The Hospitalist

Surgical site infections among colorectal surgery patients in Hawaii decreased by approximately 62% after hospital participation in a national safety program.

The Agency for Healthcare Research and Quality (AHRQ) designed the program to reduce surgical site infections (SSIs), which are harmful to patients and expensive for the health care system, wrote Della M. Lin, MD, of Johns Hopkins University, Baltimore, and the department of surgery at the University of Hawaii, Honolulu, and her colleagues.

In a study published in the Journal of the American College of Surgeons, the researchers reviewed data from a statewide intervention conducted at 15 hospitals in Hawaii from January 2013 to June 2015. The intervention included the Comprehensive Unit-based Safety Program and individualized interventions for each hospital to help reduce SSIs. The primary outcome was the number of colorectal SSIs. A secondary outcome of hospital safety culture was assessed using the AHRQ Hospital Survey on Patient Safety Culture. The participating hospitals ranged from a 25-bed critical-access hospital to a 533-bed academic medical center.

Overall, the colorectal SSI rate decreased significantly (from 12% to 5%) from the first quarter of 2013 to the second quarter of 2015, with a significant linear decrease over the study period. The rate of superficial SSIs decreased significantly, falling from 8% to 3%. However, the rate of deep SSIs was not significantly different before and after the intervention program (2% vs. 0%), nor was the organ space SSI rate (3% vs. 2%). The standardized infection ratio decreased from 1.83 to 0.92.

The culture of safety in the hospitals improved, but more modestly, in 10 of 12 areas that were measured over the study period.

The overall perception of patient safety improved from 49% to 53%, teamwork across different units improved from 49% to 54%, management and support for patient safety improved from 53% to 60%, and nonpunitive response to errors improved from 36% to 40%.

In addition, communication and openness improved from 50% to 53%, frequency of reported events improved from 51% to 60%, feedback and communication about errors improved from 52% to 59%, organizational learning and continuous improvement increased from 59% to 70%, teamwork within units improved from 68% to 75%, and expectations and actions by supervisors and managers to promote safety improved from 58% to 64%. Staff responses reflect agreement on improvement in the areas of issues of communication, feedback mechanisms, and teamwork, but the change in culture was not on the order of the SSI change.

The most common interventions to reduce SSIs were the use of reliable chlorhexidine wash or wipe before surgery/surgical prep; appropriate use of antibiotics with respect to selection, dosage, and timing; standardized postsurgical debriefing; and differentiating clean/dirty/clean in the use of anastomosis trays and closing trays.

One bundle component, the implementation of the standard operating room debrief, was found to be of particular value to participants. The investigators noted that debrief questions such as “What went well?” and “What needs to be improved?” had “encouraged new processes of thinking beyond first-order problem solving. The debrief challenge embraced by the teams emphasized that ‘bundles’ did not consist of only technical interventions [e.g. clean/dirty trays, chlorhexidine gluconate wipes in preop], but embedded culture interventions—new processes for problem solving.”

The study findings were limited by several factors, such as the use of public SSI data that were not audited for accuracy and the inability to monitor the reliability of the implementation of the various interventions, the researchers said. In addition, “In this current study, there was a change in SSI rates and a change in safety culture, but correlations between the two were negligible or weak for most domains of safety culture,” they noted. The question of sustainability of the SSI improvement without the concomitant staff support of culture change was not addressed by the investigators.

However, the results suggest that a 62% decrease is robust, and that for some hospitals with a low volume of colorectal cases, “teams could attend to iteratively reduce surgical harm beyond SSI,” the researchers wrote.

The study was supported in part by the AHRQ. Dr. Lin disclosed serving as a board member and as a paid independent contractor to the Hawaii Medical Service Association. Her coauthors had no financial conflicts to disclose.

SOURCE: Lin DM et al. J Am Coll Surg. 2018 May 18. doi: 10.1016/j.jamcollsurg.2018.04.031.

Surgical site infections among colorectal surgery patients in Hawaii decreased by approximately 62% after hospital participation in a national safety program.

The Agency for Healthcare Research and Quality (AHRQ) designed the program to reduce surgical site infections (SSIs), which are harmful to patients and expensive for the health care system, wrote Della M. Lin, MD, of Johns Hopkins University, Baltimore, and the department of surgery at the University of Hawaii, Honolulu, and her colleagues.

In a study published in the Journal of the American College of Surgeons, the researchers reviewed data from a statewide intervention conducted at 15 hospitals in Hawaii from January 2013 to June 2015. The intervention included the Comprehensive Unit-based Safety Program and individualized interventions for each hospital to help reduce SSIs. The primary outcome was the number of colorectal SSIs. A secondary outcome of hospital safety culture was assessed using the AHRQ Hospital Survey on Patient Safety Culture. The participating hospitals ranged from a 25-bed critical-access hospital to a 533-bed academic medical center.

Overall, the colorectal SSI rate decreased significantly (from 12% to 5%) from the first quarter of 2013 to the second quarter of 2015, with a significant linear decrease over the study period. The rate of superficial SSIs decreased significantly, falling from 8% to 3%. However, the rate of deep SSIs was not significantly different before and after the intervention program (2% vs. 0%), nor was the organ space SSI rate (3% vs. 2%). The standardized infection ratio decreased from 1.83 to 0.92.

The culture of safety in the hospitals improved, but more modestly, in 10 of 12 areas that were measured over the study period.

The overall perception of patient safety improved from 49% to 53%, teamwork across different units improved from 49% to 54%, management and support for patient safety improved from 53% to 60%, and nonpunitive response to errors improved from 36% to 40%.

In addition, communication and openness improved from 50% to 53%, frequency of reported events improved from 51% to 60%, feedback and communication about errors improved from 52% to 59%, organizational learning and continuous improvement increased from 59% to 70%, teamwork within units improved from 68% to 75%, and expectations and actions by supervisors and managers to promote safety improved from 58% to 64%. Staff responses reflect agreement on improvement in the areas of issues of communication, feedback mechanisms, and teamwork, but the change in culture was not on the order of the SSI change.

The most common interventions to reduce SSIs were the use of reliable chlorhexidine wash or wipe before surgery/surgical prep; appropriate use of antibiotics with respect to selection, dosage, and timing; standardized postsurgical debriefing; and differentiating clean/dirty/clean in the use of anastomosis trays and closing trays.

One bundle component, the implementation of the standard operating room debrief, was found to be of particular value to participants. The investigators noted that debrief questions such as “What went well?” and “What needs to be improved?” had “encouraged new processes of thinking beyond first-order problem solving. The debrief challenge embraced by the teams emphasized that ‘bundles’ did not consist of only technical interventions [e.g. clean/dirty trays, chlorhexidine gluconate wipes in preop], but embedded culture interventions—new processes for problem solving.”

The study findings were limited by several factors, such as the use of public SSI data that were not audited for accuracy and the inability to monitor the reliability of the implementation of the various interventions, the researchers said. In addition, “In this current study, there was a change in SSI rates and a change in safety culture, but correlations between the two were negligible or weak for most domains of safety culture,” they noted. The question of sustainability of the SSI improvement without the concomitant staff support of culture change was not addressed by the investigators.

However, the results suggest that a 62% decrease is robust, and that for some hospitals with a low volume of colorectal cases, “teams could attend to iteratively reduce surgical harm beyond SSI,” the researchers wrote.

The study was supported in part by the AHRQ. Dr. Lin disclosed serving as a board member and as a paid independent contractor to the Hawaii Medical Service Association. Her coauthors had no financial conflicts to disclose.

SOURCE: Lin DM et al. J Am Coll Surg. 2018 May 18. doi: 10.1016/j.jamcollsurg.2018.04.031.

