalist would result in approximately 172 boarders not being admitted annually.

Though the ED LOS was higher during the study period compared to 2007, it was lower than the 2 months immediately preceding implementation of the ED hospitalist role. The ED LOS was 732 and 658 minutes for January and February 2008, respectively, which was markedly increased from 2007 (288 minutes), and prompted development of the ED hospitalist role. The ED LOS during the study period subsequently decreased to 440 minutes. Though the wide fluctuations in ED LOS and the short time period with high ED LOS prior to implementation preclude concluding that the ED hospitalist role decreased ED LOS, the data suggest that an ED hospitalist may be able to improve ED throughput.

The majority of the discharges made by the ED hospitalist are patients who had been admitted for chest pain, had improved, and had negative cardiac enzymes and stress tests. Patients with syncope who were discharged were likely patients without any comorbidities. The COPD and pneumonia admissions were likely patients who improved after aggressive treatment in the ED.

The impact of ED overcrowding on the quality of patient care and outcomes may be substantial. Hwang et al.19 found a direct correlation between ED census and time to pain assessment and administration of analgesic medication. A study at an academic medical center found that higher ED volume was associated with less likelihood of antibiotics being administered within 4 hours for patients with community‐acquired pneumonia.20 A comprehensive review of the literature identified 41 studies examining the effects of ED overcrowding on clinical outcomes and the investigators noted that ED overcrowding was associated with increased in‐hospital mortality.8

Causes of poor outcomes during periods of overcrowding may be the high volume of acute patients preventing adequate time and attention for each ED patient, as well as confusion during the transition from ED to ward physicians. For example, a patient may receive their initial dose of antibiotics from the ED physician, but subsequent doses may be overlooked in the transition of care from the ED physician to the inpatient team. In addition, having admitted patients located in the ED for extended periods of time may lead to these patients not being seen as frequently as patients admitted to the inpatient wards. Another potential consequence of prolonged ED stay for admitted patients is delay in inpatient management. Tests done in the ED may prompt further studies that may not be ordered promptly while patients remain in the ED, which subsequently increases LOS. Other potential issues may be an increase in confusion among geriatric patients in a noisy and crowded ED; decreased access to specialized nursing care that may be available on a hospital ward; decreased access to physical therapy and occupational therapy services; and decreased comfort and satisfaction as patients wait in overcrowded EDs for prolonged periods.

Several other potential innovative solutions to ED overcrowding have been proposed, studied, and tested. These measures generally are focused on improving the three interdependent components of ED workflow: INPUT THROUGHPUT OUTPUT.21, 22 However, process redesign and intervention on these 3 interdependent ED workflow components may be difficult to achieve, especially when hospital resources are limited and when inpatient hospital capacity is already maximized. In some institutions, efforts have been reported to successfully streamline the transfer of admitted ED patients to inpatient beds, through transfer‐to‐ward policy interventions (eg, physician coordinators for patient flow and bed management or transfers made within a defined period of time).2326 However, in a study by Quinn et al.,27 implementation of a rapid admission policy resulted in a decrease of only 10.1 minutes in the ED LOS. Several studies have demonstrated the benefits of an acute medical admissions unit in alleviating ED overcrowding.28, 29 Other unconventional solutions by some hospitals include sending admitted patients to the unit's hallways or placing discharged patients in the hallway while waiting for transportation so that the ED bed will be readily available.30

The ED hospitalist is well‐situated to have an impact on several key hospital outcomes. As the ED hospitalist role was shown to affect processes that relate to ED throughput, it is possible that the role will improve ED overcrowding and decrease ED LOS. Specifically, identifying patients who can be discharged and for whom telemetry is no longer indicated decreases unnecessary bed utilization and allows these beds to be available for other ED patients. This initiative also may promote patient satisfaction by assuring patients that their medical and concerns are being fully addressed while they are in the ED. Increased emphasis on hospital reporting will make patient satisfaction a priority for many hospitals, and the ED hospitalist will be in a unique position to meet and greet patients admitted to the Medicine Service and to reassure them that the medical team is present and addressing their concerns. The hospitalist's ability to facilitate diagnostic testing and treatment while patients remain in the ED may also help decrease the total LOS in the hospital. In addition, the ED hospitalist is also in position to recognize social factors at the earliest stage of admission so that they can be immediately addressed. Future studies will need to be done to determine if this model of transitional care impacts these important factors.

Our study has several important limitations. Most notably, the lack of a comparison interval for which a hospitalist was not assigned to this role prevents us from drawing any definitive conclusions on the benefits of the ED hospitalist model. Also, we collected only summary data and do not have demographic data on the patients managed by the ED hospitalist or information on the ED course of patients who were discharged or had telemetry downgraded. This prevents determination of whether discharged patients did not require admission initially or whose condition evolved over a prolonged ED stay. In addition, other key outcomes, such as patient satisfaction and satisfaction of the ED physicians and nursing staff have not yet been formally measured. Future studies will be needed to determine if an ED hospital model can improve important process and clinical outcomes.

The greatest challenge of this initiative was introducing and familiarizing this role to the key stakeholders, including the ED physicians and nursing staff, house staff, and private practice physicians. Though we did not perform structured surveys on satisfaction, through informal discussions we noted that the role was welcomed with enthusiasm by the ED physicians. Notably, several ED physicians expressed appreciation that they were able to focus their care on new ED patients rather than on the boarded ED patients. Through feedback, we noted soon after implementation that ED faculty and nurses needed further clarification about the potential overlapping roles of the ED hospitalist and ED physicians and ward physicians. These concerns were addressed by educational sessions and announcements, including presentations at ED faculty and staff meetings. The hospitalist assigned to the role each month received individualized orientation prior to assuming the role, and an ED Hospitalist Manual was distributed. Possibly due to these focused sessions, the hospitalists assigned to the role became quickly acclimated.

Conclusions

We have found that designating a hospitalist to directly address the care of ED boarders can enhance the quality and timeliness of care and decrease bed and telemetry utilization with the potential to impact ED and hospital LOS. Given the success of the pilot model, the role was expanded at our institution to 10 hours per day, 7 days per week. Hospitals struggling to address the needs of their admitted patients in the ED should consider incorporating an ED hospitalist to enhance clinical care and address issues relating to throughput. A follow‐up study is needed to more precisely describe the impact of the ED hospitalist model.

