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Rib fracture diagnosis in the panscan era
Clinical question: Do rib fractures observed on chest CT carry the same morbidity and mortality risk as those observed in chest radiograph?
Background: Traditionally studies have shown that first and second rib fractures on chest radiograph after blunt trauma are associated with substantial morbidity and mortality. With growing frequency of CT imaging in the “panscan” era, it is unknown whether similar rib fractures found on CT carry the same meaning.
Setting: 10 level I trauma centers.
Synopsis: Data from the National Emergency X-Radiography Utilization Study showed that, of the 8,661 patients who suffered blunt trauma and received both chest radiograph and chest CT, 23.9% had rib fractures. Rib fractures were observed in 66.1% of chest CT–only cases. Patients with rib fractures had a higher admission rate (88.7% versus 45.8%) and higher mortality (5.6% versus 2.7%) than patients without rib fractures. Mortality rate and great-vessel injury were higher in those with first or second rib fractures. The mortality of patients with rib fractures observed only on chest CT was not statistically different from those whose fractures were also seen in chest radiograph. The study included patients who were more severely injured and may have been more likely to receive a CT, which may have led to an overestimation of fractures found. The actual causes of admission and death were not reviewed.
Bottom line: CT in trauma-imaging protocol can identify patients with rib fractures well, compared with combined CT with chest radiograph. Rib fractures are associated with higher rates of admission and mortality risk than those without rib fractures. Specifically, first or second rib fractures are found to have greater risk for mortality and great-vessel injury.
Citation: Murphy CE 4th, Raja AS, Baumann BM, et al. Rib fracture diagnosis in the panscan era. Ann Emerg Med. 2017. doi: 10.1016/j.annemergmed.2017.04.011.
Dr. Xu is assistant professor and hospitalist, Icahn School of Medicine of the Mount Sinai Health System, New York.
Clinical question: Do rib fractures observed on chest CT carry the same morbidity and mortality risk as those observed in chest radiograph?
Background: Traditionally studies have shown that first and second rib fractures on chest radiograph after blunt trauma are associated with substantial morbidity and mortality. With growing frequency of CT imaging in the “panscan” era, it is unknown whether similar rib fractures found on CT carry the same meaning.
Setting: 10 level I trauma centers.
Synopsis: Data from the National Emergency X-Radiography Utilization Study showed that, of the 8,661 patients who suffered blunt trauma and received both chest radiograph and chest CT, 23.9% had rib fractures. Rib fractures were observed in 66.1% of chest CT–only cases. Patients with rib fractures had a higher admission rate (88.7% versus 45.8%) and higher mortality (5.6% versus 2.7%) than patients without rib fractures. Mortality rate and great-vessel injury were higher in those with first or second rib fractures. The mortality of patients with rib fractures observed only on chest CT was not statistically different from those whose fractures were also seen in chest radiograph. The study included patients who were more severely injured and may have been more likely to receive a CT, which may have led to an overestimation of fractures found. The actual causes of admission and death were not reviewed.
Bottom line: CT in trauma-imaging protocol can identify patients with rib fractures well, compared with combined CT with chest radiograph. Rib fractures are associated with higher rates of admission and mortality risk than those without rib fractures. Specifically, first or second rib fractures are found to have greater risk for mortality and great-vessel injury.
Citation: Murphy CE 4th, Raja AS, Baumann BM, et al. Rib fracture diagnosis in the panscan era. Ann Emerg Med. 2017. doi: 10.1016/j.annemergmed.2017.04.011.
Dr. Xu is assistant professor and hospitalist, Icahn School of Medicine of the Mount Sinai Health System, New York.
Clinical question: Do rib fractures observed on chest CT carry the same morbidity and mortality risk as those observed in chest radiograph?
Background: Traditionally studies have shown that first and second rib fractures on chest radiograph after blunt trauma are associated with substantial morbidity and mortality. With growing frequency of CT imaging in the “panscan” era, it is unknown whether similar rib fractures found on CT carry the same meaning.
Setting: 10 level I trauma centers.
Synopsis: Data from the National Emergency X-Radiography Utilization Study showed that, of the 8,661 patients who suffered blunt trauma and received both chest radiograph and chest CT, 23.9% had rib fractures. Rib fractures were observed in 66.1% of chest CT–only cases. Patients with rib fractures had a higher admission rate (88.7% versus 45.8%) and higher mortality (5.6% versus 2.7%) than patients without rib fractures. Mortality rate and great-vessel injury were higher in those with first or second rib fractures. The mortality of patients with rib fractures observed only on chest CT was not statistically different from those whose fractures were also seen in chest radiograph. The study included patients who were more severely injured and may have been more likely to receive a CT, which may have led to an overestimation of fractures found. The actual causes of admission and death were not reviewed.
Bottom line: CT in trauma-imaging protocol can identify patients with rib fractures well, compared with combined CT with chest radiograph. Rib fractures are associated with higher rates of admission and mortality risk than those without rib fractures. Specifically, first or second rib fractures are found to have greater risk for mortality and great-vessel injury.
Citation: Murphy CE 4th, Raja AS, Baumann BM, et al. Rib fracture diagnosis in the panscan era. Ann Emerg Med. 2017. doi: 10.1016/j.annemergmed.2017.04.011.
Dr. Xu is assistant professor and hospitalist, Icahn School of Medicine of the Mount Sinai Health System, New York.
Mortality risks associated with emergency admission during weekends and public holidays
Clinical question: What factors contribute to increased mortality in weekend hospital admissions?
Background: The “weekend effect” is a commonly known phenomenon, where patients admitted to the hospital on weekends have higher mortality risk than those admitted on weekdays. However, little is known about the factors contributing to the excess mortality associated with weekend admissions.
Setting: Four Oxford University National Health Service hospitals in the United Kingdom (a district general hospital, a large teaching hospital, a specialist orthopedic hospital, and a major cancer center).
Synopsis: Data from the Infections in Oxfordshire Research Database of 503,938 admissions between Jan. 1, 2006, and Dec. 31, 2014 were analyzed. Thirty-day mortality was 4.7%, 5.1%, and 5.8% for patients admitted during weekdays, weekends, and public holidays, respectively (P less than .0001). Fifteen routine hematology and biochemistry test results were determined to be prognostic of high mortality risk. Adjustment for these routine test results reduced excess mortality associated with emergency admissions on weekends and public holidays. Excess mortality was notable for patients admitted on Saturdays and Sundays between 11:00 a.m. and 3:00 p.m. Hospital staffing and workload were not associated with excess mortality. The study is limited by a lack of additional patient factors such as vital signs and blood gas results that may further explain excess mortality on weekends and public holidays.
Bottom line: Patient factors, including laboratory abnormalities, rather than hospital workload and staffing may be the major contributing factors for the excess mortality seen for emergency admissions on weekends and public holidays.
Citation: Walker AS, Mason A, Quan TP, et al. Mortality risks associated with emergency admissions during weekends and public holidays: An analysis of electronic health records. The Lancet. 2017;390(10089):62-72.
Dr. Xu is assistant professor and hospitalist, Icahn School of Medicine of the Mount Sinai Health System, New York.
Clinical question: What factors contribute to increased mortality in weekend hospital admissions?
Background: The “weekend effect” is a commonly known phenomenon, where patients admitted to the hospital on weekends have higher mortality risk than those admitted on weekdays. However, little is known about the factors contributing to the excess mortality associated with weekend admissions.
Setting: Four Oxford University National Health Service hospitals in the United Kingdom (a district general hospital, a large teaching hospital, a specialist orthopedic hospital, and a major cancer center).