Surgical site infections among colorectal surgery patients in Hawaii decreased by approximately 62% after hospital participation in a national safety program.

The Agency for Healthcare Research and Quality (AHRQ) designed the program to reduce surgical site infections (SSIs), which are harmful to patients and expensive for the health care system, wrote Della M. Lin, MD, of Johns Hopkins University, Baltimore, and the department of surgery at the University of Hawaii, Honolulu, and her colleagues.

In a study published in the Journal of the American College of Surgeons, the researchers reviewed data from a statewide intervention conducted at 15 hospitals in Hawaii from January 2013 to June 2015. The intervention included the Comprehensive Unit-based Safety Program and individualized interventions for each hospital to help reduce SSIs. The primary outcome was the number of colorectal SSIs. A secondary outcome of hospital safety culture was assessed using the AHRQ Hospital Survey on Patient Safety Culture. The participating hospitals ranged from a 25-bed critical-access hospital to a 533-bed academic medical center.

Overall, the colorectal SSI rate decreased significantly (from 12% to 5%) from the first quarter of 2013 to the second quarter of 2015, with a significant linear decrease over the study period. The rate of superficial SSIs decreased significantly, falling from 8% to 3%. However, the rate of deep SSIs was not significantly different before and after the intervention program (2% vs. 0%), nor was the organ space SSI rate (3% vs. 2%). The standardized infection ratio decreased from 1.83 to 0.92.

The culture of safety in the hospitals improved, but more modestly, in 10 of 12 areas that were measured over the study period.

The overall perception of patient safety improved from 49% to 53%, teamwork across different units improved from 49% to 54%, management and support for patient safety improved from 53% to 60%, and nonpunitive response to errors improved from 36% to 40%.

In addition, communication and openness improved from 50% to 53%, frequency of reported events improved from 51% to 60%, feedback and communication about errors improved from 52% to 59%, organizational learning and continuous improvement increased from 59% to 70%, teamwork within units improved from 68% to 75%, and expectations and actions by supervisors and managers to promote safety improved from 58% to 64%. Staff responses reflect agreement on improvement in the areas of issues of communication, feedback mechanisms, and teamwork, but the change in culture was not on the order of the SSI change.

The most common interventions to reduce SSIs were the use of reliable chlorhexidine wash or wipe before surgery/surgical prep; appropriate use of antibiotics with respect to selection, dosage, and timing; standardized postsurgical debriefing; and differentiating clean/dirty/clean in the use of anastomosis trays and closing trays.

One bundle component, the implementation of the standard operating room debrief, was found to be of particular value to participants. The investigators noted that debrief questions such as “What went well?” and “What needs to be improved?” had “encouraged new processes of thinking beyond first-order problem solving. The debrief challenge embraced by the teams emphasized that ‘bundles’ did not consist of only technical interventions [e.g. clean/dirty trays, chlorhexidine gluconate wipes in preop], but embedded culture interventions—new processes for problem solving.”

The study findings were limited by several factors, such as the use of public SSI data that were not audited for accuracy and the inability to monitor the reliability of the implementation of the various interventions, the researchers said. In addition, “In this current study, there was a change in SSI rates and a change in safety culture, but correlations between the two were negligible or weak for most domains of safety culture,” they noted. The question of sustainability of the SSI improvement without the concomitant staff support of culture change was not addressed by the investigators.

However, the results suggest that a 62% decrease is robust, and that for some hospitals with a low volume of colorectal cases, “teams could attend to iteratively reduce surgical harm beyond SSI,” the researchers wrote.

The study was supported in part by the AHRQ. Dr. Lin disclosed serving as a board member and as a paid independent contractor to the Hawaii Medical Service Association. Her coauthors had no financial conflicts to disclose.

SOURCE: Lin DM et al. J Am Coll Surg. 2018 May 18. doi: 10.1016/j.jamcollsurg.2018.04.031.

Background: Literature regarding patient satisfaction often focuses on nonspecific recommendations to improve patient-centered communication. There is lack of guidance on concrete advice for clinicians, particularly with regard to how a provider’s responses to different patient requests are received.

Study design: Cross-sectional study.

Setting: An outpatient family medicine clinic.

Synopsis: Patient requests from 1,141 patients visiting the University of California, Davis, Family Medicine Clinic were sampled. The study examined clinician’s approval or denial of patients’ requests for referrals, pain medications, other new medicines, laboratory testing, radiology testing, or other testing and the patients’ reported satisfaction of the clinician.

Clinician denial of particular requests was associated with decreased patient satisfaction. Specifically, a 19.75% drop for referral, 10.72% drop for pain medication, 20.36% drop for other new medications, and 9.19% drop for laboratory test. This study did not examine other potential reasons for decreased satisfaction.

Bottom line: Clinicians can better understand how to communicate in a patient-centered manner by understanding that not all patient requests are perceived as equal.

Citation: Jerant A et al. Association of clinical denial of patient requests with patient satisfaction. JAMA Intern Med. 2018 Jan 1;178(1):85-91.

Dr. Shaffie is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Background: Literature regarding patient satisfaction often focuses on nonspecific recommendations to improve patient-centered communication. There is lack of guidance on concrete advice for clinicians, particularly with regard to how a provider’s responses to different patient requests are received.

Study design: Cross-sectional study.

Setting: An outpatient family medicine clinic.

Synopsis: Patient requests from 1,141 patients visiting the University of California, Davis, Family Medicine Clinic were sampled. The study examined clinician’s approval or denial of patients’ requests for referrals, pain medications, other new medicines, laboratory testing, radiology testing, or other testing and the patients’ reported satisfaction of the clinician.

Clinician denial of particular requests was associated with decreased patient satisfaction. Specifically, a 19.75% drop for referral, 10.72% drop for pain medication, 20.36% drop for other new medications, and 9.19% drop for laboratory test. This study did not examine other potential reasons for decreased satisfaction.

Bottom line: Clinicians can better understand how to communicate in a patient-centered manner by understanding that not all patient requests are perceived as equal.

Citation: Jerant A et al. Association of clinical denial of patient requests with patient satisfaction. JAMA Intern Med. 2018 Jan 1;178(1):85-91.

Dr. Shaffie is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Background: Literature regarding patient satisfaction often focuses on nonspecific recommendations to improve patient-centered communication. There is lack of guidance on concrete advice for clinicians, particularly with regard to how a provider’s responses to different patient requests are received.

Study design: Cross-sectional study.

Setting: An outpatient family medicine clinic.

Synopsis: Patient requests from 1,141 patients visiting the University of California, Davis, Family Medicine Clinic were sampled. The study examined clinician’s approval or denial of patients’ requests for referrals, pain medications, other new medicines, laboratory testing, radiology testing, or other testing and the patients’ reported satisfaction of the clinician.

Clinician denial of particular requests was associated with decreased patient satisfaction. Specifically, a 19.75% drop for referral, 10.72% drop for pain medication, 20.36% drop for other new medications, and 9.19% drop for laboratory test. This study did not examine other potential reasons for decreased satisfaction.

Bottom line: Clinicians can better understand how to communicate in a patient-centered manner by understanding that not all patient requests are perceived as equal.

Citation: Jerant A et al. Association of clinical denial of patient requests with patient satisfaction. JAMA Intern Med. 2018 Jan 1;178(1):85-91.

Dr. Shaffie is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

A study suggests that delirium in older adults is a postoperative variable that should be included in surgical quality registries, outcome measures, and assessment of hospital performance.

Lead author Julia R. Berian, MD, of the University of Chicago Medical Center and her colleagues wrote, “Postoperative delirium has been associated with mortality, morbidity, prolonged length of stay, and increased costs of care. Furthermore, postoperative delirium may be associated with long-term cognitive and functional decline. However, postoperative delirium has not been incorporated as an outcome measure into major surgical quality registries. Approximately one-third of hospitalized delirium is believed to be preventable, making postoperative delirium an ideal target for surgical quality improvement efforts,” Dr. Berian and her colleagues reported in the Annals of Surgery.