References

Weiss SJ, Derlet R, Arnhdal J, et al.Estimating the degree of emergency department overcrowding in academic medical centers: results of the National ED Overcrowding Study (NEDOCS).Acad Emerg Med.2004;11:38–50.
Bond K, Ospina MB, Blitz S, et al.Frequency, determinants, and impact of overcrowding in emergency departments in Canada: a national survey.Healthc Q.2007;10:32–40.
Steele R, Kiss A.EMDOC (emergency department overcrowding) internet‐based safety net research.Admin Emerg Med.2008;35:101–107.
United States General Accounting Office.Hospital Emergency Departments: Crowded Conditions Vary Among Hospitals and Communities. March 2003.Washington, DC:General Accounting Office;2003.
Derlet RW.Overcrowding in emergency department: increased demand and decreased capacity.Ann Emerg Med.2002;39:430–432.
Rathlev NK, Chessare J, Olshaker J, et al.Time series analysis of variables associated with daily mean emergency department length of stay.Ann Emerg Med.2007;49:265–271.
Forster A, Stiell I, Wells G, et al.Effect of hospital occupancy on emergency department length of stay and patient disposition.Ann Emerg Med.2003;10:127–133.
Bersnstein SL, Aronsky D, Duseja R, et al.The effect of emergency department crowding on clinically oriented outcomes.Acad Emerg Med.2009;16:1–10.
Rondeau KV, Francescutti LH.Emergency department overcrowding: the impact of resource scarcity on physician job satisfaction.J Health Manag.2005;50:327–340.
Pines JM, Iyer S, Disbot M, Hollander JE, Shofer FS, Datner EM.The effect of emergency department crowding on patient satisfaction for admitted patients.Acad Emerg Med.2008;15:825–831.
Vieth TL, Rhodes KV.The effect of crowding on access and quality in an academic ED.Am J Emerg Med.2006;24:787–794.
Nawar EW, Niska RW, Xu J.National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary. Advance Data from Vital and Health Statistics. No. 386.Hyattsville, MD:National Center for Health Statistics;2007.
American Hospital Association (AHA).Table 1: Historical trends in utilization, personnel, and finances: year 1946–2006.AHA Hospital Statistics.2008 ed.Chicago:Health Forum LLC;2008:3.
Trzeciak S, Rivers EP.Emergency department overcrowding in the US: an emerging threat to patient safety and public health.Emerg Med J.2003;20:402–405.
Derlet RW, Richards JR.Overcrowding in the nation's emergency departments: complex causes and disturbing effects.Ann Emerg Med.2000;35:63–68.
Cowan RM, Trzeciak S.Clinical review: emergency department overcrowding and the potential impact on the critically ill.Crit Care.2005;9:291–295.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO): Sentinel event alert 2002, Issue 26. Available at: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_26.htm. Accessed October2009.
Gordon JA, Billings J, Asplin BR, et al.Safety net research in emergency medicine: proceedings of the Academic Emergency Consensus Conference on “The Unraveling Safety Net.”Acad Emerg Med.2001;8:1024–1029.
Hwang U, Richardson L, Livote E, Harris B, Spencer N, Morrison SR.Emergency department crowding and decreased quality of pain care.Acad Emerg Med.2008;15:1248–1256.
Fee C, Weber EJ, Maak CA, Bacchetti P.Effect of emergency department crowding on time to antibiotics in patients admitted with community‐acquired pneumonia.Ann Emerg Med.2007;50:501–509.
Asplin BR, Magid DJ, Rhodes KV, et al.A conceptual model of emergency department crowding.Ann Emerg Med.2003;42:173–180.
Solberg LI, Asplin BR, Weinick RM, et al.Emergency department crowding: consensus development of potential measures.Ann Emerg Med.2003;42:824–834.
Cardin S, Afilalo M, Lang E, et al.Intervention to decrease emergency department crowding: does it have an effect on return visits and hospital readmission?Ann Emerg Med.2003;41:173–185.
Spaite DW, Bartholomeaux F, Guisto JM, et al.Rapid process design in a university‐based emergency department: decreasing waiting time intervals and improving patient satisfaction.Ann Emerg Med.2002;39:168–177.
Viccellio P.Emergency department crowding: an action plan.Acad Emerg Med.2001;18:185–187.
Howell EE, Bessman ES, Rubin HR.Hospitalists and an innovative emergency department admission process.J Gen Intern Med.2004;19:266–268.
Quinn JV, Mahadevan SV, Eggers G et al.Effects of implementing a rapid admission policy in the ED.Am J Emerg Med.2007;25:559–563.
Kelen GD, Scheulen PA, Hill PM.Effect of an emergency department managed acute care unit on ED overcrowding and emergency medical services diversion.Acad Emerg Med.2001;8:1085–1100.
Maloney ED, Bennett K, O'Riordan D, Silke B.Emergency department census of patients awaiting admission following reorganization of an admissions process.Emerg Med J.2006;23:363–367.
Greene J.Emergency department flow and the boarded patient: how to get admitted patients upstairs.Ann Emerg Med.2007;49:68–70.

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Table 1.Responsibilities of the ED Hospitalist
Abbreviation: ED, emergency department.
1	Round on all patients admitted to the Department of Medicine located in the ED, including those on the Teaching and Nonteaching Services. Rounds focus on patient safety, such as ensuring vital home and hospital medications are administered and changes in stability are noted. All patient updates are documented in the ED electronic medical records (IBEX).
2	Identify admitted patients who may be downgraded from telemetry to nontelemetry status. Telemetry and cardiac beds are in high demand, and decreasing utilization facilitates obtaining the appropriate ward bed for ED patients.
3	Assess admitted patients for possible discharge. The patient's condition may have improved or results may indicate that admission is no longer required. The ED hospitalist communicates with the ED physician and wards teams, facilitates management, implements the discharge, and ensures adequate follow‐up.
4	Refer patients to an ED social worker as needed.
5	Facilitate referrals to other medical or surgical specialties if indicated.
6	Clarify the plan of care with the ED staff and facilitates ED communication with the ward team. Acts as a liaison and a resource for the ED physicians and nursing staff.
7	Supervise the triage duties of the medical admitting resident.
8	Provide medical consultation to ED physicians for patients not being admitted to the hospital or who are being admitted to other services (eg, surgery).

Methods

Setting

Admission Process

Responsibilities

Data Collection

Results

The key elements of the delivery of care by the ED hospitalist are summarized in Table 2.

Table 2.Elements of Care Delivered by the ED Hospitalist to ED Boarders
Elements	Boarders (n = 3555) [n (%)]	Patients Intervened on (n = 634) [n (%)]
Abbreviation: ED, emergency department. * Forty‐four patients improved and 2 left against medical advice.
Laboratory results acted upon	472 (13.2)	472 (74.5)
Medication follow‐up	506 (14.2)	506 (79.8)
Discharges from the ED*	46 (1.3)	46 (7.3)
Admissions avoided	6 (0.2)	6 (0.95)
Telemetry downgrades	61 (1.8)	61 (9.6)

Table 3 shows the discharge diagnoses made from the ED. Chest pain was the most common diagnosis, followed by syncope, pneumonia, and chronic obstructive pulmonary disease (COPD).

Table 3.Diagnoses of Patients Discharged from the ED by the ED Hospitalist
Diagnoses	Patients (n = 46) [n (%)]
Abbreviations: COPD, chronic obstructive pulmonary disease; ED, emergency department.
Chest pain	12 (26)
Syncope/dizziness	7 (15)
Pneumonia	4 (9)
COPD	4 (9)
Congestive heart failure	3 (7)
Gastroenteritis	3 (7)
Dermatitis/rash	3 (7)
Alcohol abuse	3 (7)
Abdominal pain	3 (7)
End stage renal disease	2 (4)
Vaginal bleeding	1 (2)
Fall	1 (2)
Asthma	1 (2)

Discussion

Conclusions

Table 1.Responsibilities of the ED Hospitalist
Abbreviation: ED, emergency department.
1	Round on all patients admitted to the Department of Medicine located in the ED, including those on the Teaching and Nonteaching Services. Rounds focus on patient safety, such as ensuring vital home and hospital medications are administered and changes in stability are noted. All patient updates are documented in the ED electronic medical records (IBEX).
2	Identify admitted patients who may be downgraded from telemetry to nontelemetry status. Telemetry and cardiac beds are in high demand, and decreasing utilization facilitates obtaining the appropriate ward bed for ED patients.
3	Assess admitted patients for possible discharge. The patient's condition may have improved or results may indicate that admission is no longer required. The ED hospitalist communicates with the ED physician and wards teams, facilitates management, implements the discharge, and ensures adequate follow‐up.
4	Refer patients to an ED social worker as needed.
5	Facilitate referrals to other medical or surgical specialties if indicated.
6	Clarify the plan of care with the ED staff and facilitates ED communication with the ward team. Acts as a liaison and a resource for the ED physicians and nursing staff.
7	Supervise the triage duties of the medical admitting resident.
8	Provide medical consultation to ED physicians for patients not being admitted to the hospital or who are being admitted to other services (eg, surgery).

Methods

Setting

Admission Process

Responsibilities

Data Collection

Results

The key elements of the delivery of care by the ED hospitalist are summarized in Table 2.

Table 2.Elements of Care Delivered by the ED Hospitalist to ED Boarders
Elements	Boarders (n = 3555) [n (%)]	Patients Intervened on (n = 634) [n (%)]
Abbreviation: ED, emergency department. * Forty‐four patients improved and 2 left against medical advice.
Laboratory results acted upon	472 (13.2)	472 (74.5)
Medication follow‐up	506 (14.2)	506 (79.8)
Discharges from the ED*	46 (1.3)	46 (7.3)
Admissions avoided	6 (0.2)	6 (0.95)
Telemetry downgrades	61 (1.8)	61 (9.6)

Table 3 shows the discharge diagnoses made from the ED. Chest pain was the most common diagnosis, followed by syncope, pneumonia, and chronic obstructive pulmonary disease (COPD).