Synopsis: Data from the Infections in Oxfordshire Research Database of 503,938 admissions between Jan. 1, 2006, and Dec. 31, 2014 were analyzed. Thirty-day mortality was 4.7%, 5.1%, and 5.8% for patients admitted during weekdays, weekends, and public holidays, respectively (P less than .0001). Fifteen routine hematology and biochemistry test results were determined to be prognostic of high mortality risk. Adjustment for these routine test results reduced excess mortality associated with emergency admissions on weekends and public holidays. Excess mortality was notable for patients admitted on Saturdays and Sundays between 11:00 a.m. and 3:00 p.m. Hospital staffing and workload were not associated with excess mortality. The study is limited by a lack of additional patient factors such as vital signs and blood gas results that may further explain excess mortality on weekends and public holidays.
Bottom line: Patient factors, including laboratory abnormalities, rather than hospital workload and staffing may be the major contributing factors for the excess mortality seen for emergency admissions on weekends and public holidays.
Citation: Walker AS, Mason A, Quan TP, et al. Mortality risks associated with emergency admissions during weekends and public holidays: An analysis of electronic health records. The Lancet. 2017;390(10089):62-72.
Dr. Xu is assistant professor and hospitalist, Icahn School of Medicine of the Mount Sinai Health System, New York.
Clinical question: What factors contribute to increased mortality in weekend hospital admissions?
Background: The “weekend effect” is a commonly known phenomenon, where patients admitted to the hospital on weekends have higher mortality risk than those admitted on weekdays. However, little is known about the factors contributing to the excess mortality associated with weekend admissions.
Setting: Four Oxford University National Health Service hospitals in the United Kingdom (a district general hospital, a large teaching hospital, a specialist orthopedic hospital, and a major cancer center).
Synopsis: Data from the Infections in Oxfordshire Research Database of 503,938 admissions between Jan. 1, 2006, and Dec. 31, 2014 were analyzed. Thirty-day mortality was 4.7%, 5.1%, and 5.8% for patients admitted during weekdays, weekends, and public holidays, respectively (P less than .0001). Fifteen routine hematology and biochemistry test results were determined to be prognostic of high mortality risk. Adjustment for these routine test results reduced excess mortality associated with emergency admissions on weekends and public holidays. Excess mortality was notable for patients admitted on Saturdays and Sundays between 11:00 a.m. and 3:00 p.m. Hospital staffing and workload were not associated with excess mortality. The study is limited by a lack of additional patient factors such as vital signs and blood gas results that may further explain excess mortality on weekends and public holidays.
Bottom line: Patient factors, including laboratory abnormalities, rather than hospital workload and staffing may be the major contributing factors for the excess mortality seen for emergency admissions on weekends and public holidays.
Citation: Walker AS, Mason A, Quan TP, et al. Mortality risks associated with emergency admissions during weekends and public holidays: An analysis of electronic health records. The Lancet. 2017;390(10089):62-72.
Dr. Xu is assistant professor and hospitalist, Icahn School of Medicine of the Mount Sinai Health System, New York.
Applying Choosing Wisely principles to telemetry and catheter use
The Choosing Wisely recommendations for hospitalists have launched numerous research projects. One dealing with telemetry and catheter use was published in September’s American Journal of Medicine.
After reviewing the literature on how people were implementing these recommendations, the researchers noticed most projects “1) narrowly focused on only one of the recommendations; 2) often used intrusive interventions that appeared to be burdensome and not adaptable to physician workflow; and 3) were expensive to implement,” said lead author Charlie M. Wray, DO, MS, of the Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, and the University of California, San Francisco. “We set out to design a project that could minimize these aspects while hopefully decreasing the use of telemetry and Foley catheters.”
The researchers created a “silent” reminder that was posted on a widely used screen within their EHR and was only activated when the user clicked on it. “Additionally, we wanted to make sure that this intervention made its way to teaching rounds and the patients’ bedsides,” Dr. Wray said. “So, when the attendings and residents would print out their daily census, it would contain the reminders, which allowed the team to quickly review which patients were actively using telemetry or had a Foley and discuss, at a team-level, whose telemetry or Foley could be stopped.”
The project demonstrated a trend toward less telemetry use, less time spent on telemetry, fewer catheters ordered, and more selective utilization of catheters in sicker patients.
“We believe that our project shows that the bundling of interventions has the potential to impart an effect on a greater proportion of the population than those that focus on a single issue,” Dr. Wray said. “Second, future interventions that look to utilize EHR-based clinical reminders should consider utilizing a ‘silent’ design that is prominent but doesn’t intrude upon practitioners workflow.”
You don’t need to be at a large academic institution to implement this idea, he added. “A few hours with your IT expert and a champion who is willing to take the lead could easily implement this project and hopefully see similar outcomes.”
Reference
Wray, Charlie M. et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.
The Choosing Wisely recommendations for hospitalists have launched numerous research projects. One dealing with telemetry and catheter use was published in September’s American Journal of Medicine.
After reviewing the literature on how people were implementing these recommendations, the researchers noticed most projects “1) narrowly focused on only one of the recommendations; 2) often used intrusive interventions that appeared to be burdensome and not adaptable to physician workflow; and 3) were expensive to implement,” said lead author Charlie M. Wray, DO, MS, of the Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, and the University of California, San Francisco. “We set out to design a project that could minimize these aspects while hopefully decreasing the use of telemetry and Foley catheters.”
The researchers created a “silent” reminder that was posted on a widely used screen within their EHR and was only activated when the user clicked on it. “Additionally, we wanted to make sure that this intervention made its way to teaching rounds and the patients’ bedsides,” Dr. Wray said. “So, when the attendings and residents would print out their daily census, it would contain the reminders, which allowed the team to quickly review which patients were actively using telemetry or had a Foley and discuss, at a team-level, whose telemetry or Foley could be stopped.”
The project demonstrated a trend toward less telemetry use, less time spent on telemetry, fewer catheters ordered, and more selective utilization of catheters in sicker patients.
“We believe that our project shows that the bundling of interventions has the potential to impart an effect on a greater proportion of the population than those that focus on a single issue,” Dr. Wray said. “Second, future interventions that look to utilize EHR-based clinical reminders should consider utilizing a ‘silent’ design that is prominent but doesn’t intrude upon practitioners workflow.”
You don’t need to be at a large academic institution to implement this idea, he added. “A few hours with your IT expert and a champion who is willing to take the lead could easily implement this project and hopefully see similar outcomes.”
Reference
Wray, Charlie M. et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.
The Choosing Wisely recommendations for hospitalists have launched numerous research projects. One dealing with telemetry and catheter use was published in September’s American Journal of Medicine.
After reviewing the literature on how people were implementing these recommendations, the researchers noticed most projects “1) narrowly focused on only one of the recommendations; 2) often used intrusive interventions that appeared to be burdensome and not adaptable to physician workflow; and 3) were expensive to implement,” said lead author Charlie M. Wray, DO, MS, of the Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, and the University of California, San Francisco. “We set out to design a project that could minimize these aspects while hopefully decreasing the use of telemetry and Foley catheters.”
The researchers created a “silent” reminder that was posted on a widely used screen within their EHR and was only activated when the user clicked on it. “Additionally, we wanted to make sure that this intervention made its way to teaching rounds and the patients’ bedsides,” Dr. Wray said. “So, when the attendings and residents would print out their daily census, it would contain the reminders, which allowed the team to quickly review which patients were actively using telemetry or had a Foley and discuss, at a team-level, whose telemetry or Foley could be stopped.”
The project demonstrated a trend toward less telemetry use, less time spent on telemetry, fewer catheters ordered, and more selective utilization of catheters in sicker patients.
“We believe that our project shows that the bundling of interventions has the potential to impart an effect on a greater proportion of the population than those that focus on a single issue,” Dr. Wray said. “Second, future interventions that look to utilize EHR-based clinical reminders should consider utilizing a ‘silent’ design that is prominent but doesn’t intrude upon practitioners workflow.”
