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Fluid Resuscitation in Sepsis: Systematic Review and Network Meta-Analysis
Clinical question: Is there any difference between different resuscitative fluids (crystalloids or colloids) on mortality in critically ill sepsis patients?
Background: Fluid resuscitation, in addition to antibiotics and source control, is a cornerstone of initial management of sepsis. Resuscitation with crystalloids compared with colloids for critically ill patients has been evaluated in large randomized, controlled trials and meta-analyses; however, whether any of these fluid properties translates into a survival advantage, particularly regarding the optimal fluid for resuscitation in critically ill sepsis patients, remains unclear.
Study design: Systematic review, network meta-analysis (NMA).
Setting: Database search in MEDLINE, Embase, ACP Journal Club, Cumulative Index to Nursing and Allied Health Literature (CINAHL), HealthSTAR, the Allied and Complementary Medicine Database (AMED), and the Cochrane Central Register of Controlled Trials (CENTRAL).
Synopsis: Of 9,875 records that involved adult (aged ≥16 years) critically ill patients with severe sepsis or septic shock who required fluid resuscitation, with no restrictions on language or publication date, 14 randomized controlled trials were considered eligible. Interventions studied included any fluid or fluid strategy used for resuscitation compared with another fluid or fluid strategy. The endpoint was 90-day mortality or, if not available, 30-day intensive care unit or hospital mortality, whichever was longest. The analysis classified fluids as crystalloids or colloids. The relevant analyses were a four-node NMA (crystalloids vs. albumin vs. HES [hydroxyethyl starch] vs. gelatin) and a six-node NMA (crystalloids vs. albumin vs. HES vs. gelatin, with crystalloids divided into balanced or unbalanced and HES divided into low or high molecular weight), and a conventional fixed-effects meta-analytic comparison of crystalloids vs. colloids.
In the four-node analysis, the results suggested higher mortality with starches (vs. crystalloids) and lower mortality with albumin (vs. crystalloids and starches). In the six-node analysis, the results suggested that albumin is superior to saline and low molecular weight starch, and balanced crystalloids are superior to saline and starch (both high and low molecular weight).
These results highlight potentially important differences in mortality among solutions; it suggests an advantage of balanced crystalloids versus saline and low or high molecular weight starch, with similar mortality results for balanced crystalloids and albumin. These differences were not detectable using a standard meta-analytic approach directly comparing “any crystalloids vs. any colloids.” Biological rationale is consistent with the findings of lower mortality with balanced crystalloid solutions than with saline, as it mimics the homeostatic composition of body fluids to a greater extent than unbalanced fluids.
These results raise concerns about using unbalanced crystalloids in the acute resuscitation of patients with sepsis.
Bottom line: Among patients with sepsis, resuscitation with balanced crystalloids or albumin is associated with reduced mortality compared to other fluids.
Clinical question: Is there any difference between different resuscitative fluids (crystalloids or colloids) on mortality in critically ill sepsis patients?
Background: Fluid resuscitation, in addition to antibiotics and source control, is a cornerstone of initial management of sepsis. Resuscitation with crystalloids compared with colloids for critically ill patients has been evaluated in large randomized, controlled trials and meta-analyses; however, whether any of these fluid properties translates into a survival advantage, particularly regarding the optimal fluid for resuscitation in critically ill sepsis patients, remains unclear.
Study design: Systematic review, network meta-analysis (NMA).
Setting: Database search in MEDLINE, Embase, ACP Journal Club, Cumulative Index to Nursing and Allied Health Literature (CINAHL), HealthSTAR, the Allied and Complementary Medicine Database (AMED), and the Cochrane Central Register of Controlled Trials (CENTRAL).
Synopsis: Of 9,875 records that involved adult (aged ≥16 years) critically ill patients with severe sepsis or septic shock who required fluid resuscitation, with no restrictions on language or publication date, 14 randomized controlled trials were considered eligible. Interventions studied included any fluid or fluid strategy used for resuscitation compared with another fluid or fluid strategy. The endpoint was 90-day mortality or, if not available, 30-day intensive care unit or hospital mortality, whichever was longest. The analysis classified fluids as crystalloids or colloids. The relevant analyses were a four-node NMA (crystalloids vs. albumin vs. HES [hydroxyethyl starch] vs. gelatin) and a six-node NMA (crystalloids vs. albumin vs. HES vs. gelatin, with crystalloids divided into balanced or unbalanced and HES divided into low or high molecular weight), and a conventional fixed-effects meta-analytic comparison of crystalloids vs. colloids.