Study authors noted that screening for postoperative delirium in older adults is likely in the best interests of patients. However, they also mentioned that such screening may identify cases of postoperative delirium that were previously unrecognized, resulting in higher rates. In addition, the inclusion of only ACS NSQIP hospitals and the voluntary participation may mean a biased dataset. No one delirium prevention intervention was implemented across the hospitals and so the study doesn’t indicate why some hospitals are more successful than are others. Chart-based identification of patients who have delirium needs further study to assess validity.

Authors concluded that one solution may be to “standardize and consistently employ delirium screening in high-risk patients across hospitals, as has been advocated by a coalition of interdisciplinary experts in geriatric care.”

This project is funded in part by a grant from the John A. Hartford Foundation. The authors declare no conflict of interests.

SOURCE: Berlan JR et al. Ann Surg. 2017 July 24. doi: 10.1097/SLA.0000000000002436

A study suggests that delirium in older adults is a postoperative variable that should be included in surgical quality registries, outcome measures, and assessment of hospital performance.

Lead author Julia R. Berian, MD, of the University of Chicago Medical Center and her colleagues wrote, “Postoperative delirium has been associated with mortality, morbidity, prolonged length of stay, and increased costs of care. Furthermore, postoperative delirium may be associated with long-term cognitive and functional decline. However, postoperative delirium has not been incorporated as an outcome measure into major surgical quality registries. Approximately one-third of hospitalized delirium is believed to be preventable, making postoperative delirium an ideal target for surgical quality improvement efforts,” Dr. Berian and her colleagues reported in the Annals of Surgery.

Study authors noted that screening for postoperative delirium in older adults is likely in the best interests of patients. However, they also mentioned that such screening may identify cases of postoperative delirium that were previously unrecognized, resulting in higher rates. In addition, the inclusion of only ACS NSQIP hospitals and the voluntary participation may mean a biased dataset. No one delirium prevention intervention was implemented across the hospitals and so the study doesn’t indicate why some hospitals are more successful than are others. Chart-based identification of patients who have delirium needs further study to assess validity.

Authors concluded that one solution may be to “standardize and consistently employ delirium screening in high-risk patients across hospitals, as has been advocated by a coalition of interdisciplinary experts in geriatric care.”

This project is funded in part by a grant from the John A. Hartford Foundation. The authors declare no conflict of interests.

SOURCE: Berlan JR et al. Ann Surg. 2017 July 24. doi: 10.1097/SLA.0000000000002436

A study suggests that delirium in older adults is a postoperative variable that should be included in surgical quality registries, outcome measures, and assessment of hospital performance.

Lead author Julia R. Berian, MD, of the University of Chicago Medical Center and her colleagues wrote, “Postoperative delirium has been associated with mortality, morbidity, prolonged length of stay, and increased costs of care. Furthermore, postoperative delirium may be associated with long-term cognitive and functional decline. However, postoperative delirium has not been incorporated as an outcome measure into major surgical quality registries. Approximately one-third of hospitalized delirium is believed to be preventable, making postoperative delirium an ideal target for surgical quality improvement efforts,” Dr. Berian and her colleagues reported in the Annals of Surgery.

Study authors noted that screening for postoperative delirium in older adults is likely in the best interests of patients. However, they also mentioned that such screening may identify cases of postoperative delirium that were previously unrecognized, resulting in higher rates. In addition, the inclusion of only ACS NSQIP hospitals and the voluntary participation may mean a biased dataset. No one delirium prevention intervention was implemented across the hospitals and so the study doesn’t indicate why some hospitals are more successful than are others. Chart-based identification of patients who have delirium needs further study to assess validity.

Authors concluded that one solution may be to “standardize and consistently employ delirium screening in high-risk patients across hospitals, as has been advocated by a coalition of interdisciplinary experts in geriatric care.”

This project is funded in part by a grant from the John A. Hartford Foundation. The authors declare no conflict of interests.

SOURCE: Berlan JR et al. Ann Surg. 2017 July 24. doi: 10.1097/SLA.0000000000002436

MADRID – The anticipated global emergence of multidrug resistant Candida auris is now an established fact, but a case study presented at the European Society of Clinical Microbiology and Infectious Diseases annual congress demonstrates just how devastating an outbreak can be to a medical facility and its surgical ICU patients.

The dangerous invasive infection is spreading through Asia, Europe, and the Americas, causing potentially fatal candidemias and proving devilishly difficult to eradicate in health care facilities once it becomes established.

Several multidrug resistant (MDR) C. auris outbreaks were reported at the ECCMID meeting. Most troubling: a continuing outbreak in a hospital in Valencia, Spain, in which 17 patients have died – a 41% fatality rate among those who developed a fulminant C. auris candidemia, Javier Pemán, MD, said at the meeting. The strain appeared to be a clonal population not previously identified in published reports.

“C. auris is hard to remove from the hospital environment,” once it becomes established, said Dr. Pemán of La Fe University and Polytechnic Hospital, Valencia. “When an outbreak lasts for months, as ours has, it is difficult, but necessary, to maintain control measures, identify it early in the lab, and isolate and treat patients early with combination therapy.”

Michele G. Sullivan/MDedge News

Michele G. Sullivan/MDedge News

• A 71-year-old man who underwent cardiovascular surgery and received a prosthetic heart valve developed endocarditis. He is alive and at last report, on week 26 of AMB+ECN, flucytosine, and isavuconazole.

• A 68-year-old man who underwent abdominal surgery for hepatocellular carcinoma developed spondylodiscitis and is alive after 24 weeks of AMB+ECN.

• A 48-year old female multiple trauma patient developed spondylodiscitis and is alive after 48 weeks of treatment with AMB+ECN.


A multivariate analysis determined that antibacterial treatment increased the risk of candidemia by almost 30 times (odds ratio, 29.59). The next highest risk was neutropenia (OR, 20.7) and then simply being a hospital and SICU patient. Dr. Pemán’s poster said, “In the 16 months before the index case, La Fe recorded 89 candidemias, none caused by C. auris. In the 16 months afterward, there were 154 candidemias, largely C. auris. Before April 2016, C. parapsilosis accounted for the largest portion of candidemias (46%) followed by C. albicans. After the index case, C. auris accounted for 42%, followed by C. parapsilosis (21%) and C. albicans (18%).”

Because of its fluconazole resistance, patients with C. auris received a combined antifungal treatment of liposomal amphotericin B 3 mg/kg per day for 5 days, and a standard dose of echinocandin for 3 weeks. Many C. auris strains are echinocandin resistant, Dr. Pemán noted. This particular strain was clonal, different from any other previously reported, he said.

“Our results confirm those previously reported by other authors, that C. auris is grouped in different independent clusters according to its geographical origin. Although all Spanish isolates were genotypically distinct from Indian, Omani, U.K., and Venezuelan isolates, there seems to be some connection with South African isolates.”

Hospital Le Fe continues to struggle with C. auris. As of March, 335 patients have tested positive for the pathogen, and 80 have developed candidemias.

“We feel we may be approaching the end of this episode, but it’s really not possible to be sure,” he said.

Dr. Pemán had no relevant financial disclosures.

[email protected]

SOURCE: ECCMID 2018 Peman et al. S0067.

MADRID – The anticipated global emergence of multidrug resistant Candida auris is now an established fact, but a case study presented at the European Society of Clinical Microbiology and Infectious Diseases annual congress demonstrates just how devastating an outbreak can be to a medical facility and its surgical ICU patients.