You don’t need to be at a large academic institution to implement this idea, he added. “A few hours with your IT expert and a champion who is willing to take the lead could easily implement this project and hopefully see similar outcomes.”
Reference
Wray, Charlie M. et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.
IGRA preferred test for latent TB diagnosis
TORONTO – U.S.-based pulmonary and infectious disease specialists prefer interferon-gamma release assays (IGRA) over tuberculin skin tests (TST) for the diagnosis of latent TB infection, but may not fully understand how to use and interpret the test results, according to survey results presented at the CHEST annual meeting.
Adam G. Green, MD, conducted the research while he was a fellow in pulmonology/critical care at Montefiore Medical Center in New York. Dr. Green told attendees that about one-third of the world’s population are infected with TB and about 15 million of those live in the United States. Two-thirds of U.S. cases are seen in foreign-born individuals and are clustered in four states—New, York, California, Florida, and Texas.
Among 304 clinicians who responded to an invitation to an online questionnaire, 78% said they preferred to use IGRA over TST and 91% said they had a “good understanding” of how to use and interpret IGRA. However, when queried further on how to best use and interpret IGRAs according to current guidelines, their answers to 11 knowledge-based questions told a somewhat different story, said Dr. Green, who is an intensivist at Cooper University Health Care in Camden, N.J.
While 96% knew IGRAs are not helpful in monitoring response to TB treatment, 20% erroneously thought that a positive IGRA predicts latent TB infection reactivation in the future.
Most respondents correctly answered two “fundamental” questions on cross-reactivity of IGRAs with Mycobacterium avium complex and bacilli Calmette-Guérin (BCG) vaccination (84% and 96%, respectively). “While 80% sounds good, I think we’re talking about ID and pulmonary docs at the best institutions across the United States, so I would have expected much higher,” Dr. Green said.
Only one-third of respondents knew that the T-SPOT.TB test, an IGRA, had the highest sensitivity for identifying those with latent TB infection. And only about half were able to appropriately identify the need to initiate therapy for latent TB in a scenario in which the patient was at “high risk for latent tuberculosis with a positive tuberculin skin test and a negative interferon-gamma release assay.”
Fellows comprised 42.5% of respondents and the remainder were attendings of varying levels of seniority. About half of respondents were pulmonologists and the other half infectious disease specialists. The majority (91%) were practicing or training in university hospitals.
One major limitation of the study, said Dr. Green, is the low response rate. “I would have liked 3,000 responses,” he said, rather than just over 300.
To disseminate the questionnaire, he contacted pulmonary and infectious disease academic program directors and coordinators and asked them to forward the survey invitation to their full-time faculty and fellows. Dr. Green also acknowledged that his project missed those physicians not working in academic centers.
“I would like to think that the reason people didn’t do as well as I had hoped is because of the conflicting literature out there and using not necessarily the guidelines but rather their current knowledge on what was most recently published,” said Dr. Green. “But maybe there is a true misunderstanding.”
The authors reported there were no product or funding disclosures relevant to this study.
TORONTO – U.S.-based pulmonary and infectious disease specialists prefer interferon-gamma release assays (IGRA) over tuberculin skin tests (TST) for the diagnosis of latent TB infection, but may not fully understand how to use and interpret the test results, according to survey results presented at the CHEST annual meeting.
Adam G. Green, MD, conducted the research while he was a fellow in pulmonology/critical care at Montefiore Medical Center in New York. Dr. Green told attendees that about one-third of the world’s population are infected with TB and about 15 million of those live in the United States. Two-thirds of U.S. cases are seen in foreign-born individuals and are clustered in four states—New, York, California, Florida, and Texas.
Among 304 clinicians who responded to an invitation to an online questionnaire, 78% said they preferred to use IGRA over TST and 91% said they had a “good understanding” of how to use and interpret IGRA. However, when queried further on how to best use and interpret IGRAs according to current guidelines, their answers to 11 knowledge-based questions told a somewhat different story, said Dr. Green, who is an intensivist at Cooper University Health Care in Camden, N.J.
While 96% knew IGRAs are not helpful in monitoring response to TB treatment, 20% erroneously thought that a positive IGRA predicts latent TB infection reactivation in the future.
Most respondents correctly answered two “fundamental” questions on cross-reactivity of IGRAs with Mycobacterium avium complex and bacilli Calmette-Guérin (BCG) vaccination (84% and 96%, respectively). “While 80% sounds good, I think we’re talking about ID and pulmonary docs at the best institutions across the United States, so I would have expected much higher,” Dr. Green said.
Only one-third of respondents knew that the T-SPOT.TB test, an IGRA, had the highest sensitivity for identifying those with latent TB infection. And only about half were able to appropriately identify the need to initiate therapy for latent TB in a scenario in which the patient was at “high risk for latent tuberculosis with a positive tuberculin skin test and a negative interferon-gamma release assay.”
Fellows comprised 42.5% of respondents and the remainder were attendings of varying levels of seniority. About half of respondents were pulmonologists and the other half infectious disease specialists. The majority (91%) were practicing or training in university hospitals.
One major limitation of the study, said Dr. Green, is the low response rate. “I would have liked 3,000 responses,” he said, rather than just over 300.
To disseminate the questionnaire, he contacted pulmonary and infectious disease academic program directors and coordinators and asked them to forward the survey invitation to their full-time faculty and fellows. Dr. Green also acknowledged that his project missed those physicians not working in academic centers.
“I would like to think that the reason people didn’t do as well as I had hoped is because of the conflicting literature out there and using not necessarily the guidelines but rather their current knowledge on what was most recently published,” said Dr. Green. “But maybe there is a true misunderstanding.”
The authors reported there were no product or funding disclosures relevant to this study.
TORONTO – U.S.-based pulmonary and infectious disease specialists prefer interferon-gamma release assays (IGRA) over tuberculin skin tests (TST) for the diagnosis of latent TB infection, but may not fully understand how to use and interpret the test results, according to survey results presented at the CHEST annual meeting.
Adam G. Green, MD, conducted the research while he was a fellow in pulmonology/critical care at Montefiore Medical Center in New York. Dr. Green told attendees that about one-third of the world’s population are infected with TB and about 15 million of those live in the United States. Two-thirds of U.S. cases are seen in foreign-born individuals and are clustered in four states—New, York, California, Florida, and Texas.
Among 304 clinicians who responded to an invitation to an online questionnaire, 78% said they preferred to use IGRA over TST and 91% said they had a “good understanding” of how to use and interpret IGRA. However, when queried further on how to best use and interpret IGRAs according to current guidelines, their answers to 11 knowledge-based questions told a somewhat different story, said Dr. Green, who is an intensivist at Cooper University Health Care in Camden, N.J.
While 96% knew IGRAs are not helpful in monitoring response to TB treatment, 20% erroneously thought that a positive IGRA predicts latent TB infection reactivation in the future.
Most respondents correctly answered two “fundamental” questions on cross-reactivity of IGRAs with Mycobacterium avium complex and bacilli Calmette-Guérin (BCG) vaccination (84% and 96%, respectively). “While 80% sounds good, I think we’re talking about ID and pulmonary docs at the best institutions across the United States, so I would have expected much higher,” Dr. Green said.
Only one-third of respondents knew that the T-SPOT.TB test, an IGRA, had the highest sensitivity for identifying those with latent TB infection. And only about half were able to appropriately identify the need to initiate therapy for latent TB in a scenario in which the patient was at “high risk for latent tuberculosis with a positive tuberculin skin test and a negative interferon-gamma release assay.”
Fellows comprised 42.5% of respondents and the remainder were attendings of varying levels of seniority. About half of respondents were pulmonologists and the other half infectious disease specialists. The majority (91%) were practicing or training in university hospitals.