In the four-node analysis, the results suggested higher mortality with starches (vs. crystalloids) and lower mortality with albumin (vs. crystalloids and starches). In the six-node analysis, the results suggested that albumin is superior to saline and low molecular weight starch, and balanced crystalloids are superior to saline and starch (both high and low molecular weight).
These results highlight potentially important differences in mortality among solutions; it suggests an advantage of balanced crystalloids versus saline and low or high molecular weight starch, with similar mortality results for balanced crystalloids and albumin. These differences were not detectable using a standard meta-analytic approach directly comparing “any crystalloids vs. any colloids.” Biological rationale is consistent with the findings of lower mortality with balanced crystalloid solutions than with saline, as it mimics the homeostatic composition of body fluids to a greater extent than unbalanced fluids.
These results raise concerns about using unbalanced crystalloids in the acute resuscitation of patients with sepsis.
Bottom line: Among patients with sepsis, resuscitation with balanced crystalloids or albumin is associated with reduced mortality compared to other fluids.
Clinical question: Is there any difference between different resuscitative fluids (crystalloids or colloids) on mortality in critically ill sepsis patients?
Background: Fluid resuscitation, in addition to antibiotics and source control, is a cornerstone of initial management of sepsis. Resuscitation with crystalloids compared with colloids for critically ill patients has been evaluated in large randomized, controlled trials and meta-analyses; however, whether any of these fluid properties translates into a survival advantage, particularly regarding the optimal fluid for resuscitation in critically ill sepsis patients, remains unclear.
Study design: Systematic review, network meta-analysis (NMA).
Setting: Database search in MEDLINE, Embase, ACP Journal Club, Cumulative Index to Nursing and Allied Health Literature (CINAHL), HealthSTAR, the Allied and Complementary Medicine Database (AMED), and the Cochrane Central Register of Controlled Trials (CENTRAL).
Synopsis: Of 9,875 records that involved adult (aged ≥16 years) critically ill patients with severe sepsis or septic shock who required fluid resuscitation, with no restrictions on language or publication date, 14 randomized controlled trials were considered eligible. Interventions studied included any fluid or fluid strategy used for resuscitation compared with another fluid or fluid strategy. The endpoint was 90-day mortality or, if not available, 30-day intensive care unit or hospital mortality, whichever was longest. The analysis classified fluids as crystalloids or colloids. The relevant analyses were a four-node NMA (crystalloids vs. albumin vs. HES [hydroxyethyl starch] vs. gelatin) and a six-node NMA (crystalloids vs. albumin vs. HES vs. gelatin, with crystalloids divided into balanced or unbalanced and HES divided into low or high molecular weight), and a conventional fixed-effects meta-analytic comparison of crystalloids vs. colloids.
In the four-node analysis, the results suggested higher mortality with starches (vs. crystalloids) and lower mortality with albumin (vs. crystalloids and starches). In the six-node analysis, the results suggested that albumin is superior to saline and low molecular weight starch, and balanced crystalloids are superior to saline and starch (both high and low molecular weight).
These results highlight potentially important differences in mortality among solutions; it suggests an advantage of balanced crystalloids versus saline and low or high molecular weight starch, with similar mortality results for balanced crystalloids and albumin. These differences were not detectable using a standard meta-analytic approach directly comparing “any crystalloids vs. any colloids.” Biological rationale is consistent with the findings of lower mortality with balanced crystalloid solutions than with saline, as it mimics the homeostatic composition of body fluids to a greater extent than unbalanced fluids.
These results raise concerns about using unbalanced crystalloids in the acute resuscitation of patients with sepsis.
Bottom line: Among patients with sepsis, resuscitation with balanced crystalloids or albumin is associated with reduced mortality compared to other fluids.
Hip Fracture Adverse Outcomes Among Nursing Home Residents
Clinical question: What are the risk factors for mortality and functional decline following hip fracture among nursing home residents?
Background: Little is known about the survival and functional outcomes of nursing home residents who sustain hip fracture. Previous studies on hip fracture have either excluded nursing home residents or have been limited by small sample size.
Study design: Retrospective cohort study.
Setting: Fee-for-service Medicare beneficiaries.
Synopsis: This retrospective study of 60,111 patients residing in nursing homes who were hospitalized for hip fracture between 2005 and 2010 found that 36.2% died within six months. Within this cohort, 53.5% of the patients who did not have total dependence prior to the hip fracture either died or became totally disabled within six months.