The dangerous invasive infection is spreading through Asia, Europe, and the Americas, causing potentially fatal candidemias and proving devilishly difficult to eradicate in health care facilities once it becomes established.

Several multidrug resistant (MDR) C. auris outbreaks were reported at the ECCMID meeting. Most troubling: a continuing outbreak in a hospital in Valencia, Spain, in which 17 patients have died – a 41% fatality rate among those who developed a fulminant C. auris candidemia, Javier Pemán, MD, said at the meeting. The strain appeared to be a clonal population not previously identified in published reports.

“C. auris is hard to remove from the hospital environment,” once it becomes established, said Dr. Pemán of La Fe University and Polytechnic Hospital, Valencia. “When an outbreak lasts for months, as ours has, it is difficult, but necessary, to maintain control measures, identify it early in the lab, and isolate and treat patients early with combination therapy.”

Michele G. Sullivan/MDedge News

Michele G. Sullivan/MDedge News

• A 71-year-old man who underwent cardiovascular surgery and received a prosthetic heart valve developed endocarditis. He is alive and at last report, on week 26 of AMB+ECN, flucytosine, and isavuconazole.

• A 68-year-old man who underwent abdominal surgery for hepatocellular carcinoma developed spondylodiscitis and is alive after 24 weeks of AMB+ECN.

• A 48-year old female multiple trauma patient developed spondylodiscitis and is alive after 48 weeks of treatment with AMB+ECN.


A multivariate analysis determined that antibacterial treatment increased the risk of candidemia by almost 30 times (odds ratio, 29.59). The next highest risk was neutropenia (OR, 20.7) and then simply being a hospital and SICU patient. Dr. Pemán’s poster said, “In the 16 months before the index case, La Fe recorded 89 candidemias, none caused by C. auris. In the 16 months afterward, there were 154 candidemias, largely C. auris. Before April 2016, C. parapsilosis accounted for the largest portion of candidemias (46%) followed by C. albicans. After the index case, C. auris accounted for 42%, followed by C. parapsilosis (21%) and C. albicans (18%).”

Because of its fluconazole resistance, patients with C. auris received a combined antifungal treatment of liposomal amphotericin B 3 mg/kg per day for 5 days, and a standard dose of echinocandin for 3 weeks. Many C. auris strains are echinocandin resistant, Dr. Pemán noted. This particular strain was clonal, different from any other previously reported, he said.

“Our results confirm those previously reported by other authors, that C. auris is grouped in different independent clusters according to its geographical origin. Although all Spanish isolates were genotypically distinct from Indian, Omani, U.K., and Venezuelan isolates, there seems to be some connection with South African isolates.”

Hospital Le Fe continues to struggle with C. auris. As of March, 335 patients have tested positive for the pathogen, and 80 have developed candidemias.

“We feel we may be approaching the end of this episode, but it’s really not possible to be sure,” he said.

Dr. Pemán had no relevant financial disclosures.

[email protected]

SOURCE: ECCMID 2018 Peman et al. S0067.

MADRID – The anticipated global emergence of multidrug resistant Candida auris is now an established fact, but a case study presented at the European Society of Clinical Microbiology and Infectious Diseases annual congress demonstrates just how devastating an outbreak can be to a medical facility and its surgical ICU patients.

The dangerous invasive infection is spreading through Asia, Europe, and the Americas, causing potentially fatal candidemias and proving devilishly difficult to eradicate in health care facilities once it becomes established.

Several multidrug resistant (MDR) C. auris outbreaks were reported at the ECCMID meeting. Most troubling: a continuing outbreak in a hospital in Valencia, Spain, in which 17 patients have died – a 41% fatality rate among those who developed a fulminant C. auris candidemia, Javier Pemán, MD, said at the meeting. The strain appeared to be a clonal population not previously identified in published reports.

“C. auris is hard to remove from the hospital environment,” once it becomes established, said Dr. Pemán of La Fe University and Polytechnic Hospital, Valencia. “When an outbreak lasts for months, as ours has, it is difficult, but necessary, to maintain control measures, identify it early in the lab, and isolate and treat patients early with combination therapy.”

Michele G. Sullivan/MDedge News

Michele G. Sullivan/MDedge News

• A 71-year-old man who underwent cardiovascular surgery and received a prosthetic heart valve developed endocarditis. He is alive and at last report, on week 26 of AMB+ECN, flucytosine, and isavuconazole.

• A 68-year-old man who underwent abdominal surgery for hepatocellular carcinoma developed spondylodiscitis and is alive after 24 weeks of AMB+ECN.

• A 48-year old female multiple trauma patient developed spondylodiscitis and is alive after 48 weeks of treatment with AMB+ECN.


A multivariate analysis determined that antibacterial treatment increased the risk of candidemia by almost 30 times (odds ratio, 29.59). The next highest risk was neutropenia (OR, 20.7) and then simply being a hospital and SICU patient. Dr. Pemán’s poster said, “In the 16 months before the index case, La Fe recorded 89 candidemias, none caused by C. auris. In the 16 months afterward, there were 154 candidemias, largely C. auris. Before April 2016, C. parapsilosis accounted for the largest portion of candidemias (46%) followed by C. albicans. After the index case, C. auris accounted for 42%, followed by C. parapsilosis (21%) and C. albicans (18%).”

Because of its fluconazole resistance, patients with C. auris received a combined antifungal treatment of liposomal amphotericin B 3 mg/kg per day for 5 days, and a standard dose of echinocandin for 3 weeks. Many C. auris strains are echinocandin resistant, Dr. Pemán noted. This particular strain was clonal, different from any other previously reported, he said.

“Our results confirm those previously reported by other authors, that C. auris is grouped in different independent clusters according to its geographical origin. Although all Spanish isolates were genotypically distinct from Indian, Omani, U.K., and Venezuelan isolates, there seems to be some connection with South African isolates.”

Hospital Le Fe continues to struggle with C. auris. As of March, 335 patients have tested positive for the pathogen, and 80 have developed candidemias.

“We feel we may be approaching the end of this episode, but it’s really not possible to be sure,” he said.

Dr. Pemán had no relevant financial disclosures.

[email protected]

SOURCE: ECCMID 2018 Peman et al. S0067.

Background: Because thrombi typically form in the left atrial appendage, LAAC may be an alternative to chronic oral anticoagulation in nonvalvular atrial fibrillation. Two prior randomized controlled trials compared outcomes in patients treated with LAAC with outcomes with warfarin. PROTECT AF trial showed noninferiority of LAAC to warfarin but noted high procedural complication rates. Subsequently, PREVAIL trial failed to demonstrate noninferiority, although complication rates were low overall and similar in both groups. However, longer-term follow-up data were lacking.

Study design: Patient-level meta-analysis of two prospective randomized trials.

Setting: Fifty-nine centers in the United States and Europe (PROTECT AF trial) and 41 centers in the United States (PREVAIL trial).

Synopsis: Meta-analysis of 5-year follow-up data from 1,114 adult patients with atrial fibrillation, most with CHADS2 score greater than or equal to 2 , randomized to receive LAAC or warfarin showed similar frequency of the composite endpoint of stroke, systemic embolism, or cardiovascular/unexplained death (hazard ratio, 0.820; P = .27). Subgroup analysis showed no significant difference in outcomes by patient subset, including CHADS2 or HAS-BLED scores. While the rate of ischemic stroke was similar between groups, the rates of hemorrhagic and disabling/fatal stroke were significantly lower with LAAC (HR, 0.20; P = .0022 and HR, 0.45; P = .034, respectively). All-cause and cardiovascular mortality also were significantly lower with LAAC (HR, 0.73; P = .035 and HR, 0.59; P = .027, respectively), likely because of lower incidence of hemorrhagic stroke.