One major limitation of the study, said Dr. Green, is the low response rate. “I would have liked 3,000 responses,” he said, rather than just over 300.
To disseminate the questionnaire, he contacted pulmonary and infectious disease academic program directors and coordinators and asked them to forward the survey invitation to their full-time faculty and fellows. Dr. Green also acknowledged that his project missed those physicians not working in academic centers.
“I would like to think that the reason people didn’t do as well as I had hoped is because of the conflicting literature out there and using not necessarily the guidelines but rather their current knowledge on what was most recently published,” said Dr. Green. “But maybe there is a true misunderstanding.”
The authors reported there were no product or funding disclosures relevant to this study.
AT CHEST 2017
Key clinical point: Most physicians queried preferred IGRAs over TST for the detection of latent TB infection.
Major finding: Of the 304 respondents to a survey, 78% said they preferred IGRAs over TST for TB testing and 91% reported having a good understanding of how to use and interpret IGRAs.
Data source: Online survey of 304 pulmonary and infectious disease attending physicians and fellows from U.S.-based academic programs.
Disclosures: The authors reported there were no product or funding disclosures relevant to this study.
Taking urine samples from infants
Urinary tract infection (UTI) is one of the most common bacterial infections in young febrile infants, but doctors know that collecting a urine sample to diagnose or exclude UTI can be very challenging in practice.
Recently, researchers in Australia conducted a randomized controlled trial in a pediatric hospital emergency department to test a method that could stimulate voiding within 5 minutes. It’s called the Quick-Wee method, and the technique involves the clinician rubbing the suprapubic area of the child in a circular pattern with gauze soaked in cold saline held with disposable plastic forceps. In the trial, this was done until the sample was obtained or until 5 minutes passed.
For some young children, when a urine sample is required, a catheter or suprapubic needle aspirate sample will be indicated, he added. “But for many others, the Quick-Wee method may allow clinicians to collect a clean catch sample, and spare the need for painful and invasive procedures in some circumstances.”
Reference
Kaufman J, Fitzpatrick P, Tosif S, et al. Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial. BMJ 2017;357:j1341. doi: 10.1136/bmj.j1341. Accessed June 12, 2017.
Urinary tract infection (UTI) is one of the most common bacterial infections in young febrile infants, but doctors know that collecting a urine sample to diagnose or exclude UTI can be very challenging in practice.
Recently, researchers in Australia conducted a randomized controlled trial in a pediatric hospital emergency department to test a method that could stimulate voiding within 5 minutes. It’s called the Quick-Wee method, and the technique involves the clinician rubbing the suprapubic area of the child in a circular pattern with gauze soaked in cold saline held with disposable plastic forceps. In the trial, this was done until the sample was obtained or until 5 minutes passed.
For some young children, when a urine sample is required, a catheter or suprapubic needle aspirate sample will be indicated, he added. “But for many others, the Quick-Wee method may allow clinicians to collect a clean catch sample, and spare the need for painful and invasive procedures in some circumstances.”
Reference
Kaufman J, Fitzpatrick P, Tosif S, et al. Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial. BMJ 2017;357:j1341. doi: 10.1136/bmj.j1341. Accessed June 12, 2017.
Urinary tract infection (UTI) is one of the most common bacterial infections in young febrile infants, but doctors know that collecting a urine sample to diagnose or exclude UTI can be very challenging in practice.
Recently, researchers in Australia conducted a randomized controlled trial in a pediatric hospital emergency department to test a method that could stimulate voiding within 5 minutes. It’s called the Quick-Wee method, and the technique involves the clinician rubbing the suprapubic area of the child in a circular pattern with gauze soaked in cold saline held with disposable plastic forceps. In the trial, this was done until the sample was obtained or until 5 minutes passed.
For some young children, when a urine sample is required, a catheter or suprapubic needle aspirate sample will be indicated, he added. “But for many others, the Quick-Wee method may allow clinicians to collect a clean catch sample, and spare the need for painful and invasive procedures in some circumstances.”
Reference
Kaufman J, Fitzpatrick P, Tosif S, et al. Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial. BMJ 2017;357:j1341. doi: 10.1136/bmj.j1341. Accessed June 12, 2017.
Coordinating data collection in a QI project
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
I am currently working with my mentor, Dr. Ian Jenkins, an attending in the Division of Hospital Medicine at the University of California, San Diego, to start piloting data collection on our project to cut catheter-associated urinary tract infections (CAUTI). We have contacted a number of potential units to recruit for CAUTI prevention efforts, but we are hoping to do a preliminary trial of data collection to better estimate the amount of time it takes to gather data for an individual unit.
I am quickly learning that conducting a successful quality improvement project requires one to be forward-looking in an attempt to identify challenges before they arise. With respect to coordinating data collection, it may have been helpful for us to initially meet with hospital staff to identify the best staff for coordinating data collection efforts (i.e. physician, nurse, trainee) within each individual unit. This could potentially have helped us to also better communicate and recruit individuals to partner with us for our project.
I am continuing to enjoy the challenges of performing a quality improvement project. One skill that I have developed is learning how to be forward-thinking in my approach to research in an attempt to handle challenges prospectively, as opposed to retrospectively. This has helped me improve everything from how I think about data collection to how I think about displaying results. I am truly grateful to my mentor Dr. Jenkins for his help in this regard.
Victor Ekuta is a third-year medical student at UC San Diego.
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
I am currently working with my mentor, Dr. Ian Jenkins, an attending in the Division of Hospital Medicine at the University of California, San Diego, to start piloting data collection on our project to cut catheter-associated urinary tract infections (CAUTI). We have contacted a number of potential units to recruit for CAUTI prevention efforts, but we are hoping to do a preliminary trial of data collection to better estimate the amount of time it takes to gather data for an individual unit.
I am quickly learning that conducting a successful quality improvement project requires one to be forward-looking in an attempt to identify challenges before they arise. With respect to coordinating data collection, it may have been helpful for us to initially meet with hospital staff to identify the best staff for coordinating data collection efforts (i.e. physician, nurse, trainee) within each individual unit. This could potentially have helped us to also better communicate and recruit individuals to partner with us for our project.
I am continuing to enjoy the challenges of performing a quality improvement project. One skill that I have developed is learning how to be forward-thinking in my approach to research in an attempt to handle challenges prospectively, as opposed to retrospectively. This has helped me improve everything from how I think about data collection to how I think about displaying results. I am truly grateful to my mentor Dr. Jenkins for his help in this regard.
Victor Ekuta is a third-year medical student at UC San Diego.
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
I am currently working with my mentor, Dr. Ian Jenkins, an attending in the Division of Hospital Medicine at the University of California, San Diego, to start piloting data collection on our project to cut catheter-associated urinary tract infections (CAUTI). We have contacted a number of potential units to recruit for CAUTI prevention efforts, but we are hoping to do a preliminary trial of data collection to better estimate the amount of time it takes to gather data for an individual unit.
I am quickly learning that conducting a successful quality improvement project requires one to be forward-looking in an attempt to identify challenges before they arise. With respect to coordinating data collection, it may have been helpful for us to initially meet with hospital staff to identify the best staff for coordinating data collection efforts (i.e. physician, nurse, trainee) within each individual unit. This could potentially have helped us to also better communicate and recruit individuals to partner with us for our project.
I am continuing to enjoy the challenges of performing a quality improvement project. One skill that I have developed is learning how to be forward-thinking in my approach to research in an attempt to handle challenges prospectively, as opposed to retrospectively. This has helped me improve everything from how I think about data collection to how I think about displaying results. I am truly grateful to my mentor Dr. Jenkins for his help in this regard.
Victor Ekuta is a third-year medical student at UC San Diego.