Specifically, patients older than 90 years (vs. those younger than 75 years: RR 1.42; P<0.001), with severe cognitive impairment (vs. intact cognition: RR 1.66, P<0.001), and receiving nonoperative management (vs. internal fixation: RR 1.48, P<0.001) had a higher combined risk of death or new total dependence in locomotion within six months of the hip fracture.
The findings suggest there is substantial mortality and functional decline following hip fracture among residents in nursing homes. A profound decrease in activities of daily living across the spectrum was observed. Interestingly, patients who underwent nonoperative treatment, even after risk adjustment, were more likely to have adverse outcomes, suggesting surgery should be considered, if consistent with the patient’s overall goal of care.
Bottom line: Significant mortality and functional decline occurs following hip fracture among nursing home patients. Patients with severe cognitive impairment, older age (more than 90 years), and receiving nonoperative treatment are more likely to die or develop complete dependence in locomotion.
Clinical question: What are the risk factors for mortality and functional decline following hip fracture among nursing home residents?
Background: Little is known about the survival and functional outcomes of nursing home residents who sustain hip fracture. Previous studies on hip fracture have either excluded nursing home residents or have been limited by small sample size.
Study design: Retrospective cohort study.
Setting: Fee-for-service Medicare beneficiaries.
Synopsis: This retrospective study of 60,111 patients residing in nursing homes who were hospitalized for hip fracture between 2005 and 2010 found that 36.2% died within six months. Within this cohort, 53.5% of the patients who did not have total dependence prior to the hip fracture either died or became totally disabled within six months.
Specifically, patients older than 90 years (vs. those younger than 75 years: RR 1.42; P<0.001), with severe cognitive impairment (vs. intact cognition: RR 1.66, P<0.001), and receiving nonoperative management (vs. internal fixation: RR 1.48, P<0.001) had a higher combined risk of death or new total dependence in locomotion within six months of the hip fracture.
The findings suggest there is substantial mortality and functional decline following hip fracture among residents in nursing homes. A profound decrease in activities of daily living across the spectrum was observed. Interestingly, patients who underwent nonoperative treatment, even after risk adjustment, were more likely to have adverse outcomes, suggesting surgery should be considered, if consistent with the patient’s overall goal of care.
Bottom line: Significant mortality and functional decline occurs following hip fracture among nursing home patients. Patients with severe cognitive impairment, older age (more than 90 years), and receiving nonoperative treatment are more likely to die or develop complete dependence in locomotion.
Clinical question: What are the risk factors for mortality and functional decline following hip fracture among nursing home residents?
Background: Little is known about the survival and functional outcomes of nursing home residents who sustain hip fracture. Previous studies on hip fracture have either excluded nursing home residents or have been limited by small sample size.
Study design: Retrospective cohort study.
Setting: Fee-for-service Medicare beneficiaries.
Synopsis: This retrospective study of 60,111 patients residing in nursing homes who were hospitalized for hip fracture between 2005 and 2010 found that 36.2% died within six months. Within this cohort, 53.5% of the patients who did not have total dependence prior to the hip fracture either died or became totally disabled within six months.
Specifically, patients older than 90 years (vs. those younger than 75 years: RR 1.42; P<0.001), with severe cognitive impairment (vs. intact cognition: RR 1.66, P<0.001), and receiving nonoperative management (vs. internal fixation: RR 1.48, P<0.001) had a higher combined risk of death or new total dependence in locomotion within six months of the hip fracture.
The findings suggest there is substantial mortality and functional decline following hip fracture among residents in nursing homes. A profound decrease in activities of daily living across the spectrum was observed. Interestingly, patients who underwent nonoperative treatment, even after risk adjustment, were more likely to have adverse outcomes, suggesting surgery should be considered, if consistent with the patient’s overall goal of care.
Bottom line: Significant mortality and functional decline occurs following hip fracture among nursing home patients. Patients with severe cognitive impairment, older age (more than 90 years), and receiving nonoperative treatment are more likely to die or develop complete dependence in locomotion.
Post-Operative Pneumonia Reduced by Standardization in Noncritical Surgical Patients
Clinical question: What is the long-term effectiveness of a standardized pneumonia prevention program among surgical noncritical inpatients?
Background: Few studies have focused on the prevention of post-operative pneumonia in non-mechanically ventilated patients. The current study describes the effectiveness of an intervention designed to reduce post-operative pneumonia among noncritical patients who did not require mechanical ventilation.
Study design: Retrospective, cohort study.