Table 3.Diagnoses of Patients Discharged from the ED by the ED Hospitalist
Diagnoses	Patients (n = 46) [n (%)]
Abbreviations: COPD, chronic obstructive pulmonary disease; ED, emergency department.
Chest pain	12 (26)
Syncope/dizziness	7 (15)
Pneumonia	4 (9)
COPD	4 (9)
Congestive heart failure	3 (7)
Gastroenteritis	3 (7)
Dermatitis/rash	3 (7)
Alcohol abuse	3 (7)
Abdominal pain	3 (7)
End stage renal disease	2 (4)
Vaginal bleeding	1 (2)
Fall	1 (2)
Asthma	1 (2)

Discussion

Conclusions

References

Weiss SJ, Derlet R, Arnhdal J, et al.Estimating the degree of emergency department overcrowding in academic medical centers: results of the National ED Overcrowding Study (NEDOCS).Acad Emerg Med.2004;11:38–50.
Bond K, Ospina MB, Blitz S, et al.Frequency, determinants, and impact of overcrowding in emergency departments in Canada: a national survey.Healthc Q.2007;10:32–40.
Steele R, Kiss A.EMDOC (emergency department overcrowding) internet‐based safety net research.Admin Emerg Med.2008;35:101–107.
United States General Accounting Office.Hospital Emergency Departments: Crowded Conditions Vary Among Hospitals and Communities. March 2003.Washington, DC:General Accounting Office;2003.
Derlet RW.Overcrowding in emergency department: increased demand and decreased capacity.Ann Emerg Med.2002;39:430–432.
Rathlev NK, Chessare J, Olshaker J, et al.Time series analysis of variables associated with daily mean emergency department length of stay.Ann Emerg Med.2007;49:265–271.
Forster A, Stiell I, Wells G, et al.Effect of hospital occupancy on emergency department length of stay and patient disposition.Ann Emerg Med.2003;10:127–133.
Bersnstein SL, Aronsky D, Duseja R, et al.The effect of emergency department crowding on clinically oriented outcomes.Acad Emerg Med.2009;16:1–10.
Rondeau KV, Francescutti LH.Emergency department overcrowding: the impact of resource scarcity on physician job satisfaction.J Health Manag.2005;50:327–340.
Pines JM, Iyer S, Disbot M, Hollander JE, Shofer FS, Datner EM.The effect of emergency department crowding on patient satisfaction for admitted patients.Acad Emerg Med.2008;15:825–831.
Vieth TL, Rhodes KV.The effect of crowding on access and quality in an academic ED.Am J Emerg Med.2006;24:787–794.
Nawar EW, Niska RW, Xu J.National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary. Advance Data from Vital and Health Statistics. No. 386.Hyattsville, MD:National Center for Health Statistics;2007.
American Hospital Association (AHA).Table 1: Historical trends in utilization, personnel, and finances: year 1946–2006.AHA Hospital Statistics.2008 ed.Chicago:Health Forum LLC;2008:3.
Trzeciak S, Rivers EP.Emergency department overcrowding in the US: an emerging threat to patient safety and public health.Emerg Med J.2003;20:402–405.
Derlet RW, Richards JR.Overcrowding in the nation's emergency departments: complex causes and disturbing effects.Ann Emerg Med.2000;35:63–68.
Cowan RM, Trzeciak S.Clinical review: emergency department overcrowding and the potential impact on the critically ill.Crit Care.2005;9:291–295.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO): Sentinel event alert 2002, Issue 26. Available at: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_26.htm. Accessed October2009.
Gordon JA, Billings J, Asplin BR, et al.Safety net research in emergency medicine: proceedings of the Academic Emergency Consensus Conference on “The Unraveling Safety Net.”Acad Emerg Med.2001;8:1024–1029.
Hwang U, Richardson L, Livote E, Harris B, Spencer N, Morrison SR.Emergency department crowding and decreased quality of pain care.Acad Emerg Med.2008;15:1248–1256.
Fee C, Weber EJ, Maak CA, Bacchetti P.Effect of emergency department crowding on time to antibiotics in patients admitted with community‐acquired pneumonia.Ann Emerg Med.2007;50:501–509.
Asplin BR, Magid DJ, Rhodes KV, et al.A conceptual model of emergency department crowding.Ann Emerg Med.2003;42:173–180.
Solberg LI, Asplin BR, Weinick RM, et al.Emergency department crowding: consensus development of potential measures.Ann Emerg Med.2003;42:824–834.
Cardin S, Afilalo M, Lang E, et al.Intervention to decrease emergency department crowding: does it have an effect on return visits and hospital readmission?Ann Emerg Med.2003;41:173–185.
Spaite DW, Bartholomeaux F, Guisto JM, et al.Rapid process design in a university‐based emergency department: decreasing waiting time intervals and improving patient satisfaction.Ann Emerg Med.2002;39:168–177.
Viccellio P.Emergency department crowding: an action plan.Acad Emerg Med.2001;18:185–187.
Howell EE, Bessman ES, Rubin HR.Hospitalists and an innovative emergency department admission process.J Gen Intern Med.2004;19:266–268.
Quinn JV, Mahadevan SV, Eggers G et al.Effects of implementing a rapid admission policy in the ED.Am J Emerg Med.2007;25:559–563.
Kelen GD, Scheulen PA, Hill PM.Effect of an emergency department managed acute care unit on ED overcrowding and emergency medical services diversion.Acad Emerg Med.2001;8:1085–1100.
Maloney ED, Bennett K, O'Riordan D, Silke B.Emergency department census of patients awaiting admission following reorganization of an admissions process.Emerg Med J.2006;23:363–367.
Greene J.Emergency department flow and the boarded patient: how to get admitted patients upstairs.Ann Emerg Med.2007;49:68–70.

References

Weiss SJ, Derlet R, Arnhdal J, et al.Estimating the degree of emergency department overcrowding in academic medical centers: results of the National ED Overcrowding Study (NEDOCS).Acad Emerg Med.2004;11:38–50.
Bond K, Ospina MB, Blitz S, et al.Frequency, determinants, and impact of overcrowding in emergency departments in Canada: a national survey.Healthc Q.2007;10:32–40.
Steele R, Kiss A.EMDOC (emergency department overcrowding) internet‐based safety net research.Admin Emerg Med.2008;35:101–107.
United States General Accounting Office.Hospital Emergency Departments: Crowded Conditions Vary Among Hospitals and Communities. March 2003.Washington, DC:General Accounting Office;2003.
Derlet RW.Overcrowding in emergency department: increased demand and decreased capacity.Ann Emerg Med.2002;39:430–432.
Rathlev NK, Chessare J, Olshaker J, et al.Time series analysis of variables associated with daily mean emergency department length of stay.Ann Emerg Med.2007;49:265–271.
Forster A, Stiell I, Wells G, et al.Effect of hospital occupancy on emergency department length of stay and patient disposition.Ann Emerg Med.2003;10:127–133.
Bersnstein SL, Aronsky D, Duseja R, et al.The effect of emergency department crowding on clinically oriented outcomes.Acad Emerg Med.2009;16:1–10.
Rondeau KV, Francescutti LH.Emergency department overcrowding: the impact of resource scarcity on physician job satisfaction.J Health Manag.2005;50:327–340.
Pines JM, Iyer S, Disbot M, Hollander JE, Shofer FS, Datner EM.The effect of emergency department crowding on patient satisfaction for admitted patients.Acad Emerg Med.2008;15:825–831.
Vieth TL, Rhodes KV.The effect of crowding on access and quality in an academic ED.Am J Emerg Med.2006;24:787–794.
Nawar EW, Niska RW, Xu J.National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary. Advance Data from Vital and Health Statistics. No. 386.Hyattsville, MD:National Center for Health Statistics;2007.
American Hospital Association (AHA).Table 1: Historical trends in utilization, personnel, and finances: year 1946–2006.AHA Hospital Statistics.2008 ed.Chicago:Health Forum LLC;2008:3.
Trzeciak S, Rivers EP.Emergency department overcrowding in the US: an emerging threat to patient safety and public health.Emerg Med J.2003;20:402–405.
Derlet RW, Richards JR.Overcrowding in the nation's emergency departments: complex causes and disturbing effects.Ann Emerg Med.2000;35:63–68.
Cowan RM, Trzeciak S.Clinical review: emergency department overcrowding and the potential impact on the critically ill.Crit Care.2005;9:291–295.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO): Sentinel event alert 2002, Issue 26. Available at: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_26.htm. Accessed October2009.
Gordon JA, Billings J, Asplin BR, et al.Safety net research in emergency medicine: proceedings of the Academic Emergency Consensus Conference on “The Unraveling Safety Net.”Acad Emerg Med.2001;8:1024–1029.
Hwang U, Richardson L, Livote E, Harris B, Spencer N, Morrison SR.Emergency department crowding and decreased quality of pain care.Acad Emerg Med.2008;15:1248–1256.
Fee C, Weber EJ, Maak CA, Bacchetti P.Effect of emergency department crowding on time to antibiotics in patients admitted with community‐acquired pneumonia.Ann Emerg Med.2007;50:501–509.
Asplin BR, Magid DJ, Rhodes KV, et al.A conceptual model of emergency department crowding.Ann Emerg Med.2003;42:173–180.
Solberg LI, Asplin BR, Weinick RM, et al.Emergency department crowding: consensus development of potential measures.Ann Emerg Med.2003;42:824–834.
Cardin S, Afilalo M, Lang E, et al.Intervention to decrease emergency department crowding: does it have an effect on return visits and hospital readmission?Ann Emerg Med.2003;41:173–185.
Spaite DW, Bartholomeaux F, Guisto JM, et al.Rapid process design in a university‐based emergency department: decreasing waiting time intervals and improving patient satisfaction.Ann Emerg Med.2002;39:168–177.
Viccellio P.Emergency department crowding: an action plan.Acad Emerg Med.2001;18:185–187.
Howell EE, Bessman ES, Rubin HR.Hospitalists and an innovative emergency department admission process.J Gen Intern Med.2004;19:266–268.
Quinn JV, Mahadevan SV, Eggers G et al.Effects of implementing a rapid admission policy in the ED.Am J Emerg Med.2007;25:559–563.
Kelen GD, Scheulen PA, Hill PM.Effect of an emergency department managed acute care unit on ED overcrowding and emergency medical services diversion.Acad Emerg Med.2001;8:1085–1100.
Maloney ED, Bennett K, O'Riordan D, Silke B.Emergency department census of patients awaiting admission following reorganization of an admissions process.Emerg Med J.2006;23:363–367.
Greene J.Emergency department flow and the boarded patient: how to get admitted patients upstairs.Ann Emerg Med.2007;49:68–70.