VIDEO: Balanced crystalloids protect kidney better than saline
TORONTO – Treatment with balanced crystalloid IV fluids cut adverse renal events modestly but with statistical significance, compared with 0.9% saline in hospitalized patients in a pair of single-center randomized trials with more than 29,000 total patients.
Despite showing a number needed to treat with balanced crystalloids of roughly 100 to prevent one major renal event, compared with saline, the scope of IV fluid use makes even this relatively small improvement potentially important to tens of thousands of patients annually.
“It’s a small but clinically important difference,” Wesley H. Self, MD, said at the CHEST annual meeting.
“These fluids are used every day and in millions of patients annually in the United States and worldwide. There is no functional cost difference between them, and now we have the data to show that [balanced crystalloid fluids] produce a better patient outcome. It’s reasonable to consider changing practice,” based on the results, said Matthew W. Semler, MD, a pulmonologist at Vanderbilt University Medical Center in Nashville, Tenn., who led one of the two trials.
At Vanderbilt, where the two studies ran, “we’ve changed our practice and are transitioning from primarily using saline to primarily balanced crystalloid,” Dr. Semler said in a video interview. The main limitation to changing practice now because of the results is that the two trials both ran at a single center.
The findings Dr. Semler reported came from the Isotonic Solutions and Major Adverse Renal Events Trial (SMART), which randomized 7,860 ICU patients to treatment with 0.9% saline fluid and 7,942 ICU patients to treatment with balanced crystalloid fluid, either lactated Ringer’s or Plasma-Lyte A. The study’s primary endpoint was the combined 30-day rate of in-hospital death, incident need for renal replacement therapy, or at least a doubling of the patient’s baseline creatinine level, a marker of persistent renal dysfunction.
This outcome occurred in 14.3% of patients on balanced crystalloid fluid and 15.4% on saline, a 1.1% statistically significant absolute difference. The endpoint components showed that patients treated with balanced crystalloid had 0.8% less in-hospital death and 0.4% less incident renal replacement therapy; both of these between-group differences were close to having statistical significance. The two treatment groups showed less difference in the rate of persistent renal dysfunction.
The second trial had an identical design but ran instead in the emergency department. The Saline Against Lactated Ringers or Plasmalyte in the Emergency Department (SALT-ED) trial randomized 6,708 to receive balanced crystalloid and 6,639 to receive saline. The combined primary renal endpoint was 0.9% less frequent with balanced crystalloid fluid, a statistically significant difference, Dr. Self, an emergency medicine physician at Vanderbilt, reported at the meeting. In this study the between-group differences for both incident renal replacement therapy and persistent renal dysfunction were statistically significant in favor of balanced crystalloid, but the between-group mortality difference was not significantly different.
The reason why balanced crystalloid fluid produced better renal outcomes than saline remains unclear. Both Dr. Semler and Dr. Self noted that the two balanced crystalloid fluids used in the study have chloride levels that closely match normal plasma levels, but the chloride concentration in 0.9% saline is about 50% higher than plasma. Some researchers have hypothesized, based on animal findings, that this difference may influence inflammation, blood pressure, acute kidney injury, and renal vasoconstriction.
The SMART and SALT-ED trials received no commercial funding. Dr. Semler had no disclosures. Dr. Self has been a consultant to Abbott Point of Care, BioTest, Cempra, Ferring, Gilead, and Pfizer.
[email protected]
On Twitter @mitchelzoler
Bennett P. deBoisblanc, MD , is professor of medicine at Louisiana State University Health and director of Critical Care Services at the Medical Center of Louisiana in New Orleans. He had no disclosures. He made these comments from the floor during discussion of the two reports.
Bennett P. deBoisblanc, MD , is professor of medicine at Louisiana State University Health and director of Critical Care Services at the Medical Center of Louisiana in New Orleans. He had no disclosures. He made these comments from the floor during discussion of the two reports.
Bennett P. deBoisblanc, MD , is professor of medicine at Louisiana State University Health and director of Critical Care Services at the Medical Center of Louisiana in New Orleans. He had no disclosures. He made these comments from the floor during discussion of the two reports.
TORONTO – Treatment with balanced crystalloid IV fluids cut adverse renal events modestly but with statistical significance, compared with 0.9% saline in hospitalized patients in a pair of single-center randomized trials with more than 29,000 total patients.
Despite showing a number needed to treat with balanced crystalloids of roughly 100 to prevent one major renal event, compared with saline, the scope of IV fluid use makes even this relatively small improvement potentially important to tens of thousands of patients annually.
“It’s a small but clinically important difference,” Wesley H. Self, MD, said at the CHEST annual meeting.
“These fluids are used every day and in millions of patients annually in the United States and worldwide. There is no functional cost difference between them, and now we have the data to show that [balanced crystalloid fluids] produce a better patient outcome. It’s reasonable to consider changing practice,” based on the results, said Matthew W. Semler, MD, a pulmonologist at Vanderbilt University Medical Center in Nashville, Tenn., who led one of the two trials.
At Vanderbilt, where the two studies ran, “we’ve changed our practice and are transitioning from primarily using saline to primarily balanced crystalloid,” Dr. Semler said in a video interview. The main limitation to changing practice now because of the results is that the two trials both ran at a single center.
The findings Dr. Semler reported came from the Isotonic Solutions and Major Adverse Renal Events Trial (SMART), which randomized 7,860 ICU patients to treatment with 0.9% saline fluid and 7,942 ICU patients to treatment with balanced crystalloid fluid, either lactated Ringer’s or Plasma-Lyte A. The study’s primary endpoint was the combined 30-day rate of in-hospital death, incident need for renal replacement therapy, or at least a doubling of the patient’s baseline creatinine level, a marker of persistent renal dysfunction.
This outcome occurred in 14.3% of patients on balanced crystalloid fluid and 15.4% on saline, a 1.1% statistically significant absolute difference. The endpoint components showed that patients treated with balanced crystalloid had 0.8% less in-hospital death and 0.4% less incident renal replacement therapy; both of these between-group differences were close to having statistical significance. The two treatment groups showed less difference in the rate of persistent renal dysfunction.
The second trial had an identical design but ran instead in the emergency department. The Saline Against Lactated Ringers or Plasmalyte in the Emergency Department (SALT-ED) trial randomized 6,708 to receive balanced crystalloid and 6,639 to receive saline. The combined primary renal endpoint was 0.9% less frequent with balanced crystalloid fluid, a statistically significant difference, Dr. Self, an emergency medicine physician at Vanderbilt, reported at the meeting. In this study the between-group differences for both incident renal replacement therapy and persistent renal dysfunction were statistically significant in favor of balanced crystalloid, but the between-group mortality difference was not significantly different.
The reason why balanced crystalloid fluid produced better renal outcomes than saline remains unclear. Both Dr. Semler and Dr. Self noted that the two balanced crystalloid fluids used in the study have chloride levels that closely match normal plasma levels, but the chloride concentration in 0.9% saline is about 50% higher than plasma. Some researchers have hypothesized, based on animal findings, that this difference may influence inflammation, blood pressure, acute kidney injury, and renal vasoconstriction.
The SMART and SALT-ED trials received no commercial funding. Dr. Semler had no disclosures. Dr. Self has been a consultant to Abbott Point of Care, BioTest, Cempra, Ferring, Gilead, and Pfizer.
[email protected]
On Twitter @mitchelzoler
TORONTO – Treatment with balanced crystalloid IV fluids cut adverse renal events modestly but with statistical significance, compared with 0.9% saline in hospitalized patients in a pair of single-center randomized trials with more than 29,000 total patients.
Despite showing a number needed to treat with balanced crystalloids of roughly 100 to prevent one major renal event, compared with saline, the scope of IV fluid use makes even this relatively small improvement potentially important to tens of thousands of patients annually.