Setting: University-affiliated VA hospital involving all noncardiac surgical patients.
Synopsis: A standardized pneumonia prevention program was implemented in 2007 in noncritical care settings for noncardiac surgery patients. Post-operative pneumonia rates were compared to pre-intervention and to American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) benchmarks. Rates of post-operative pneumonia following the intervention dropped from 0.78% to 0.44%, a 43% decrease (P=0.01). Both pre- and post-intervention rates were significantly better than those reported in the ACS-NSQIP database (2.56%).
It was proposed that widespread implementation of the program could lead to a 43% reduction of pneumonia cases in the ACS-NSQIP population, which would translate into a cost savings of more than $280 million.
Bottom line: A sustained reduction of post-operative pneumonia among noncritical surgical patients can be achieved by a standardized pneumonia prevention program, which may lead to improved outcomes and substantial cost savings.
Clinical question: What is the long-term effectiveness of a standardized pneumonia prevention program among surgical noncritical inpatients?
Background: Few studies have focused on the prevention of post-operative pneumonia in non-mechanically ventilated patients. The current study describes the effectiveness of an intervention designed to reduce post-operative pneumonia among noncritical patients who did not require mechanical ventilation.
Study design: Retrospective, cohort study.
Setting: University-affiliated VA hospital involving all noncardiac surgical patients.
Synopsis: A standardized pneumonia prevention program was implemented in 2007 in noncritical care settings for noncardiac surgery patients. Post-operative pneumonia rates were compared to pre-intervention and to American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) benchmarks. Rates of post-operative pneumonia following the intervention dropped from 0.78% to 0.44%, a 43% decrease (P=0.01). Both pre- and post-intervention rates were significantly better than those reported in the ACS-NSQIP database (2.56%).
It was proposed that widespread implementation of the program could lead to a 43% reduction of pneumonia cases in the ACS-NSQIP population, which would translate into a cost savings of more than $280 million.
Bottom line: A sustained reduction of post-operative pneumonia among noncritical surgical patients can be achieved by a standardized pneumonia prevention program, which may lead to improved outcomes and substantial cost savings.
Clinical question: What is the long-term effectiveness of a standardized pneumonia prevention program among surgical noncritical inpatients?
Background: Few studies have focused on the prevention of post-operative pneumonia in non-mechanically ventilated patients. The current study describes the effectiveness of an intervention designed to reduce post-operative pneumonia among noncritical patients who did not require mechanical ventilation.
Study design: Retrospective, cohort study.
Setting: University-affiliated VA hospital involving all noncardiac surgical patients.
Synopsis: A standardized pneumonia prevention program was implemented in 2007 in noncritical care settings for noncardiac surgery patients. Post-operative pneumonia rates were compared to pre-intervention and to American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) benchmarks. Rates of post-operative pneumonia following the intervention dropped from 0.78% to 0.44%, a 43% decrease (P=0.01). Both pre- and post-intervention rates were significantly better than those reported in the ACS-NSQIP database (2.56%).
It was proposed that widespread implementation of the program could lead to a 43% reduction of pneumonia cases in the ACS-NSQIP population, which would translate into a cost savings of more than $280 million.
Bottom line: A sustained reduction of post-operative pneumonia among noncritical surgical patients can be achieved by a standardized pneumonia prevention program, which may lead to improved outcomes and substantial cost savings.
Aspirin vs. Anticoagulation for VTE Prevention in Lower Extremity Orthopedic Surgery
Clinical question: What are rates of venous thromboembolism (VTE) and bleeding among adult patients receiving aspirin versus anticoagulants after major lower extremity orthopedic surgery?
Background: VTE is common after hip fracture surgery and elective total knee/hip arthroplasty. National guidelines recommend pharmacologic thromboprophylaxis but leave clinicians to select the specific agents. The efficiency and safety of aspirin in these patient populations, compared to other anticoagulants, has been a source of great controversy.
Study design: Meta-analysis.
Setting: Eight randomized trials in the U.S., Spain, Sweden, and Canada.
Synopsis: The trials included 1,408 subjects; aspirin was compared with other anticoagulants for VTE prevention and bleeding after major lower extremity orthopedic surgery. The primary outcome was the rate of proximal deep vein thrombosis (DVT). The different classes of anticoagulants included warfarin, heparin, low molecular weight heparin (LMWH), and danaparoid. Treatment duration was seven to 21 days with clinical follow-up extended up to six months.