These data cannot be generalized to patients who have an absolute contraindication to anticoagulation, as these patients were excluded. Further, these trials were conducted before widespread clinical use of novel oral anticoagulants, and LAAC has not yet been compared with these anticoagulants.

Bottom line: In patients with nonvalvular atrial fibrillation, LAAC with the Watchman device provides all-stroke prevention comparable with that of warfarin, and is associated with significantly lower rates of hemorrhagic stroke, disabling or fatal stroke, and mortality.

Citation: Reddy VY et al. 5-year outcomes after left atrial appendage closure: From the PREVAIL and PROTECT AF trials. J Am Coll Cardiol. 2017;70(24):2964-75.

Dr. Indovina is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Background: Because thrombi typically form in the left atrial appendage, LAAC may be an alternative to chronic oral anticoagulation in nonvalvular atrial fibrillation. Two prior randomized controlled trials compared outcomes in patients treated with LAAC with outcomes with warfarin. PROTECT AF trial showed noninferiority of LAAC to warfarin but noted high procedural complication rates. Subsequently, PREVAIL trial failed to demonstrate noninferiority, although complication rates were low overall and similar in both groups. However, longer-term follow-up data were lacking.

Study design: Patient-level meta-analysis of two prospective randomized trials.

Setting: Fifty-nine centers in the United States and Europe (PROTECT AF trial) and 41 centers in the United States (PREVAIL trial).

Synopsis: Meta-analysis of 5-year follow-up data from 1,114 adult patients with atrial fibrillation, most with CHADS2 score greater than or equal to 2 , randomized to receive LAAC or warfarin showed similar frequency of the composite endpoint of stroke, systemic embolism, or cardiovascular/unexplained death (hazard ratio, 0.820; P = .27). Subgroup analysis showed no significant difference in outcomes by patient subset, including CHADS2 or HAS-BLED scores. While the rate of ischemic stroke was similar between groups, the rates of hemorrhagic and disabling/fatal stroke were significantly lower with LAAC (HR, 0.20; P = .0022 and HR, 0.45; P = .034, respectively). All-cause and cardiovascular mortality also were significantly lower with LAAC (HR, 0.73; P = .035 and HR, 0.59; P = .027, respectively), likely because of lower incidence of hemorrhagic stroke.

These data cannot be generalized to patients who have an absolute contraindication to anticoagulation, as these patients were excluded. Further, these trials were conducted before widespread clinical use of novel oral anticoagulants, and LAAC has not yet been compared with these anticoagulants.

Bottom line: In patients with nonvalvular atrial fibrillation, LAAC with the Watchman device provides all-stroke prevention comparable with that of warfarin, and is associated with significantly lower rates of hemorrhagic stroke, disabling or fatal stroke, and mortality.

Citation: Reddy VY et al. 5-year outcomes after left atrial appendage closure: From the PREVAIL and PROTECT AF trials. J Am Coll Cardiol. 2017;70(24):2964-75.

Dr. Indovina is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Background: Because thrombi typically form in the left atrial appendage, LAAC may be an alternative to chronic oral anticoagulation in nonvalvular atrial fibrillation. Two prior randomized controlled trials compared outcomes in patients treated with LAAC with outcomes with warfarin. PROTECT AF trial showed noninferiority of LAAC to warfarin but noted high procedural complication rates. Subsequently, PREVAIL trial failed to demonstrate noninferiority, although complication rates were low overall and similar in both groups. However, longer-term follow-up data were lacking.

Study design: Patient-level meta-analysis of two prospective randomized trials.

Setting: Fifty-nine centers in the United States and Europe (PROTECT AF trial) and 41 centers in the United States (PREVAIL trial).

Synopsis: Meta-analysis of 5-year follow-up data from 1,114 adult patients with atrial fibrillation, most with CHADS2 score greater than or equal to 2 , randomized to receive LAAC or warfarin showed similar frequency of the composite endpoint of stroke, systemic embolism, or cardiovascular/unexplained death (hazard ratio, 0.820; P = .27). Subgroup analysis showed no significant difference in outcomes by patient subset, including CHADS2 or HAS-BLED scores. While the rate of ischemic stroke was similar between groups, the rates of hemorrhagic and disabling/fatal stroke were significantly lower with LAAC (HR, 0.20; P = .0022 and HR, 0.45; P = .034, respectively). All-cause and cardiovascular mortality also were significantly lower with LAAC (HR, 0.73; P = .035 and HR, 0.59; P = .027, respectively), likely because of lower incidence of hemorrhagic stroke.

These data cannot be generalized to patients who have an absolute contraindication to anticoagulation, as these patients were excluded. Further, these trials were conducted before widespread clinical use of novel oral anticoagulants, and LAAC has not yet been compared with these anticoagulants.

Bottom line: In patients with nonvalvular atrial fibrillation, LAAC with the Watchman device provides all-stroke prevention comparable with that of warfarin, and is associated with significantly lower rates of hemorrhagic stroke, disabling or fatal stroke, and mortality.

Citation: Reddy VY et al. 5-year outcomes after left atrial appendage closure: From the PREVAIL and PROTECT AF trials. J Am Coll Cardiol. 2017;70(24):2964-75.

Dr. Indovina is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Clinical question: Does pharmacist-led medication reconciliation in the community after hospital discharge reduce health care utilization, readmission rates, ED visits, primary care visits, or primary care workload?

Background: Accurate medication reconciliation is essential to ensure safe transitions of care after hospital discharge. Studies have shown that harm from prescribed or omitted medications is higher after discharge and pharmacist-led medication reconciliation on discharge has been shown to improve clinical outcomes. The effect of medication reconciliation after discharge performed by primary care and community-based pharmacist is unclear.

Study design: A meta-analysis.

Setting: This meta-analysis included five randomized, controlled trials, six cohort studies, two pre- and postintervention studies performed in the United Kingdom and United States as well as one quality improvement project performed in Canada.

Synopsis: The studies included demonstrated that community-based pharmacists were more effective at identifying and resolving discrepancies, compared with usual care, but the clinical relevance was unclear. There was no evidence that this reduced readmission rates. Because of the the heterogeneity of the settings, methods, and data reporting in the included trials, no firm conclusion could be drawn regarding the impact on either ED visits and primary care burden, and no consistent evidence of benefit was found. The benefit in clinical outcomes seen in prior studies may be related to other interventions, including patient education, medication review, and improved communication with primary care physicians. This study aimed to specifically isolate the impact of postdischarge, pharmacist-led medication reconciliation, and further research is still needed to understand the clinical relevance of medication discrepancies and which pharmacist-led interventions are most important.

Bottom line: Community-based pharmacists can identify and resolve discrepancies while performing medication reconciliation after hospital discharge, but there is no conclusive benefit in clinical outcomes, such as readmission rates, health care utilization, and primary care visits.

Citation: McNab D et al. Systematic review and meta-analysis of the effectiveness of pharmacist-led medication reconciliation in the community after hospital discharge. BMJ Qual Saf. 2017 Dec 16. pii: bmjqs-2017-007087. doi: 10.1136/bmjqs-2017-007087.

Dr. Rao is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Clinical question: Does pharmacist-led medication reconciliation in the community after hospital discharge reduce health care utilization, readmission rates, ED visits, primary care visits, or primary care workload?

Background: Accurate medication reconciliation is essential to ensure safe transitions of care after hospital discharge. Studies have shown that harm from prescribed or omitted medications is higher after discharge and pharmacist-led medication reconciliation on discharge has been shown to improve clinical outcomes. The effect of medication reconciliation after discharge performed by primary care and community-based pharmacist is unclear.

Study design: A meta-analysis.

Setting: This meta-analysis included five randomized, controlled trials, six cohort studies, two pre- and postintervention studies performed in the United Kingdom and United States as well as one quality improvement project performed in Canada.