“It’s a small but clinically important difference,” Wesley H. Self, MD, said at the CHEST annual meeting.
“These fluids are used every day and in millions of patients annually in the United States and worldwide. There is no functional cost difference between them, and now we have the data to show that [balanced crystalloid fluids] produce a better patient outcome. It’s reasonable to consider changing practice,” based on the results, said Matthew W. Semler, MD, a pulmonologist at Vanderbilt University Medical Center in Nashville, Tenn., who led one of the two trials.
At Vanderbilt, where the two studies ran, “we’ve changed our practice and are transitioning from primarily using saline to primarily balanced crystalloid,” Dr. Semler said in a video interview. The main limitation to changing practice now because of the results is that the two trials both ran at a single center.
The findings Dr. Semler reported came from the Isotonic Solutions and Major Adverse Renal Events Trial (SMART), which randomized 7,860 ICU patients to treatment with 0.9% saline fluid and 7,942 ICU patients to treatment with balanced crystalloid fluid, either lactated Ringer’s or Plasma-Lyte A. The study’s primary endpoint was the combined 30-day rate of in-hospital death, incident need for renal replacement therapy, or at least a doubling of the patient’s baseline creatinine level, a marker of persistent renal dysfunction.
This outcome occurred in 14.3% of patients on balanced crystalloid fluid and 15.4% on saline, a 1.1% statistically significant absolute difference. The endpoint components showed that patients treated with balanced crystalloid had 0.8% less in-hospital death and 0.4% less incident renal replacement therapy; both of these between-group differences were close to having statistical significance. The two treatment groups showed less difference in the rate of persistent renal dysfunction.
The second trial had an identical design but ran instead in the emergency department. The Saline Against Lactated Ringers or Plasmalyte in the Emergency Department (SALT-ED) trial randomized 6,708 to receive balanced crystalloid and 6,639 to receive saline. The combined primary renal endpoint was 0.9% less frequent with balanced crystalloid fluid, a statistically significant difference, Dr. Self, an emergency medicine physician at Vanderbilt, reported at the meeting. In this study the between-group differences for both incident renal replacement therapy and persistent renal dysfunction were statistically significant in favor of balanced crystalloid, but the between-group mortality difference was not significantly different.
The reason why balanced crystalloid fluid produced better renal outcomes than saline remains unclear. Both Dr. Semler and Dr. Self noted that the two balanced crystalloid fluids used in the study have chloride levels that closely match normal plasma levels, but the chloride concentration in 0.9% saline is about 50% higher than plasma. Some researchers have hypothesized, based on animal findings, that this difference may influence inflammation, blood pressure, acute kidney injury, and renal vasoconstriction.
The SMART and SALT-ED trials received no commercial funding. Dr. Semler had no disclosures. Dr. Self has been a consultant to Abbott Point of Care, BioTest, Cempra, Ferring, Gilead, and Pfizer.
[email protected]
On Twitter @mitchelzoler
AT CHEST 2017
Key clinical point:
Major finding: Balanced crystalloids reduced combined adverse renal events by 1.1% in ICU patients and 0.9% in ED patients.
Data source: The SMART and SALT-ED trials, both single-center studies with a total of 29,149 patients.
Disclosures: The SMART and SALT-ED trials received no commercial funding. Dr. Semler had no disclosures. Dr. Self has been a consultant to Abbott Point of Care, BioTest, Cempra, Ferring, Gilead, and Pfizer.
Improving transitions for elderly patients
Transitions are always a time of concern for hospitalists, and the transition from hospital to skilled nursing facilities (SNF) is no exception.
“During the transition and in the 30 days after discharge from the hospital to a SNF, patients are at high risk for death, rehospitalization, and high-cost health care,” said Amber Moore, MD, MPH, a hospitalist at Beth Israel Deaconess Medical Center, and instructor of medicine, Harvard Medical School. “Elderly adults are especially vulnerable because of impairments that may prevent them from participating in the discharge process and an increase in the risk that information is lost or incomplete during the care transition.” 
To address this, she and several other physicians studied a novel video-conference program called Extension for Community Health Outcomes–Care Transitions (ECHO-CT) that connects an interdisciplinary hospital-based team with clinicians at SNFs to help reduce patient mortality, hospital readmission, skilled nursing facility length of stay, and 30-day health care costs.
The results of their study suggest that this intervention significantly decreased SNF length of stay, readmission rate, and costs of care, she says; the model they used is reproducible and has the potential to significantly improve care of these patients. “Our model was hospitalist run and is a mechanism to help hospitalists improve care to their patients during the transition time and beyond,” Dr. Moore said. “Furthermore, in participating in this model, hospitalists have the opportunity to better understand the challenges that face their patients after discharge and learn from postacute care providers.”
Ideally, she would like to see the model spread to other hospitals; she says hospitalists are well positioned to set up this program at their institution. “I also hope that our study highlights the incredible opportunity for improvement in the care of patients during transition from hospital to SNF and encourages hospitalists to look for innovative ways to improve care at this transition,” she said.
Reference
Moore AB, Krupp JE, Dufour AB, et al. Improving transitions to post-acute care for elderly patients using a novel video-conferencing program: ECHO-Care transitions. Am J Med. 2017 Oct;130(10):1199-204. Accessed June 6, 2017.
Transitions are always a time of concern for hospitalists, and the transition from hospital to skilled nursing facilities (SNF) is no exception.
“During the transition and in the 30 days after discharge from the hospital to a SNF, patients are at high risk for death, rehospitalization, and high-cost health care,” said Amber Moore, MD, MPH, a hospitalist at Beth Israel Deaconess Medical Center, and instructor of medicine, Harvard Medical School. “Elderly adults are especially vulnerable because of impairments that may prevent them from participating in the discharge process and an increase in the risk that information is lost or incomplete during the care transition.”
To address this, she and several other physicians studied a novel video-conference program called Extension for Community Health Outcomes–Care Transitions (ECHO-CT) that connects an interdisciplinary hospital-based team with clinicians at SNFs to help reduce patient mortality, hospital readmission, skilled nursing facility length of stay, and 30-day health care costs.
The results of their study suggest that this intervention significantly decreased SNF length of stay, readmission rate, and costs of care, she says; the model they used is reproducible and has the potential to significantly improve care of these patients. “Our model was hospitalist run and is a mechanism to help hospitalists improve care to their patients during the transition time and beyond,” Dr. Moore said. “Furthermore, in participating in this model, hospitalists have the opportunity to better understand the challenges that face their patients after discharge and learn from postacute care providers.”
Ideally, she would like to see the model spread to other hospitals; she says hospitalists are well positioned to set up this program at their institution. “I also hope that our study highlights the incredible opportunity for improvement in the care of patients during transition from hospital to SNF and encourages hospitalists to look for innovative ways to improve care at this transition,” she said.
Reference
Moore AB, Krupp JE, Dufour AB, et al. Improving transitions to post-acute care for elderly patients using a novel video-conferencing program: ECHO-Care transitions. Am J Med. 2017 Oct;130(10):1199-204. Accessed June 6, 2017.
Transitions are always a time of concern for hospitalists, and the transition from hospital to skilled nursing facilities (SNF) is no exception.
“During the transition and in the 30 days after discharge from the hospital to a SNF, patients are at high risk for death, rehospitalization, and high-cost health care,” said Amber Moore, MD, MPH, a hospitalist at Beth Israel Deaconess Medical Center, and instructor of medicine, Harvard Medical School. “Elderly adults are especially vulnerable because of impairments that may prevent them from participating in the discharge process and an increase in the risk that information is lost or incomplete during the care transition.”
To address this, she and several other physicians studied a novel video-conference program called Extension for Community Health Outcomes–Care Transitions (ECHO-CT) that connects an interdisciplinary hospital-based team with clinicians at SNFs to help reduce patient mortality, hospital readmission, skilled nursing facility length of stay, and 30-day health care costs.