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A model of a hospitalist role in the care of admitted patients in the emergency department

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In the Literature: February 2010

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In the Literature: February 2010

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Jill Goldenberg, MD

Alan Briones, MD

Dennis Chang, MD

Brian Markoff, MD, FHM

Erin Rule, MD

Andrew Dunn, MD, FACP, FHM

Division Of General

In This Edition

Literature at a Glance

A guide to this month’s studies

Perioperative oxygen use and infection rate.

Effects of adverse events and healthcare costs

Impact of DVT on PE rates in trauma

VTE prevention and treatment in cancer patients

Effect of perioperative beta-blocker discontinuation

Endovascular vs. open AAA repair

OTC analgesics in patients with hepatic dysfunction

Cardiovascular disease and risk of hip fracture

High Perioperative Oxygen Fraction Does Not Improve Surgical-Site Infection Frequency after Abdominal Surgery

Clinical question: Does the use of 80% oxygen perioperatively in abdominal surgery decrease the frequency of surgical-site infection within 14 days without increasing the rate of pulmonary complications?

Background: Low oxygen tension in wounds can negatively impact immune response and healing. Increasing inspiratory oxygen fraction during the perioperative period translates into higher wound oxygen tension. However, the benefit of increased oxygen fraction therapy in abdominal surgery healing and complications is not clear, nor is the frequency of pulmonary complications.

Study design: Patient- and observer-blinded clinical trial.

Setting: Fourteen Danish hospitals from October 2006 to October 2008.

Synopsis: Patients were randomized to receive a fraction of inspired oxygen (FIO₂) of 0.80 or 0.30. The primary outcome—surgical-site infection in the superficial or deep wound or intra-abdominal cavity within 14 days of surgery—was defined using Centers for Disease Control and Prevention (CDC) criteria. Secondary outcomes included pulmonary complications within 14 days (pneumonia, atelectasis, or respiratory failure), 30-day mortality, duration of post-op course, ICU stay within 14 days post-op, and any abdominal operation within 14 days. The 1,386 patients were enrolled in the intention-to-treat analysis.

Infection occurred in 19.1% of patients given 0.80 FIO2 and in 20.1% of patients given 0.30 FIO2; odds ratio of 0.94 (95% CI 0.72 to 1.22; P=0.64). Numbers of pulmonary complications were not significantly different between the groups.

This trial included acute and nonacute laparotomies with followup for adverse outcomes. Study limitations included the inability to ensure that both groups received timely antibiotics and prevention for hypothermia. Of patients in the 30% FIO2 group, 7.3% required higher oxygen administration. Additionally, infection might have been underestimated in 11.3% of patients who were not followed up on between days 13 and 30.

Bottom line: High oxygen concentration administered during and after laparotomy did not lead to fewer surgical site infections, nor did it significantly increase the frequency of pulmonary complications or death.

Citation: Meyhoff CS, Wetterslev J, Jorgensen LN, et al. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial. JAMA. 2009;302(14):1543-1550.

Clinical Shorts

Therapy with corticosteroids in severe alcoholic hepatitis is not associated with higher infection risK

Prospective study demonstrating that patients with severe alcoholic hepatitis are at high risk for infection; patients with a limited response to steroids are more likely to develop infection than responders.

Citation: Louvet A, Wartel F, Castel H, et al. Infection in patients with severe alcoholic hepatitis treated with steroids: early response to therapy is the key factor. Gastroenterology. 2009;137(2):541-548.

Postoperative pain and analgesic consumption are predicted by multiple factors

A systematic review showed that preoperative pain, anxiety, age, and type of surgery predict postoperative pain, and psychological distress, age, and type of surgery predict postoperative analgesic consumption.

Citation: Ip HY, Abrishami A, Peng PW, Wong J, Chung F. Predictors of postoperative pain and analgesic consumption: a qualitative and systematic review. Anesthesiology. 2009;111(3):657-677.

Delirium in postoperative patients did not limit PCA use

This nested cohort study of 335 postoperative patients showed patients with delirium required higher doses of narcotics compared with nondelirious patients without reducing their pain scores.

Citation: Leung JM, Sands LP, Paul S, Joseph T, Kinjo S, Tsai T. Does postoperative delirium limit the use of patient-controlled analgesia in older surgical patients? Anesthesiology. 2009;111(3):625-631.

Patients starting dialysis are at approximately EIGHTfold higher risk FOR cardiac and noncardiac death

Administrative database of European patients starting dialysis found all-cause mortality increased from 12 per 1,000 person-years in the general population to 192 per 1,000 person-years in patients starting dialysis.

Citation: De Jager DJ, Grootendorst DC, Jager KJ, et al. Cardiovascular and noncardiovascular mortality among patients starting dialysis. JAMA. 2009;302(16):1782-1799.

Bronchoalveolar lavage (BAL) enzyme-linked immunospot (ELISpot) is effective for diagnosis of smear-negative pulmonary tuberculosis

Prospective multicenter trial found that BAL mononuclear cell ELISpot effectively differentiated active pulmonary tuberculosis (TB) from latent TB with a sensitivity of 91% and specificity of 80%.

Citation: Jafari C, Thijsen S, Sotgiu G, et al. Bronchoalveolar lavage enzyme-linked immunospot for a rapid diagnosis of tuberculosis: a Tuberculosis Network European Trialsgroup study. Am J Respir Crit Care Med. 2009;180(7):666-673.

Moxifloxacin is equivalent to Isoniazid in a Four-drug regimen for treatment of pulmonary tuberculosis

Randomized, blinded, placebo-controlled trial with smear positive TB treated with isoniazid or moxifloxacin in addition to rifampin, pyrazinamide, and ethambutol showed no difference in culture negativity or side effects at eight weeks.

Citation: Dorman SE, Johnson JL, Goldberg S, et al. Substitution of moxifloxacin for isoniazid during intensive phase treatment of pulmonary tuberculosis. Am J Respir Crit Care Med. 2009;180(3):273-280.

Intensity of rate control in persistent atrial fibrillation does not affect outcomes

In persistent atrial fibrillation, heart rate <80 versus heart rate ≥80 showed no difference in cardiovascular morbidity, mortality, or quality of life.

Citation: Groenveld HF, Crijns HJ, Rienstra M, Van den Berg MP, Van Veldhuisen DJ, Van Gelder IC. Does intensity of rate control influence outcome in persistent atrial fibrillation? Data of the RACE study. Am Heart J. 2009; 158(5):785-791.

N-acetylcysteine can improve nonacetaminophen acute liver failure

Patients with early-stage, non-acetaminophen-related acute liver failure have better transplant-free survival at three weeks and one year with N-acetylcysteine. There was no benefit in late-stage patients.