Synopsis: The studies included demonstrated that community-based pharmacists were more effective at identifying and resolving discrepancies, compared with usual care, but the clinical relevance was unclear. There was no evidence that this reduced readmission rates. Because of the the heterogeneity of the settings, methods, and data reporting in the included trials, no firm conclusion could be drawn regarding the impact on either ED visits and primary care burden, and no consistent evidence of benefit was found. The benefit in clinical outcomes seen in prior studies may be related to other interventions, including patient education, medication review, and improved communication with primary care physicians. This study aimed to specifically isolate the impact of postdischarge, pharmacist-led medication reconciliation, and further research is still needed to understand the clinical relevance of medication discrepancies and which pharmacist-led interventions are most important.

Bottom line: Community-based pharmacists can identify and resolve discrepancies while performing medication reconciliation after hospital discharge, but there is no conclusive benefit in clinical outcomes, such as readmission rates, health care utilization, and primary care visits.

Citation: McNab D et al. Systematic review and meta-analysis of the effectiveness of pharmacist-led medication reconciliation in the community after hospital discharge. BMJ Qual Saf. 2017 Dec 16. pii: bmjqs-2017-007087. doi: 10.1136/bmjqs-2017-007087.

Dr. Rao is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Clinical question: Does pharmacist-led medication reconciliation in the community after hospital discharge reduce health care utilization, readmission rates, ED visits, primary care visits, or primary care workload?

Background: Accurate medication reconciliation is essential to ensure safe transitions of care after hospital discharge. Studies have shown that harm from prescribed or omitted medications is higher after discharge and pharmacist-led medication reconciliation on discharge has been shown to improve clinical outcomes. The effect of medication reconciliation after discharge performed by primary care and community-based pharmacist is unclear.

Study design: A meta-analysis.

Setting: This meta-analysis included five randomized, controlled trials, six cohort studies, two pre- and postintervention studies performed in the United Kingdom and United States as well as one quality improvement project performed in Canada.

Synopsis: The studies included demonstrated that community-based pharmacists were more effective at identifying and resolving discrepancies, compared with usual care, but the clinical relevance was unclear. There was no evidence that this reduced readmission rates. Because of the the heterogeneity of the settings, methods, and data reporting in the included trials, no firm conclusion could be drawn regarding the impact on either ED visits and primary care burden, and no consistent evidence of benefit was found. The benefit in clinical outcomes seen in prior studies may be related to other interventions, including patient education, medication review, and improved communication with primary care physicians. This study aimed to specifically isolate the impact of postdischarge, pharmacist-led medication reconciliation, and further research is still needed to understand the clinical relevance of medication discrepancies and which pharmacist-led interventions are most important.

Bottom line: Community-based pharmacists can identify and resolve discrepancies while performing medication reconciliation after hospital discharge, but there is no conclusive benefit in clinical outcomes, such as readmission rates, health care utilization, and primary care visits.

Citation: McNab D et al. Systematic review and meta-analysis of the effectiveness of pharmacist-led medication reconciliation in the community after hospital discharge. BMJ Qual Saf. 2017 Dec 16. pii: bmjqs-2017-007087. doi: 10.1136/bmjqs-2017-007087.

Dr. Rao is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

SAN DIEGO – About one in four intubated or mechanically ventilated patients with gram-negative pneumonia die during hospitalization, results from a large retrospective cohort study found.

In a poster abstract presented at an international conference of the American Thoracic Society, researchers led by Thomas P. Lodise Jr., PharmD, noted that ventilator-associated pneumonia is one of the most common hospital-acquired infections in intensive care units and affected an estimated 9%-27% of all intubated patients. “While data are readily available surrounding mortality associated with VAP, scant data are available on outcomes associated with any type of pneumonia requiring intubation and mechanical ventilation (MV) caused by gram-negative organisms,” they wrote.

XiXinXing/ThinkStock

In an effort to describe mortality rates and associated risk factors for intubated and MV patients diagnosed with gram-negative pneumonia, Dr. Lodise of the Albany (N.Y.) College of Pharmacy and Health Sciences and his associates conducted a retrospective cohort study of data from the Healthcare Cost and Utilization Project (HCUP) National Readmission Database (NRD). HCUP is the largest source of hospital care data in the United States, accounting for 49.3% of the total U.S. resident population and 49.1% of U.S. hospitalizations. The researchers included patients at least 18 years of age who were hospitalized with a primary or secondary diagnosis of gram-negative pneumonia between Feb. 1, 2013, and Nov. 30, 2013. They excluded index hospitalizations with a primary or secondary diagnosis of viral pneumonia, fungal pneumonia, atypical organisms, gram-positive bacterial pneumonia, or pneumonia occurring secondary to an infectious disease. They examined mortality rates descriptively and modeled them via adjusted multivariate logistic regression to evaluate the impact of baseline characteristics and comorbidities on risk of mortality. All analyses incorporated sample weights to increase generalizability and allow for extrapolation to the entire U.S. population.

A total of 32,683 patients met all study criteria. Of these, 2,323 (7.1%) had a primary diagnosis and 30,360 (92.9%) had a secondary diagnosis for gram-negative pneumonia. Their mean age was 64 years, and 61.1% were male. In all, 7,928 patients (24.3%) died during hospitalization. Multivariate analysis revealed that patients with concomitant sepsis had the highest risk of mortality (odds ratio, 2.60), followed by patients aged 65 years and older (OR, 1.88) and those with any prior hospitalization within 30 days (OR, 1.34). Comorbidities upon admission with highest risk of mortality included cancer (OR, 2.45), liver disease (OR, 1.91), AIDS/HIV (OR, 1.59), renal disease (OR, 1.33), and congestive heart failure (OR, 1.15). Diabetes was found to have a decreased risk of mortality, with an OR of 0.80. “However, a majority of patients with diabetes had no complications; thus, these patients may be representative of a less severe patient population,” Dr. Lodise and his associates noted in the poster.

They acknowledged certain limitations of the study, including the potential for coding errors. They also pointed out the HCUP NRD does not contain treatment-specific information, drugs administered or treatment patterns during hospitalization, the number of days patients spent in the ICU, or the number of days on ventilation, “which can influence outcomes in pneumonia patients.” In addition, the study did not attempt to determine cause of death. “Death may have been due to combinations of factors separate from pneumonia,” they wrote.

Bayer Healthcare Pharmaceuticals funded the study. Dr. Lodise reported having no financial disclosures.

[email protected]

SOURCE: Lodise T. et al. ATS 2018, Poster 272.

SAN DIEGO – About one in four intubated or mechanically ventilated patients with gram-negative pneumonia die during hospitalization, results from a large retrospective cohort study found.

In a poster abstract presented at an international conference of the American Thoracic Society, researchers led by Thomas P. Lodise Jr., PharmD, noted that ventilator-associated pneumonia is one of the most common hospital-acquired infections in intensive care units and affected an estimated 9%-27% of all intubated patients. “While data are readily available surrounding mortality associated with VAP, scant data are available on outcomes associated with any type of pneumonia requiring intubation and mechanical ventilation (MV) caused by gram-negative organisms,” they wrote.