The results of their study suggest that this intervention significantly decreased SNF length of stay, readmission rate, and costs of care, she says; the model they used is reproducible and has the potential to significantly improve care of these patients. “Our model was hospitalist run and is a mechanism to help hospitalists improve care to their patients during the transition time and beyond,” Dr. Moore said. “Furthermore, in participating in this model, hospitalists have the opportunity to better understand the challenges that face their patients after discharge and learn from postacute care providers.”
Ideally, she would like to see the model spread to other hospitals; she says hospitalists are well positioned to set up this program at their institution. “I also hope that our study highlights the incredible opportunity for improvement in the care of patients during transition from hospital to SNF and encourages hospitalists to look for innovative ways to improve care at this transition,” she said.
Reference
Moore AB, Krupp JE, Dufour AB, et al. Improving transitions to post-acute care for elderly patients using a novel video-conferencing program: ECHO-Care transitions. Am J Med. 2017 Oct;130(10):1199-204. Accessed June 6, 2017.
Some measures to control HAI sound better than they perform
SAN DIEGO – Some almost universally accepted measures against hospital-acquired infections are more costly, annoying, and time consuming than they’re worth, presenters agreed during a panel discussion at the annual clinical congress of the American College of Surgeons.
Intra-abdominal antibiotic irrigation, chlorhexidine bathing, and even postsurgical antibiotic infusions have not consistently been shown to reduce infections. These measures do, however, ratchet up costs and can contribute to antibiotic resistance.
Some of these and other measures to prevent nosocomial infections may indeed reduce the risk, but the gain is small, said Charles H. Cook, MD.
“Chlorhexidine bathing, for example, is touted by many as a panacea for all the infections we’re talking about,” said Dr. Cook, a critical care surgeon at Beth Israel Deaconess Medical Center, New York. “A recent meta-analysis in critical care units did find a reduced relative risk of 0.44 for central line bloodstream infections. But you needed to bathe 360 patients to prevent one infection. It’s what I call a long run for a short slide.”
Therese Duane, MD, FACS, agreed. A surgeon at the John Peter Smith Hospital, Ft. Worth, Tex., Dr. Duane reviewed three different guidelines for the prevention of surgical site infections: the ACS and Surgical Infection Society, the World Health Organization, and the Centers for Disease Control and Prevention. In looking for similarities between the documents, she said she found several well-accepted practices that just aren’t supported by good data.
Presurgical antimicrobial infusions got a strong thumbs-up from all the groups, but only under a very specific circumstance: The medication has to be administered well in advance of surgery for it to be effective.
“Your goal is to get the appropriate concentration into the tissues by the time of incision,” Dr. Duane said. “It takes time to get there – if you give it after the incision, you have bleeding and cellular death, and the antimicrobials cannot get to that incision and do their job. If I’m starting a case and they haven’t been given, I don’t ever start them after the incision, because then you have all of the risks and none of the benefits. In my opinion, we need to move to no further antimicrobials once the incision or case is over because it serves no purpose and is inconsistent with good antibiotic stewardship.”
Adhesive drapes got a resounding “eh” from the guidelines, Dr. Duane said. “You really do not need them. They’re expensive and they’re not improving outcomes, so don’t waste your time or money. We need to think about minimizing what isn’t helpful and maximizing the things that are worthwhile. That’s the way to practice good socially responsible surgery without breaking the bank,” she said.
Antimicrobial sutures got weak recommendations, Dr. Duane said. The evidence supporting their use was not very strong, although she said she feels triclosan-coated sutures are helpful in all kinds of surgery. Preoperative showering with an antiseptic received strong support, with alcohol-containing preps superior to chlorhexidine, which is better than povidone-iodine–containing solutions.
Deep-space irrigation with aqueous iodophor also received a weak recommendation, but Dr. Duane said the evidence does not support the use of antibiotic-containing irrigation in either the abdomen or the incision. “And the guidelines came out strongly against using antimicrobial agents on the incision,” she said. None of the guidelines issued a recommendation for or against antimicrobial dressings.
Protocolized infection-control bundles are a very great help in reducing the incidence of surgical site infections, Dr. Duane added. “They increase attention to detail and decrease the rates of infection.”
Dr. Cook agreed. “Central line bundles are one of the things that work” for line-associated bloodstream infections, he said. Since their large-scale adoption, mortality from these infections has dropped significantly; it was hovering around 28,000 per year in the mid-2000s, he said. “That’s about how many men die from prostate cancer every year.”
Central line infections are very costly too, he added – around $46,000 per event. “That comes to around $2 billion in direct and indirect costs every year.”
A 2006 study demonstrated the efficacy of central line bundles in the fight against these potentially devastating infections.
The bundled intervention comprised hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters. The median rate of catheter-related bloodstream infections per 1,000 catheter-days decreased from 2.7 at baseline to 0 at 3 months after implementation of the study intervention.
Antibiotic-coated or impregnated catheters do not work as well. A 2016 Cochrane review of 57 studies determined that the devices didn’t improve sepsis, all-cause mortality, or catheter-related local infections.
The jury may still be out on coated dressings or securing devices, however. Another Cochrane review, of 22 studies, found a 40% decrease in central line–associated bloodstream infections with these items. “There was moderate evidence that tip colonization was reduced, but the authors said more research is needed.”
The evidence looks stronger for alcohol-impregnated port protectors, Dr. Cook said. Two studies in particular support their use. In an oncology unit, the rate of these infections dropped from 2.3 to 0.3 per 1,000 catheter days after the port protectors were instituted.
In the second study, infection rates declined from 1.43 to 0.69 per 1,000 line-days after the protectors came on board.
“The advantage was seen mostly in ICUs, so the recommendations are to use them there,” Dr. Cook said.
Neither Dr. Cook nor Dr. Duane had any relevant financial disclosures.
[email protected]
On Twitter @Alz Gal
SAN DIEGO – Some almost universally accepted measures against hospital-acquired infections are more costly, annoying, and time consuming than they’re worth, presenters agreed during a panel discussion at the annual clinical congress of the American College of Surgeons.
Intra-abdominal antibiotic irrigation, chlorhexidine bathing, and even postsurgical antibiotic infusions have not consistently been shown to reduce infections. These measures do, however, ratchet up costs and can contribute to antibiotic resistance.
Some of these and other measures to prevent nosocomial infections may indeed reduce the risk, but the gain is small, said Charles H. Cook, MD.
“Chlorhexidine bathing, for example, is touted by many as a panacea for all the infections we’re talking about,” said Dr. Cook, a critical care surgeon at Beth Israel Deaconess Medical Center, New York. “A recent meta-analysis in critical care units did find a reduced relative risk of 0.44 for central line bloodstream infections. But you needed to bathe 360 patients to prevent one infection. It’s what I call a long run for a short slide.”
Therese Duane, MD, FACS, agreed. A surgeon at the John Peter Smith Hospital, Ft. Worth, Tex., Dr. Duane reviewed three different guidelines for the prevention of surgical site infections: the ACS and Surgical Infection Society, the World Health Organization, and the Centers for Disease Control and Prevention. In looking for similarities between the documents, she said she found several well-accepted practices that just aren’t supported by good data.
Presurgical antimicrobial infusions got a strong thumbs-up from all the groups, but only under a very specific circumstance: The medication has to be administered well in advance of surgery for it to be effective.
“Your goal is to get the appropriate concentration into the tissues by the time of incision,” Dr. Duane said. “It takes time to get there – if you give it after the incision, you have bleeding and cellular death, and the antimicrobials cannot get to that incision and do their job. If I’m starting a case and they haven’t been given, I don’t ever start them after the incision, because then you have all of the risks and none of the benefits. In my opinion, we need to move to no further antimicrobials once the incision or case is over because it serves no purpose and is inconsistent with good antibiotic stewardship.”