Citation: Lee WM, Hynan LS, Rossaro L, et al. Intravenous N-acetylcysteine improves transplant-free survival in early stage non-acetaminophen acute liver failure. Gastroenterology. 2009;137(3):856-864.

Eliminating Adverse Events and Redundant Tests Could Generate U.S. Healthcare Savings

Clinical question: Using available data, what is the estimated cost savings of eliminating adverse events and avoiding redundant tests?

Background: Reimbursement schemes are changing such that hospitals are reimbursed less for some adverse events. This financial disincentive is expected to spark interest in improved patient safety. The authors sought to model the cost savings generated by eliminating redundant testing and adverse events from literature-based estimates.

Study design: Development of conceptual model to identify common or costly adverse events, redundant tests, and simulated costs.

Setting: Literature review, expert opinion, data from safety organizations and epidemiologic studies, and patient data from the 2004 National Inpatient Data Sample.

Synopsis: The conceptual model identified 5.7 million adverse events in U.S. hospitals, of which 3 million were considered preventable. The most common events included hospital-acquired infections (82% preventable), adverse drug events (26%), falls (33%), and iatrogenic thromboembolic events (62%). The calculated cost savings totaled $16.6 billion (5.5% of total inpatient costs) for adverse events and $8.2 billion for the elimination of redundant tests. When looking at hospital subtypes, the greatest savings would come from major teaching hospitals.

This study is limited by its use of published and heterogeneous data spanning a 15-year period. The authors did not include events for which there was no epidemiologic or cost data. As hospital-care changes and technology is adopted, it is uncertain how this changes the costs, prevalence, and the preventable nature of these events. The model was not consistently able to identifying high- and low-risk patients. For instance, in some models, all patients were considered at risk for events.

Bottom line: Based on a conceptual model of 2004 hospitalized patients, eliminating preventable adverse events could have saved $16.6 billion, while eliminating redundant tests could have saved another $8 billion.

Citation: Jha AK, Chan DC, Ridgway AB, Franz C, Bates DW. Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Health Aff (Millwood). 2009;28(5):1475-1484.

Trauma Patients with Pulmonary Embolism Might Not Have DVT on Imaging of Lower Extremities

Clinical question: What is the relationship between acute DVT and pulmonary embolism (PE) in trauma patients?

Background: Major trauma is associated with an increased risk of acute DVT and PE. It is assumed that the majority of PEs arise from DVTs in the lower extremities. Definitive evidence demonstrating that PEs form in situ rather than embolize from leg veins could impact indications for inferior vena cava filters.

Study design: Retrospective chart review.

Setting: Academic Level 1 trauma center in Boston.

Synopsis: The medical records of 247 trauma patients with suspected PE who underwent CT angiography of the lungs and simultaneous CT venography of the pelvis and lower extremities from January 2004 to December 2007 were reviewed. High-risk patients also underwent weekly screening with duplex ultrasonagraphy of the legs.

PE was diagnosed in 46 patients (19%) and DVT in 18 patients (7%). Anticoagulant prophylaxis had been administered to 96% and 78% of the patients with PE and DVT, respectively. PE was diagnosed a median of 5.5 days after admission (range 0-40 days) and the majority (61%) were in segmental or subsegmental branches, rather than in the main or lobar pulmonary arteries (39%). Only seven of the 46 patients (15%) diagnosed with PE also had a pelvic or lower-extremity DVT on simultaneous imaging with CT venography.

Bottom line: Trauma patients with PE often do not have a DVT at the time of diagnosis, though it remains unknown whether this is due to in-situ pulmonary thrombosis or complete embolization from the lower extremities.

Citation: Velmahos GC, Spaniolas K, Tabbara M, et al. Pulmonary embolism and deep venous thrombosis in trauma: are they related? Arch Surg. 2009;144:928-932.

Cancer Guideline for VTE Prophylaxis for Inpatients and Long-Term Treatment With Low-Molecular-Weight Heparin for Acute VTE

Clinical question: On what aspects of VTE management in cancer patients are there consensus among the major guideline panels?

Background: VTE is a common and serious complication of cancer. Patients might be hypercoagulable due to prothrombotic mediators released or mediated by tumor cells, chemotherapeutic agents, debility, central venous catheters, hospitalizations, or surgical procedures. The optimal management often is problematic due to uncertain benefit and risk of bleeding.

Study design: Review of major guideline statements.

Synopsis: The authors examined five VTE guidelines of American and European cancer societies. Each guideline was reviewed to determine the main recommendations and whether there was consensus on key aspects of anticoagulant management.

The study authors concluded that consensus was reached on most key recommendations:

VTE prophylaxis in hospitalized medical patients. All five guidelines recommend the use of prophylaxis, though some guidelines recommend anticoagulant prophylaxis for all inpatients in the absence of contraindications and some recommend limiting prophylaxis to immobilized patients. All five recommend the use of either unfractionated heparin, low-molecular-weight heparin (LMWH), or fondaparinux.

VTE prevention in cancer patients undergoing surgery. All five guidelines recommend anticoagulant prophylaxis in the absence of contraindications and extending prophylaxis approximately four weeks after major surgery.

VTE prophylaxis in cancer patients with central venous catheters. Not recommended.

VTE prophylaxis in ambulatory cancer patients without central venous catheters. Recommended only for multiple myeloma patients receiving a thalidomide-lenalidomide regimen.

Long-term treatment of acute VTE in cancer patients. All five guidelines recommend initial treatment with LMWH for at least three to six months, followed by indefinite treatment with LMWH or a vitamin K antagonist.

Bottom line: Major guideline panels agree on key aspects of VTE management for cancer patients, including the use of prophylaxis for hospitalized medical and surgical patients and the use of long-term LMWH treatment for cancer patients with acute VTE.

Citation: Khorana AA, Streiff MB, Farge D, et al. Venous thromboembolism prophylaxis and treatment in cancer: a consensus statement of major guidelines panels and call to action. J Clin Oncol. 2009; 27(29):4919-4926.

Discontinuation of Beta Blockers Increases Risk of Postoperative Myocardial Infarction and Death

Clinical question: Does perioperative beta-blocker discontinuation affect postoperative myocardial infarction (MI) in low-risk patients undergoing joint arthroplasty?

Background: Recent trials show no benefit of perioperative beta blockers in reducing the incidence of perioperative myocardial infarctions (POMI) in low-risk patients. This retrospective study examined the impact of continuing or discontinuing beta blockers and the occurrence of POMI in patients undergoing elective joint arthroplasties.

Study design: Retrospective chart review.

Setting: Large academic center in Ottawa, Canada.

Synopsis: Medical records for 5,178 patients undergoing elective hip or knee arthroplasty from January 2002 to June 2006 were included in the review. The primary outcome was POMI, defined as an increased troponin level. Patients were divided into three groups: beta blocker prescribed on post-operative day (POD) zero and continued for one week or until discharge; beta blocker prescribed on POD zero and discontinued at any time in the first week; and no beta blocker on POD 0.

Beta blockers were continued in 992 patients and discontinued in 252 patients. The rate of POMI and death increased in the beta-blocker discontinuation group (odds ratio 2.0 [1.1-3.9] and 2.0 [1.1-3.9], respectively). This association persisted after adjustment for cardiac risk using a validated risk score.

The study was limited by the fact that the control group did not include patients who were on a beta blocker at home, thus potentially increasing the number of events in this group. The discontinuation beta blocker group had an increased baseline risk for POMI. The reason for discontinuing the beta blocker was not known, and cessation of beta blocker could have been due to an acute event.

Bottom line: This study adds support to the American College of Cardiology and American Heart Association (ACC/AHA) guidelines, which recommend continuation of beta-blocker therapy in the perioperative period.

Citation: Van Klei WA, Bryson GL, Yang H, Forster AJ. Effect of beta-blocker prescription on the incidence of postoperative myocardial infarction after hip and knee arthroplasty. Anesthesiology. 2009;111(4):717-724.

Lower Perioperative Mortality with Endovascular Vs. Open Abdominal Aortic Aneurysm Repair

Clinical question: How do perioperative and long-term morbidity and mortality compare in endovascular and open repair of abdominal aortic aneurysm (AAA)?

Background: Open AAA repair has relatively high perioperative mortality. Endovascular repair was developed as a less-invasive option and has been shown to reduce inpatient perioperative mortality, length of hospital stay, and ICU requirement. However, data suggest it leads to more frequent reinterventions and the same mortality rate as open repair at two years.