XiXinXing/ThinkStock

In an effort to describe mortality rates and associated risk factors for intubated and MV patients diagnosed with gram-negative pneumonia, Dr. Lodise of the Albany (N.Y.) College of Pharmacy and Health Sciences and his associates conducted a retrospective cohort study of data from the Healthcare Cost and Utilization Project (HCUP) National Readmission Database (NRD). HCUP is the largest source of hospital care data in the United States, accounting for 49.3% of the total U.S. resident population and 49.1% of U.S. hospitalizations. The researchers included patients at least 18 years of age who were hospitalized with a primary or secondary diagnosis of gram-negative pneumonia between Feb. 1, 2013, and Nov. 30, 2013. They excluded index hospitalizations with a primary or secondary diagnosis of viral pneumonia, fungal pneumonia, atypical organisms, gram-positive bacterial pneumonia, or pneumonia occurring secondary to an infectious disease. They examined mortality rates descriptively and modeled them via adjusted multivariate logistic regression to evaluate the impact of baseline characteristics and comorbidities on risk of mortality. All analyses incorporated sample weights to increase generalizability and allow for extrapolation to the entire U.S. population.

A total of 32,683 patients met all study criteria. Of these, 2,323 (7.1%) had a primary diagnosis and 30,360 (92.9%) had a secondary diagnosis for gram-negative pneumonia. Their mean age was 64 years, and 61.1% were male. In all, 7,928 patients (24.3%) died during hospitalization. Multivariate analysis revealed that patients with concomitant sepsis had the highest risk of mortality (odds ratio, 2.60), followed by patients aged 65 years and older (OR, 1.88) and those with any prior hospitalization within 30 days (OR, 1.34). Comorbidities upon admission with highest risk of mortality included cancer (OR, 2.45), liver disease (OR, 1.91), AIDS/HIV (OR, 1.59), renal disease (OR, 1.33), and congestive heart failure (OR, 1.15). Diabetes was found to have a decreased risk of mortality, with an OR of 0.80. “However, a majority of patients with diabetes had no complications; thus, these patients may be representative of a less severe patient population,” Dr. Lodise and his associates noted in the poster.

They acknowledged certain limitations of the study, including the potential for coding errors. They also pointed out the HCUP NRD does not contain treatment-specific information, drugs administered or treatment patterns during hospitalization, the number of days patients spent in the ICU, or the number of days on ventilation, “which can influence outcomes in pneumonia patients.” In addition, the study did not attempt to determine cause of death. “Death may have been due to combinations of factors separate from pneumonia,” they wrote.

Bayer Healthcare Pharmaceuticals funded the study. Dr. Lodise reported having no financial disclosures.

[email protected]

SOURCE: Lodise T. et al. ATS 2018, Poster 272.

SAN DIEGO – About one in four intubated or mechanically ventilated patients with gram-negative pneumonia die during hospitalization, results from a large retrospective cohort study found.

In a poster abstract presented at an international conference of the American Thoracic Society, researchers led by Thomas P. Lodise Jr., PharmD, noted that ventilator-associated pneumonia is one of the most common hospital-acquired infections in intensive care units and affected an estimated 9%-27% of all intubated patients. “While data are readily available surrounding mortality associated with VAP, scant data are available on outcomes associated with any type of pneumonia requiring intubation and mechanical ventilation (MV) caused by gram-negative organisms,” they wrote.

XiXinXing/ThinkStock

In an effort to describe mortality rates and associated risk factors for intubated and MV patients diagnosed with gram-negative pneumonia, Dr. Lodise of the Albany (N.Y.) College of Pharmacy and Health Sciences and his associates conducted a retrospective cohort study of data from the Healthcare Cost and Utilization Project (HCUP) National Readmission Database (NRD). HCUP is the largest source of hospital care data in the United States, accounting for 49.3% of the total U.S. resident population and 49.1% of U.S. hospitalizations. The researchers included patients at least 18 years of age who were hospitalized with a primary or secondary diagnosis of gram-negative pneumonia between Feb. 1, 2013, and Nov. 30, 2013. They excluded index hospitalizations with a primary or secondary diagnosis of viral pneumonia, fungal pneumonia, atypical organisms, gram-positive bacterial pneumonia, or pneumonia occurring secondary to an infectious disease. They examined mortality rates descriptively and modeled them via adjusted multivariate logistic regression to evaluate the impact of baseline characteristics and comorbidities on risk of mortality. All analyses incorporated sample weights to increase generalizability and allow for extrapolation to the entire U.S. population.

A total of 32,683 patients met all study criteria. Of these, 2,323 (7.1%) had a primary diagnosis and 30,360 (92.9%) had a secondary diagnosis for gram-negative pneumonia. Their mean age was 64 years, and 61.1% were male. In all, 7,928 patients (24.3%) died during hospitalization. Multivariate analysis revealed that patients with concomitant sepsis had the highest risk of mortality (odds ratio, 2.60), followed by patients aged 65 years and older (OR, 1.88) and those with any prior hospitalization within 30 days (OR, 1.34). Comorbidities upon admission with highest risk of mortality included cancer (OR, 2.45), liver disease (OR, 1.91), AIDS/HIV (OR, 1.59), renal disease (OR, 1.33), and congestive heart failure (OR, 1.15). Diabetes was found to have a decreased risk of mortality, with an OR of 0.80. “However, a majority of patients with diabetes had no complications; thus, these patients may be representative of a less severe patient population,” Dr. Lodise and his associates noted in the poster.

They acknowledged certain limitations of the study, including the potential for coding errors. They also pointed out the HCUP NRD does not contain treatment-specific information, drugs administered or treatment patterns during hospitalization, the number of days patients spent in the ICU, or the number of days on ventilation, “which can influence outcomes in pneumonia patients.” In addition, the study did not attempt to determine cause of death. “Death may have been due to combinations of factors separate from pneumonia,” they wrote.

Bayer Healthcare Pharmaceuticals funded the study. Dr. Lodise reported having no financial disclosures.

[email protected]

SOURCE: Lodise T. et al. ATS 2018, Poster 272.

Doptelet (avatrombopag) is the first drug to be approved by the Food and Drug Administration for thrombocytopenia in adults with chronic liver disease who are scheduled to undergo a medical or dental procedure, the FDA announced in a statement.

“Patients with chronic liver disease who have low platelet counts and require a procedure are at increased risk of bleeding,” said Richard Pazdur, MD, director of the FDA’s Oncology Center of Excellence and acting director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research. “Doptelet was demonstrated to safely increase the platelet count. This drug may decrease or eliminate the need for platelet transfusions, which are associated with risk of infection and other adverse reactions.”

Doptelet (avatrombopag) is the first drug to be approved by the Food and Drug Administration for thrombocytopenia in adults with chronic liver disease who are scheduled to undergo a medical or dental procedure, the FDA announced in a statement.

“Patients with chronic liver disease who have low platelet counts and require a procedure are at increased risk of bleeding,” said Richard Pazdur, MD, director of the FDA’s Oncology Center of Excellence and acting director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research. “Doptelet was demonstrated to safely increase the platelet count. This drug may decrease or eliminate the need for platelet transfusions, which are associated with risk of infection and other adverse reactions.”

Doptelet (avatrombopag) is the first drug to be approved by the Food and Drug Administration for thrombocytopenia in adults with chronic liver disease who are scheduled to undergo a medical or dental procedure, the FDA announced in a statement.

“Patients with chronic liver disease who have low platelet counts and require a procedure are at increased risk of bleeding,” said Richard Pazdur, MD, director of the FDA’s Oncology Center of Excellence and acting director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research. “Doptelet was demonstrated to safely increase the platelet count. This drug may decrease or eliminate the need for platelet transfusions, which are associated with risk of infection and other adverse reactions.”

Association between hospitalist years of experience with mortality in hospitalized patients

Cohort study showed that Medicare patients cared for by hospitalists in their first year of practice experienced higher in-hospital and 30-day mortality, compared with patients cared for by hospitalists in their second year of practice. New hospitalists may need additional monitoring and support to ensure optimal patient outcomes.

Standardized handoff improves preparedness in the ICU

Cluster randomized stepped-wedge trial in eight ICUs in an academic center showed that a standardized handoff intervention was associated with a statistically significant reduction in the odds of clinician self-reported unpreparedness from a poor-quality handoff (odds ratio, 0.19; 95% confidence interval, 0.03-0.74; P = .03).