Adhesive drapes got a resounding “eh” from the guidelines, Dr. Duane said. “You really do not need them. They’re expensive and they’re not improving outcomes, so don’t waste your time or money. We need to think about minimizing what isn’t helpful and maximizing the things that are worthwhile. That’s the way to practice good socially responsible surgery without breaking the bank,” she said.
Antimicrobial sutures got weak recommendations, Dr. Duane said. The evidence supporting their use was not very strong, although she said she feels triclosan-coated sutures are helpful in all kinds of surgery. Preoperative showering with an antiseptic received strong support, with alcohol-containing preps superior to chlorhexidine, which is better than povidone-iodine–containing solutions.
Deep-space irrigation with aqueous iodophor also received a weak recommendation, but Dr. Duane said the evidence does not support the use of antibiotic-containing irrigation in either the abdomen or the incision. “And the guidelines came out strongly against using antimicrobial agents on the incision,” she said. None of the guidelines issued a recommendation for or against antimicrobial dressings.
Protocolized infection-control bundles are a very great help in reducing the incidence of surgical site infections, Dr. Duane added. “They increase attention to detail and decrease the rates of infection.”
Dr. Cook agreed. “Central line bundles are one of the things that work” for line-associated bloodstream infections, he said. Since their large-scale adoption, mortality from these infections has dropped significantly; it was hovering around 28,000 per year in the mid-2000s, he said. “That’s about how many men die from prostate cancer every year.”
Central line infections are very costly too, he added – around $46,000 per event. “That comes to around $2 billion in direct and indirect costs every year.”
A 2006 study demonstrated the efficacy of central line bundles in the fight against these potentially devastating infections.
The bundled intervention comprised hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters. The median rate of catheter-related bloodstream infections per 1,000 catheter-days decreased from 2.7 at baseline to 0 at 3 months after implementation of the study intervention.
Antibiotic-coated or impregnated catheters do not work as well. A 2016 Cochrane review of 57 studies determined that the devices didn’t improve sepsis, all-cause mortality, or catheter-related local infections.
The jury may still be out on coated dressings or securing devices, however. Another Cochrane review, of 22 studies, found a 40% decrease in central line–associated bloodstream infections with these items. “There was moderate evidence that tip colonization was reduced, but the authors said more research is needed.”
The evidence looks stronger for alcohol-impregnated port protectors, Dr. Cook said. Two studies in particular support their use. In an oncology unit, the rate of these infections dropped from 2.3 to 0.3 per 1,000 catheter days after the port protectors were instituted.
In the second study, infection rates declined from 1.43 to 0.69 per 1,000 line-days after the protectors came on board.
“The advantage was seen mostly in ICUs, so the recommendations are to use them there,” Dr. Cook said.
Neither Dr. Cook nor Dr. Duane had any relevant financial disclosures.
[email protected]
On Twitter @Alz Gal
SAN DIEGO – Some almost universally accepted measures against hospital-acquired infections are more costly, annoying, and time consuming than they’re worth, presenters agreed during a panel discussion at the annual clinical congress of the American College of Surgeons.
Intra-abdominal antibiotic irrigation, chlorhexidine bathing, and even postsurgical antibiotic infusions have not consistently been shown to reduce infections. These measures do, however, ratchet up costs and can contribute to antibiotic resistance.
Some of these and other measures to prevent nosocomial infections may indeed reduce the risk, but the gain is small, said Charles H. Cook, MD.
“Chlorhexidine bathing, for example, is touted by many as a panacea for all the infections we’re talking about,” said Dr. Cook, a critical care surgeon at Beth Israel Deaconess Medical Center, New York. “A recent meta-analysis in critical care units did find a reduced relative risk of 0.44 for central line bloodstream infections. But you needed to bathe 360 patients to prevent one infection. It’s what I call a long run for a short slide.”
Therese Duane, MD, FACS, agreed. A surgeon at the John Peter Smith Hospital, Ft. Worth, Tex., Dr. Duane reviewed three different guidelines for the prevention of surgical site infections: the ACS and Surgical Infection Society, the World Health Organization, and the Centers for Disease Control and Prevention. In looking for similarities between the documents, she said she found several well-accepted practices that just aren’t supported by good data.
Presurgical antimicrobial infusions got a strong thumbs-up from all the groups, but only under a very specific circumstance: The medication has to be administered well in advance of surgery for it to be effective.
“Your goal is to get the appropriate concentration into the tissues by the time of incision,” Dr. Duane said. “It takes time to get there – if you give it after the incision, you have bleeding and cellular death, and the antimicrobials cannot get to that incision and do their job. If I’m starting a case and they haven’t been given, I don’t ever start them after the incision, because then you have all of the risks and none of the benefits. In my opinion, we need to move to no further antimicrobials once the incision or case is over because it serves no purpose and is inconsistent with good antibiotic stewardship.”
Adhesive drapes got a resounding “eh” from the guidelines, Dr. Duane said. “You really do not need them. They’re expensive and they’re not improving outcomes, so don’t waste your time or money. We need to think about minimizing what isn’t helpful and maximizing the things that are worthwhile. That’s the way to practice good socially responsible surgery without breaking the bank,” she said.
Antimicrobial sutures got weak recommendations, Dr. Duane said. The evidence supporting their use was not very strong, although she said she feels triclosan-coated sutures are helpful in all kinds of surgery. Preoperative showering with an antiseptic received strong support, with alcohol-containing preps superior to chlorhexidine, which is better than povidone-iodine–containing solutions.
Deep-space irrigation with aqueous iodophor also received a weak recommendation, but Dr. Duane said the evidence does not support the use of antibiotic-containing irrigation in either the abdomen or the incision. “And the guidelines came out strongly against using antimicrobial agents on the incision,” she said. None of the guidelines issued a recommendation for or against antimicrobial dressings.
Protocolized infection-control bundles are a very great help in reducing the incidence of surgical site infections, Dr. Duane added. “They increase attention to detail and decrease the rates of infection.”
Dr. Cook agreed. “Central line bundles are one of the things that work” for line-associated bloodstream infections, he said. Since their large-scale adoption, mortality from these infections has dropped significantly; it was hovering around 28,000 per year in the mid-2000s, he said. “That’s about how many men die from prostate cancer every year.”
Central line infections are very costly too, he added – around $46,000 per event. “That comes to around $2 billion in direct and indirect costs every year.”
A 2006 study demonstrated the efficacy of central line bundles in the fight against these potentially devastating infections.
The bundled intervention comprised hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters. The median rate of catheter-related bloodstream infections per 1,000 catheter-days decreased from 2.7 at baseline to 0 at 3 months after implementation of the study intervention.
Antibiotic-coated or impregnated catheters do not work as well. A 2016 Cochrane review of 57 studies determined that the devices didn’t improve sepsis, all-cause mortality, or catheter-related local infections.
The jury may still be out on coated dressings or securing devices, however. Another Cochrane review, of 22 studies, found a 40% decrease in central line–associated bloodstream infections with these items. “There was moderate evidence that tip colonization was reduced, but the authors said more research is needed.”
The evidence looks stronger for alcohol-impregnated port protectors, Dr. Cook said. Two studies in particular support their use. In an oncology unit, the rate of these infections dropped from 2.3 to 0.3 per 1,000 catheter days after the port protectors were instituted.
In the second study, infection rates declined from 1.43 to 0.69 per 1,000 line-days after the protectors came on board.
“The advantage was seen mostly in ICUs, so the recommendations are to use them there,” Dr. Cook said.
Neither Dr. Cook nor Dr. Duane had any relevant financial disclosures.
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FROM THE ACS CLINICAL CONGRESS