Study design: Randomized clinical trial.

Setting: Veterans Affairs medical centers.

Synopsis: The study randomized 881 veterans who planned to have elective AAA repair and were eligible for both endovascular and open repair. This is a planned, two-year interim report in a nine-year study.

Perioperative mortality was 0.5% in the endovascular repair group, compared with 3.0% in the open repair group. However, this difference in mortality was not statistically significant at two years. The endovascular repair group experienced shorter procedure and mechanical ventilation time, decreased hospital and ICU stay, and lower rate of blood transfusions.

Overall, there was no difference between the groups for major morbidity, procedure failure, need for secondary therapeutic intervention, quality of life, or erectile dysfunction. More data on long-term comparison of these two interventions will be available at the conclusion of this study.

Bottom line: Endovascular repair of AAA has lower perioperative mortality than open repair but did not lead to improved morbidity or mortality at two years.

Citation: Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs. open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009;302 (14):1535-1542.

OTC Analgesics Not Associated with Acute Decompensation in Cirrhotic Patients

Clinical question: Do over-the-counter (OTC) analgesics lead to acute hepatic decompensation among patients with cirrhosis?

Background: In theory, intake of acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) can worsen hepatic function and lead to complications among cirrhotic patients. The role of OTC analgesics in potentially triggering acute hepatic decompensation among cirrhotic patients has not been studied.

Study design: Prospective case-control study.

Setting: Two tertiary-care hospitals.

Synopsis: Cirrhotic patients hospitalized for acute liver decompensation were compared with compensated cirrhotic patients in the liver clinic (cirrhotic controls) and with randomly selected, noncirrhotic patients who were simultaneously hospitalized (noncirrhotic controls). Data collected through questionnaires included quantity and dose of OTC analgesics used and alcohol consumption in the past 30 days.

Thirty-five percent of the hospitalized cirrhotic patients, 52% of the cirrhotic controls, and 70% of the noncirrhotic controls used OTC analgesics. At doses lower than those recommended, acetaminophen is not associated with acute liver decompensation among cirrhotic patients, even with recent alcohol use. However, NSAIDs taken by the cirrhotic patients, when compared to control subjects, were in larger doses and used for a longer duration, suggesting NSAIDs may have contributed to the acute decompensation.

Study limitations include the nature of the study design, reliance on the patient’s recall of OTC analgesic use, and obtaining other possible causes of decompensation, such as herbal supplement intake or compliance with diuretics or dietary indiscretion.

Bottom line: Acetaminophen at doses lower than recommended is not associated with adverse complications in cirrhotic patients, but NSAIDs are possibly associated with acute decompensation.

Citation: Khalid SK, Lane J, Navarro V, Garcia-Tsao G. Use of over-the-counter analgesics is not associated with acute decompensation in patients with cirrhosis. Clin Gastroenterol Hepatol. 2009;7(9):994-999.

Cardiovascular Disease and Risk of Hip Fracture

Clinical question: Is the diagnosis of cardiovascular disease (CVD) associated with the risk of subsequent hip fracture?

Background: Osteoporosis and CVD are regarded as independent, age-related conditions. However, recent research suggests that the bone and vascular systems share common regulatory mechanisms. Stroke is a known risk factor for hip fractures, and bisphosphonates have been shown to prevent atherosclerosis and reduce total mortality rate.

Study design: Cohort study.

Setting: Swedish National Patient Registry.

Synopsis: The study identified 31,936 Swedish twins born from 1914 to 1944. This cohort was followed up to age 50, and time-dependent exposures using Cox-proportional hazard regression models were evaluated.

Times to hip fracture after CVD diagnosis were isolated. Crude absolute rate of hip fractures (per 1,000 person-years) was 12.6 after diagnosis of heart failure, 12.6 after a stroke, 6.6 after peripheral atherosclerosis, and 5.2 after ischemic heart disease (IHD), compared with 1.2 per 1,000 person-years without a CVD diagnosis. Multivariable-adjusted hazard ratio (HR) of hip fracture after heart failure was 4.40 (95% CI, 3.43-5.63); after a stroke was 5.09 (95% CI, 4.18-6.20); after peripheral atherosclerosis was 3.20 (CI, 2.28-4.50); and after an IHD event was 2.32 (CI, 1.91-2.84).

Identical twins even without heart failure and stroke also had an increased risk of hip fracture if their twin had been diagnosed with these diseases.

Bottom line: Cardiovascular disease is significantly associated with risk of subsequent hip fracture, and genetic factors probably play a role in the association.

Citation: Sennerby U, Melhus H, Gedeborg R, et al. Cardiovascular diseases and risk of hip fracture. JAMA. 2009;302(15):1666-1673. TH

PEDIATRIC HM Literature

By Mark Shen, MD

Variation in the Treatment of Henoch-Schönlein Purpura

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the degree of variation in the inpatient management of Henoch-Schönlein purpura (HSP)?

Background: HSP is the most common pediatric vasculitis, but there are no consensus recommendations or guidelines for treatment. The amount of variation in the pharmacologic management of this disease is unknown.

Study design: Retrospective database analysis.

Setting: Thirty-six children’s hospitals affiliated with the Child Health Corporation of America.

Synopsis: The Pediatric Health Information (PHIS) database was sampled for children younger than 18 years of age with an ICD-9-CM code of HSP and discharge from a hospital that submitted appropriate data from 2000 to 2007. Only index admissions were included, and children with coexisting rheumatic conditions were excluded, for a total of 1,988 subjects.

Logistic regression analysis was used to examine the effects of patient-level standardization on hospital-level rates of therapy and the degree to which variation across hospitals occurred beyond what would be expected after standardization.

Hospital-level variation in medication use was significant (P<0.001) for corticosteroids, opiates, and nonsteroidal anti-inflammatory drugs (NSAIDs), even after adjustment for severity and age at presentation.

Although variation in management is not surprising, the significant degree to which this occurred at the hospital level suggests that local institutional culture plays a dominant role in decision-making. The use of the PHIS database allows for analysis of a large population that would be otherwise difficult to study. However, significant numbers of HSP patients do not require hospitalization, and the study results might substantially over- or underestimate practice patterns. Collaborative efforts to better define optimal management of HSP are needed.

Bottom line: A significant degree of hospital-level variation exists in the inpatient management of HSP.

Citation: Weiss PF, Klink AJ, Hexem K, et al. Variation in inpatient therapy and diagnostic evaluation of children with henoch schönlein purpura. J Pediatr. 2009;155(6):812-818.e1.

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Author(s)

Brian Markoff, MD, FHM

Erin Rule, MD

Andrew Dunn, MD, FACP, FHM

Division Of General

In This Edition

Literature at a Glance

A guide to this month’s studies

Perioperative oxygen use and infection rate.

Effects of adverse events and healthcare costs

Impact of DVT on PE rates in trauma

VTE prevention and treatment in cancer patients

Effect of perioperative beta-blocker discontinuation

Endovascular vs. open AAA repair

OTC analgesics in patients with hepatic dysfunction

Cardiovascular disease and risk of hip fracture

High Perioperative Oxygen Fraction Does Not Improve Surgical-Site Infection Frequency after Abdominal Surgery

Study design: Patient- and observer-blinded clinical trial.

Setting: Fourteen Danish hospitals from October 2006 to October 2008.

Clinical Shorts

Therapy with corticosteroids in severe alcoholic hepatitis is not associated with higher infection risK

Postoperative pain and analgesic consumption are predicted by multiple factors

Citation: Ip HY, Abrishami A, Peng PW, Wong J, Chung F. Predictors of postoperative pain and analgesic consumption: a qualitative and systematic review. Anesthesiology. 2009;111(3):657-677.

Delirium in postoperative patients did not limit PCA use

This nested cohort study of 335 postoperative patients showed patients with delirium required higher doses of narcotics compared with nondelirious patients without reducing their pain scores.

Patients starting dialysis are at approximately EIGHTfold higher risk FOR cardiac and noncardiac death

Citation: De Jager DJ, Grootendorst DC, Jager KJ, et al. Cardiovascular and noncardiovascular mortality among patients starting dialysis. JAMA. 2009;302(16):1782-1799.