Overall rates of DVT did not differ statistically between aspirin and anticoagulants (10.4% vs. 9.2%); however, the balance of risk versus benefit of aspirin compared to anticoagulation differed according to type of surgery; there was a nonsignificant trend favoring anticoagulation for VTE prevention following hip fracture repair, but no difference was found for knee/hip arthroplasty. The risk of bleeding was lower with aspirin than with anticoagulants following hip fracture repair (3.1% vs. 10%) and knee/hip arthroplasty (3.9% vs. 7.8%).
Rates of pulmonary embolism were too low in all the groups to provide reliable estimates.
Bottom line: Aspirin may be associated with higher risk of VTE following hip fracture repair compared to anticoagulants, although bleeding rates were substantially lower. Aspirin was similarly effective compared to anticoagulants for VTE prevention after knee/hip arthroplasty and may be associated with lower bleeding risk.
Clinical question: What are rates of venous thromboembolism (VTE) and bleeding among adult patients receiving aspirin versus anticoagulants after major lower extremity orthopedic surgery?
Background: VTE is common after hip fracture surgery and elective total knee/hip arthroplasty. National guidelines recommend pharmacologic thromboprophylaxis but leave clinicians to select the specific agents. The efficiency and safety of aspirin in these patient populations, compared to other anticoagulants, has been a source of great controversy.
Study design: Meta-analysis.
Setting: Eight randomized trials in the U.S., Spain, Sweden, and Canada.
Synopsis: The trials included 1,408 subjects; aspirin was compared with other anticoagulants for VTE prevention and bleeding after major lower extremity orthopedic surgery. The primary outcome was the rate of proximal deep vein thrombosis (DVT). The different classes of anticoagulants included warfarin, heparin, low molecular weight heparin (LMWH), and danaparoid. Treatment duration was seven to 21 days with clinical follow-up extended up to six months.
Overall rates of DVT did not differ statistically between aspirin and anticoagulants (10.4% vs. 9.2%); however, the balance of risk versus benefit of aspirin compared to anticoagulation differed according to type of surgery; there was a nonsignificant trend favoring anticoagulation for VTE prevention following hip fracture repair, but no difference was found for knee/hip arthroplasty. The risk of bleeding was lower with aspirin than with anticoagulants following hip fracture repair (3.1% vs. 10%) and knee/hip arthroplasty (3.9% vs. 7.8%).
Rates of pulmonary embolism were too low in all the groups to provide reliable estimates.
Bottom line: Aspirin may be associated with higher risk of VTE following hip fracture repair compared to anticoagulants, although bleeding rates were substantially lower. Aspirin was similarly effective compared to anticoagulants for VTE prevention after knee/hip arthroplasty and may be associated with lower bleeding risk.
Clinical question: What are rates of venous thromboembolism (VTE) and bleeding among adult patients receiving aspirin versus anticoagulants after major lower extremity orthopedic surgery?
Background: VTE is common after hip fracture surgery and elective total knee/hip arthroplasty. National guidelines recommend pharmacologic thromboprophylaxis but leave clinicians to select the specific agents. The efficiency and safety of aspirin in these patient populations, compared to other anticoagulants, has been a source of great controversy.
Study design: Meta-analysis.
Setting: Eight randomized trials in the U.S., Spain, Sweden, and Canada.
Synopsis: The trials included 1,408 subjects; aspirin was compared with other anticoagulants for VTE prevention and bleeding after major lower extremity orthopedic surgery. The primary outcome was the rate of proximal deep vein thrombosis (DVT). The different classes of anticoagulants included warfarin, heparin, low molecular weight heparin (LMWH), and danaparoid. Treatment duration was seven to 21 days with clinical follow-up extended up to six months.
Overall rates of DVT did not differ statistically between aspirin and anticoagulants (10.4% vs. 9.2%); however, the balance of risk versus benefit of aspirin compared to anticoagulation differed according to type of surgery; there was a nonsignificant trend favoring anticoagulation for VTE prevention following hip fracture repair, but no difference was found for knee/hip arthroplasty. The risk of bleeding was lower with aspirin than with anticoagulants following hip fracture repair (3.1% vs. 10%) and knee/hip arthroplasty (3.9% vs. 7.8%).
Rates of pulmonary embolism were too low in all the groups to provide reliable estimates.
Bottom line: Aspirin may be associated with higher risk of VTE following hip fracture repair compared to anticoagulants, although bleeding rates were substantially lower. Aspirin was similarly effective compared to anticoagulants for VTE prevention after knee/hip arthroplasty and may be associated with lower bleeding risk.