Citation: Parent B et al. Effect of standardized handoff curriculum on improved clinician preparedness in the intensive care: A stepped-wedge cluster randomized clinical trial. JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5440.

Association between hospitalist years of experience with mortality in hospitalized patients

Cohort study showed that Medicare patients cared for by hospitalists in their first year of practice experienced higher in-hospital and 30-day mortality, compared with patients cared for by hospitalists in their second year of practice. New hospitalists may need additional monitoring and support to ensure optimal patient outcomes.

Standardized handoff improves preparedness in the ICU

Cluster randomized stepped-wedge trial in eight ICUs in an academic center showed that a standardized handoff intervention was associated with a statistically significant reduction in the odds of clinician self-reported unpreparedness from a poor-quality handoff (odds ratio, 0.19; 95% confidence interval, 0.03-0.74; P = .03).

Citation: Parent B et al. Effect of standardized handoff curriculum on improved clinician preparedness in the intensive care: A stepped-wedge cluster randomized clinical trial. JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5440.

Association between hospitalist years of experience with mortality in hospitalized patients

Cohort study showed that Medicare patients cared for by hospitalists in their first year of practice experienced higher in-hospital and 30-day mortality, compared with patients cared for by hospitalists in their second year of practice. New hospitalists may need additional monitoring and support to ensure optimal patient outcomes.

Standardized handoff improves preparedness in the ICU

Cluster randomized stepped-wedge trial in eight ICUs in an academic center showed that a standardized handoff intervention was associated with a statistically significant reduction in the odds of clinician self-reported unpreparedness from a poor-quality handoff (odds ratio, 0.19; 95% confidence interval, 0.03-0.74; P = .03).

Citation: Parent B et al. Effect of standardized handoff curriculum on improved clinician preparedness in the intensive care: A stepped-wedge cluster randomized clinical trial. JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5440.

Clinical question: What roles, training, and support do hospitalists have and perceive in the intensive care unit?

Background: There is a well-documented shortage of intensivists in the United States, which has left hospitalists to help fill the gap of care. Hospitalists, however, have varied levels of critical care knowledge and skills. In some regions, more than 80% of hospitalists deliver care in the ICU. It is unknown how much support hospitalized patients receive from board-certified critical care physicians.

Study design: Multistage cross-section survey.

Setting: Web-based survey initially sent through the Critical Care Task Force professional networks and later sent to 4,000 hospitalists randomly selected from Society of Hospital Medicine’s national electronic mailing list of 12,000 hospitalists.

Synopsis: This study includes 425 responses, approximately 10% of those solicited. Compared with the annual SHM survey, this included more hospitalists from academic hospitals (24% vs. 14.8%) and fewer from nonteaching hospitals (41% vs. 58.7%). A total of 77% of responders provide care in the ICU, with 66% serving as the attending physician.

Rural and nonacademic hospitalists are more prevalent in the ICU (96% rural vs. 73% nonrural; 90% nonacademic vs. 67% academic), are more likely to serve as the primary physician for all or most ICU patients (85% rural vs. 62% nonrural; 81% nonacademic vs. 44% academic), and provide all critical care services (55% rural vs. 10% nonrural; 64% nonacademic vs. 25% academic).

Many rural (43%) and nonacademic (42%) hospitalists feel that they are expected to practice beyond their perceived scope of expertise at least some of the time, which was correlated with perceived difficulty in transferring patients to higher levels of care. About 90% of rural hospitalists report at least insufficient support from board-certified intensivists. Of all responders in the study, 85% indicated interest in additional critical care training in some form, short of fellowship training.

Bottom line: Most hospitalists provide care in the ICU, however hospitalists provide critical care at significantly higher rates in rural and nonacademic hospital settings. This care is being provided with a perceived lack of intensivist support and training.

Citation: Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Clinical question: What roles, training, and support do hospitalists have and perceive in the intensive care unit?

Background: There is a well-documented shortage of intensivists in the United States, which has left hospitalists to help fill the gap of care. Hospitalists, however, have varied levels of critical care knowledge and skills. In some regions, more than 80% of hospitalists deliver care in the ICU. It is unknown how much support hospitalized patients receive from board-certified critical care physicians.

Study design: Multistage cross-section survey.

Setting: Web-based survey initially sent through the Critical Care Task Force professional networks and later sent to 4,000 hospitalists randomly selected from Society of Hospital Medicine’s national electronic mailing list of 12,000 hospitalists.

Synopsis: This study includes 425 responses, approximately 10% of those solicited. Compared with the annual SHM survey, this included more hospitalists from academic hospitals (24% vs. 14.8%) and fewer from nonteaching hospitals (41% vs. 58.7%). A total of 77% of responders provide care in the ICU, with 66% serving as the attending physician.

Rural and nonacademic hospitalists are more prevalent in the ICU (96% rural vs. 73% nonrural; 90% nonacademic vs. 67% academic), are more likely to serve as the primary physician for all or most ICU patients (85% rural vs. 62% nonrural; 81% nonacademic vs. 44% academic), and provide all critical care services (55% rural vs. 10% nonrural; 64% nonacademic vs. 25% academic).

Many rural (43%) and nonacademic (42%) hospitalists feel that they are expected to practice beyond their perceived scope of expertise at least some of the time, which was correlated with perceived difficulty in transferring patients to higher levels of care. About 90% of rural hospitalists report at least insufficient support from board-certified intensivists. Of all responders in the study, 85% indicated interest in additional critical care training in some form, short of fellowship training.

Bottom line: Most hospitalists provide care in the ICU, however hospitalists provide critical care at significantly higher rates in rural and nonacademic hospital settings. This care is being provided with a perceived lack of intensivist support and training.

Citation: Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Clinical question: What roles, training, and support do hospitalists have and perceive in the intensive care unit?

Background: There is a well-documented shortage of intensivists in the United States, which has left hospitalists to help fill the gap of care. Hospitalists, however, have varied levels of critical care knowledge and skills. In some regions, more than 80% of hospitalists deliver care in the ICU. It is unknown how much support hospitalized patients receive from board-certified critical care physicians.

Study design: Multistage cross-section survey.

Setting: Web-based survey initially sent through the Critical Care Task Force professional networks and later sent to 4,000 hospitalists randomly selected from Society of Hospital Medicine’s national electronic mailing list of 12,000 hospitalists.

Synopsis: This study includes 425 responses, approximately 10% of those solicited. Compared with the annual SHM survey, this included more hospitalists from academic hospitals (24% vs. 14.8%) and fewer from nonteaching hospitals (41% vs. 58.7%). A total of 77% of responders provide care in the ICU, with 66% serving as the attending physician.

Rural and nonacademic hospitalists are more prevalent in the ICU (96% rural vs. 73% nonrural; 90% nonacademic vs. 67% academic), are more likely to serve as the primary physician for all or most ICU patients (85% rural vs. 62% nonrural; 81% nonacademic vs. 44% academic), and provide all critical care services (55% rural vs. 10% nonrural; 64% nonacademic vs. 25% academic).

Many rural (43%) and nonacademic (42%) hospitalists feel that they are expected to practice beyond their perceived scope of expertise at least some of the time, which was correlated with perceived difficulty in transferring patients to higher levels of care. About 90% of rural hospitalists report at least insufficient support from board-certified intensivists. Of all responders in the study, 85% indicated interest in additional critical care training in some form, short of fellowship training.

Bottom line: Most hospitalists provide care in the ICU, however hospitalists provide critical care at significantly higher rates in rural and nonacademic hospital settings. This care is being provided with a perceived lack of intensivist support and training.

Citation: Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.