Bronchoalveolar lavage (BAL) enzyme-linked immunospot (ELISpot) is effective for diagnosis of smear-negative pulmonary tuberculosis

Prospective multicenter trial found that BAL mononuclear cell ELISpot effectively differentiated active pulmonary tuberculosis (TB) from latent TB with a sensitivity of 91% and specificity of 80%.

Moxifloxacin is equivalent to Isoniazid in a Four-drug regimen for treatment of pulmonary tuberculosis

Intensity of rate control in persistent atrial fibrillation does not affect outcomes

In persistent atrial fibrillation, heart rate <80 versus heart rate ≥80 showed no difference in cardiovascular morbidity, mortality, or quality of life.

N-acetylcysteine can improve nonacetaminophen acute liver failure

Eliminating Adverse Events and Redundant Tests Could Generate U.S. Healthcare Savings

Clinical question: Using available data, what is the estimated cost savings of eliminating adverse events and avoiding redundant tests?

Study design: Development of conceptual model to identify common or costly adverse events, redundant tests, and simulated costs.

Setting: Literature review, expert opinion, data from safety organizations and epidemiologic studies, and patient data from the 2004 National Inpatient Data Sample.

Citation: Jha AK, Chan DC, Ridgway AB, Franz C, Bates DW. Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Health Aff (Millwood). 2009;28(5):1475-1484.

Trauma Patients with Pulmonary Embolism Might Not Have DVT on Imaging of Lower Extremities

Clinical question: What is the relationship between acute DVT and pulmonary embolism (PE) in trauma patients?

Study design: Retrospective chart review.

Setting: Academic Level 1 trauma center in Boston.

Citation: Velmahos GC, Spaniolas K, Tabbara M, et al. Pulmonary embolism and deep venous thrombosis in trauma: are they related? Arch Surg. 2009;144:928-932.

Cancer Guideline for VTE Prophylaxis for Inpatients and Long-Term Treatment With Low-Molecular-Weight Heparin for Acute VTE

Clinical question: On what aspects of VTE management in cancer patients are there consensus among the major guideline panels?

Study design: Review of major guideline statements.

The study authors concluded that consensus was reached on most key recommendations:

VTE prophylaxis in hospitalized medical patients. All five guidelines recommend the use of prophylaxis, though some guidelines recommend anticoagulant prophylaxis for all inpatients in the absence of contraindications and some recommend limiting prophylaxis to immobilized patients. All five recommend the use of either unfractionated heparin, low-molecular-weight heparin (LMWH), or fondaparinux.

VTE prevention in cancer patients undergoing surgery. All five guidelines recommend anticoagulant prophylaxis in the absence of contraindications and extending prophylaxis approximately four weeks after major surgery.

VTE prophylaxis in cancer patients with central venous catheters. Not recommended.

VTE prophylaxis in ambulatory cancer patients without central venous catheters. Recommended only for multiple myeloma patients receiving a thalidomide-lenalidomide regimen.

Long-term treatment of acute VTE in cancer patients. All five guidelines recommend initial treatment with LMWH for at least three to six months, followed by indefinite treatment with LMWH or a vitamin K antagonist.

Discontinuation of Beta Blockers Increases Risk of Postoperative Myocardial Infarction and Death

Clinical question: Does perioperative beta-blocker discontinuation affect postoperative myocardial infarction (MI) in low-risk patients undergoing joint arthroplasty?

Study design: Retrospective chart review.

Setting: Large academic center in Ottawa, Canada.

Lower Perioperative Mortality with Endovascular Vs. Open Abdominal Aortic Aneurysm Repair

Clinical question: How do perioperative and long-term morbidity and mortality compare in endovascular and open repair of abdominal aortic aneurysm (AAA)?

Study design: Randomized clinical trial.

Setting: Veterans Affairs medical centers.

Bottom line: Endovascular repair of AAA has lower perioperative mortality than open repair but did not lead to improved morbidity or mortality at two years.

Citation: Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs. open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009;302 (14):1535-1542.

OTC Analgesics Not Associated with Acute Decompensation in Cirrhotic Patients

Clinical question: Do over-the-counter (OTC) analgesics lead to acute hepatic decompensation among patients with cirrhosis?

Study design: Prospective case-control study.

Setting: Two tertiary-care hospitals.

Bottom line: Acetaminophen at doses lower than recommended is not associated with adverse complications in cirrhotic patients, but NSAIDs are possibly associated with acute decompensation.

Cardiovascular Disease and Risk of Hip Fracture

Clinical question: Is the diagnosis of cardiovascular disease (CVD) associated with the risk of subsequent hip fracture?

Study design: Cohort study.

Setting: Swedish National Patient Registry.

Identical twins even without heart failure and stroke also had an increased risk of hip fracture if their twin had been diagnosed with these diseases.

Bottom line: Cardiovascular disease is significantly associated with risk of subsequent hip fracture, and genetic factors probably play a role in the association.

Citation: Sennerby U, Melhus H, Gedeborg R, et al. Cardiovascular diseases and risk of hip fracture. JAMA. 2009;302(15):1666-1673. TH

PEDIATRIC HM Literature

By Mark Shen, MD

Variation in the Treatment of Henoch-Schönlein Purpura

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the degree of variation in the inpatient management of Henoch-Schönlein purpura (HSP)?

Study design: Retrospective database analysis.

Setting: Thirty-six children’s hospitals affiliated with the Child Health Corporation of America.

Bottom line: A significant degree of hospital-level variation exists in the inpatient management of HSP.

Citation: Weiss PF, Klink AJ, Hexem K, et al. Variation in inpatient therapy and diagnostic evaluation of children with henoch schönlein purpura. J Pediatr. 2009;155(6):812-818.e1.

In This Edition

Literature at a Glance

A guide to this month’s studies

Perioperative oxygen use and infection rate.

Effects of adverse events and healthcare costs

Impact of DVT on PE rates in trauma

VTE prevention and treatment in cancer patients

Effect of perioperative beta-blocker discontinuation

Endovascular vs. open AAA repair

OTC analgesics in patients with hepatic dysfunction

Cardiovascular disease and risk of hip fracture

High Perioperative Oxygen Fraction Does Not Improve Surgical-Site Infection Frequency after Abdominal Surgery

Study design: Patient- and observer-blinded clinical trial.

Setting: Fourteen Danish hospitals from October 2006 to October 2008.

Clinical Shorts

Therapy with corticosteroids in severe alcoholic hepatitis is not associated with higher infection risK

Postoperative pain and analgesic consumption are predicted by multiple factors

Citation: Ip HY, Abrishami A, Peng PW, Wong J, Chung F. Predictors of postoperative pain and analgesic consumption: a qualitative and systematic review. Anesthesiology. 2009;111(3):657-677.

Delirium in postoperative patients did not limit PCA use

This nested cohort study of 335 postoperative patients showed patients with delirium required higher doses of narcotics compared with nondelirious patients without reducing their pain scores.

Patients starting dialysis are at approximately EIGHTfold higher risk FOR cardiac and noncardiac death

Citation: De Jager DJ, Grootendorst DC, Jager KJ, et al. Cardiovascular and noncardiovascular mortality among patients starting dialysis. JAMA. 2009;302(16):1782-1799.

Bronchoalveolar lavage (BAL) enzyme-linked immunospot (ELISpot) is effective for diagnosis of smear-negative pulmonary tuberculosis

Prospective multicenter trial found that BAL mononuclear cell ELISpot effectively differentiated active pulmonary tuberculosis (TB) from latent TB with a sensitivity of 91% and specificity of 80%.

Moxifloxacin is equivalent to Isoniazid in a Four-drug regimen for treatment of pulmonary tuberculosis

Intensity of rate control in persistent atrial fibrillation does not affect outcomes

In persistent atrial fibrillation, heart rate <80 versus heart rate ≥80 showed no difference in cardiovascular morbidity, mortality, or quality of life.

N-acetylcysteine can improve nonacetaminophen acute liver failure

Eliminating Adverse Events and Redundant Tests Could Generate U.S. Healthcare Savings

Clinical question: Using available data, what is the estimated cost savings of eliminating adverse events and avoiding redundant tests?

Study design: Development of conceptual model to identify common or costly adverse events, redundant tests, and simulated costs.

Setting: Literature review, expert opinion, data from safety organizations and epidemiologic studies, and patient data from the 2004 National Inpatient Data Sample.

Citation: Jha AK, Chan DC, Ridgway AB, Franz C, Bates DW. Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Health Aff (Millwood). 2009;28(5):1475-1484.

Trauma Patients with Pulmonary Embolism Might Not Have DVT on Imaging of Lower Extremities

Clinical question: What is the relationship between acute DVT and pulmonary embolism (PE) in trauma patients?

Study design: Retrospective chart review.

Setting: Academic Level 1 trauma center in Boston.

Citation: Velmahos GC, Spaniolas K, Tabbara M, et al. Pulmonary embolism and deep venous thrombosis in trauma: are they related? Arch Surg. 2009;144:928-932.

Cancer Guideline for VTE Prophylaxis for Inpatients and Long-Term Treatment With Low-Molecular-Weight Heparin for Acute VTE

Clinical question: On what aspects of VTE management in cancer patients are there consensus among the major guideline panels?

Study design: Review of major guideline statements.

The study authors concluded that consensus was reached on most key recommendations:

VTE prophylaxis in hospitalized medical patients. All five guidelines recommend the use of prophylaxis, though some guidelines recommend anticoagulant prophylaxis for all inpatients in the absence of contraindications and some recommend limiting prophylaxis to immobilized patients. All five recommend the use of either unfractionated heparin, low-molecular-weight heparin (LMWH), or fondaparinux.

VTE prevention in cancer patients undergoing surgery. All five guidelines recommend anticoagulant prophylaxis in the absence of contraindications and extending prophylaxis approximately four weeks after major surgery.

VTE prophylaxis in cancer patients with central venous catheters. Not recommended.

VTE prophylaxis in ambulatory cancer patients without central venous catheters. Recommended only for multiple myeloma patients receiving a thalidomide-lenalidomide regimen.

Long-term treatment of acute VTE in cancer patients. All five guidelines recommend initial treatment with LMWH for at least three to six months, followed by indefinite treatment with LMWH or a vitamin K antagonist.

Discontinuation of Beta Blockers Increases Risk of Postoperative Myocardial Infarction and Death

Clinical question: Does perioperative beta-blocker discontinuation affect postoperative myocardial infarction (MI) in low-risk patients undergoing joint arthroplasty?

Study design: Retrospective chart review.

Setting: Large academic center in Ottawa, Canada.

Lower Perioperative Mortality with Endovascular Vs. Open Abdominal Aortic Aneurysm Repair

Clinical question: How do perioperative and long-term morbidity and mortality compare in endovascular and open repair of abdominal aortic aneurysm (AAA)?

Study design: Randomized clinical trial.

Setting: Veterans Affairs medical centers.

Bottom line: Endovascular repair of AAA has lower perioperative mortality than open repair but did not lead to improved morbidity or mortality at two years.

Citation: Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs. open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009;302 (14):1535-1542.

OTC Analgesics Not Associated with Acute Decompensation in Cirrhotic Patients

Clinical question: Do over-the-counter (OTC) analgesics lead to acute hepatic decompensation among patients with cirrhosis?

Study design: Prospective case-control study.

Setting: Two tertiary-care hospitals.

Bottom line: Acetaminophen at doses lower than recommended is not associated with adverse complications in cirrhotic patients, but NSAIDs are possibly associated with acute decompensation.

Cardiovascular Disease and Risk of Hip Fracture

Clinical question: Is the diagnosis of cardiovascular disease (CVD) associated with the risk of subsequent hip fracture?

Study design: Cohort study.

Setting: Swedish National Patient Registry.

Identical twins even without heart failure and stroke also had an increased risk of hip fracture if their twin had been diagnosed with these diseases.

Bottom line: Cardiovascular disease is significantly associated with risk of subsequent hip fracture, and genetic factors probably play a role in the association.

Citation: Sennerby U, Melhus H, Gedeborg R, et al. Cardiovascular diseases and risk of hip fracture. JAMA. 2009;302(15):1666-1673. TH

PEDIATRIC HM Literature

By Mark Shen, MD

Variation in the Treatment of Henoch-Schönlein Purpura

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the degree of variation in the inpatient management of Henoch-Schönlein purpura (HSP)?

Study design: Retrospective database analysis.

Setting: Thirty-six children’s hospitals affiliated with the Child Health Corporation of America.

Bottom line: A significant degree of hospital-level variation exists in the inpatient management of HSP.

Citation: Weiss PF, Klink AJ, Hexem K, et al. Variation in inpatient therapy and diagnostic evaluation of children with henoch schönlein purpura. J Pediatr. 2009;155(6):812-818.e1.

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The Hospitalist - 2010(02)

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In the Literature: February 2010

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Conclusions

In the Literature: February 2010

In This Edition

Literature at a Glance

High Perioperative Oxygen Fraction Does Not Improve Surgical-Site Infection Frequency after Abdominal Surgery

Clinical Shorts

Therapy with corticosteroids in severe alcoholic hepatitis is not associated with higher infection risK

Postoperative pain and analgesic consumption are predicted by multiple factors

Delirium in postoperative patients did not limit PCA use

Patients starting dialysis are at approximately EIGHTfold higher risk FOR cardiac and noncardiac death

Bronchoalveolar lavage (BAL) enzyme-linked immunospot (ELISpot) is effective for diagnosis of smear-negative pulmonary tuberculosis

Moxifloxacin is equivalent to Isoniazid in a Four-drug regimen for treatment of pulmonary tuberculosis

Intensity of rate control in persistent atrial fibrillation does not affect outcomes

N-acetylcysteine can improve nonacetaminophen acute liver failure

Eliminating Adverse Events and Redundant Tests Could Generate U.S. Healthcare Savings

Trauma Patients with Pulmonary Embolism Might Not Have DVT on Imaging of Lower Extremities

Cancer Guideline for VTE Prophylaxis for Inpatients and Long-Term Treatment With Low-Molecular-Weight Heparin for Acute VTE

Discontinuation of Beta Blockers Increases Risk of Postoperative Myocardial Infarction and Death

Lower Perioperative Mortality with Endovascular Vs. Open Abdominal Aortic Aneurysm Repair

OTC Analgesics Not Associated with Acute Decompensation in Cirrhotic Patients

Cardiovascular Disease and Risk of Hip Fracture

PEDIATRIC HM Literature

By Mark Shen, MD

Variation in the Treatment of Henoch-Schönlein Purpura

In This Edition

Literature at a Glance

High Perioperative Oxygen Fraction Does Not Improve Surgical-Site Infection Frequency after Abdominal Surgery

Clinical Shorts

Therapy with corticosteroids in severe alcoholic hepatitis is not associated with higher infection risK

Postoperative pain and analgesic consumption are predicted by multiple factors

Delirium in postoperative patients did not limit PCA use

Patients starting dialysis are at approximately EIGHTfold higher risk FOR cardiac and noncardiac death

Bronchoalveolar lavage (BAL) enzyme-linked immunospot (ELISpot) is effective for diagnosis of smear-negative pulmonary tuberculosis

Moxifloxacin is equivalent to Isoniazid in a Four-drug regimen for treatment of pulmonary tuberculosis

Intensity of rate control in persistent atrial fibrillation does not affect outcomes

N-acetylcysteine can improve nonacetaminophen acute liver failure

Eliminating Adverse Events and Redundant Tests Could Generate U.S. Healthcare Savings

Trauma Patients with Pulmonary Embolism Might Not Have DVT on Imaging of Lower Extremities

Cancer Guideline for VTE Prophylaxis for Inpatients and Long-Term Treatment With Low-Molecular-Weight Heparin for Acute VTE

Discontinuation of Beta Blockers Increases Risk of Postoperative Myocardial Infarction and Death

Lower Perioperative Mortality with Endovascular Vs. Open Abdominal Aortic Aneurysm Repair

OTC Analgesics Not Associated with Acute Decompensation in Cirrhotic Patients

Cardiovascular Disease and Risk of Hip Fracture

PEDIATRIC HM Literature

By Mark Shen, MD

Variation in the Treatment of Henoch-Schönlein Purpura

In This Edition

Literature at a Glance

High Perioperative Oxygen Fraction Does Not Improve Surgical-Site Infection Frequency after Abdominal Surgery

Clinical Shorts

Therapy with corticosteroids in severe alcoholic hepatitis is not associated with higher infection risK

Postoperative pain and analgesic consumption are predicted by multiple factors

Delirium in postoperative patients did not limit PCA use

Patients starting dialysis are at approximately EIGHTfold higher risk FOR cardiac and noncardiac death

Bronchoalveolar lavage (BAL) enzyme-linked immunospot (ELISpot) is effective for diagnosis of smear-negative pulmonary tuberculosis