Depletive Fluid Management Strategy During Weaning from Mechanical Ventilation Can Lower VAP Rates
Clinical question: What is the benefit associated with a depletive fluid management strategy on ventilator-associated complication (VAC) and ventilator-associated pneumonia (VAP) during weaning from mechanical ventilation?
Background: VAP is common in the ICU. Pulmonary edema predisposes patients to pneumonia by altering the alveolar microenvironment through enhancement of bacterial colonization and infectivity and a decrease in host bactericidal capacities. A fluid management strategy aimed at lowering lung fluid balance may prove useful in reducing both VAC and VAP.
Study design: Randomized controlled trial.
Setting: Nine ICUs in Europe and South America, between May 2007 and July 2009.
Synopsis: Data from the B-type Natriuretic Peptide for the Management of Weaning (BMW) trial was used to compare the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid management group and the usual care group during the 14 days following randomization. The trial enrolled 304 randomized patients, 152 in each group.
Compared with usual care, the interventional strategy was associated with a higher proportion of patients receiving diuretics, in higher doses, resulting in a significantly more negative fluid balance during weaning and a shorter duration of mechanical ventilation. VAC (as defined by worsening oxygenation) occurred in 13.2% of patients during the 14 days following randomization: 17.8% in the usual care group and 8.6% in the interventional group. VAP occurred in 13.5% during the 14 days following randomization: 17.8% in the usual care group and 9.2% in the interventional group.
Bottom line: A biomarker-driven, depletive fluid strategy decreases the cumulative incidence of VAC and VAP.
Clinical question: What is the benefit associated with a depletive fluid management strategy on ventilator-associated complication (VAC) and ventilator-associated pneumonia (VAP) during weaning from mechanical ventilation?
Background: VAP is common in the ICU. Pulmonary edema predisposes patients to pneumonia by altering the alveolar microenvironment through enhancement of bacterial colonization and infectivity and a decrease in host bactericidal capacities. A fluid management strategy aimed at lowering lung fluid balance may prove useful in reducing both VAC and VAP.
Study design: Randomized controlled trial.
Setting: Nine ICUs in Europe and South America, between May 2007 and July 2009.
Synopsis: Data from the B-type Natriuretic Peptide for the Management of Weaning (BMW) trial was used to compare the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid management group and the usual care group during the 14 days following randomization. The trial enrolled 304 randomized patients, 152 in each group.
Compared with usual care, the interventional strategy was associated with a higher proportion of patients receiving diuretics, in higher doses, resulting in a significantly more negative fluid balance during weaning and a shorter duration of mechanical ventilation. VAC (as defined by worsening oxygenation) occurred in 13.2% of patients during the 14 days following randomization: 17.8% in the usual care group and 8.6% in the interventional group. VAP occurred in 13.5% during the 14 days following randomization: 17.8% in the usual care group and 9.2% in the interventional group.
Bottom line: A biomarker-driven, depletive fluid strategy decreases the cumulative incidence of VAC and VAP.
Clinical question: What is the benefit associated with a depletive fluid management strategy on ventilator-associated complication (VAC) and ventilator-associated pneumonia (VAP) during weaning from mechanical ventilation?
Background: VAP is common in the ICU. Pulmonary edema predisposes patients to pneumonia by altering the alveolar microenvironment through enhancement of bacterial colonization and infectivity and a decrease in host bactericidal capacities. A fluid management strategy aimed at lowering lung fluid balance may prove useful in reducing both VAC and VAP.
Study design: Randomized controlled trial.
Setting: Nine ICUs in Europe and South America, between May 2007 and July 2009.
Synopsis: Data from the B-type Natriuretic Peptide for the Management of Weaning (BMW) trial was used to compare the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid management group and the usual care group during the 14 days following randomization. The trial enrolled 304 randomized patients, 152 in each group.
Compared with usual care, the interventional strategy was associated with a higher proportion of patients receiving diuretics, in higher doses, resulting in a significantly more negative fluid balance during weaning and a shorter duration of mechanical ventilation. VAC (as defined by worsening oxygenation) occurred in 13.2% of patients during the 14 days following randomization: 17.8% in the usual care group and 8.6% in the interventional group. VAP occurred in 13.5% during the 14 days following randomization: 17.8% in the usual care group and 9.2% in the interventional group.
Bottom line: A biomarker-driven, depletive fluid strategy decreases the cumulative incidence of VAC and VAP.
Limitations of Best Practice Alerts on Curbing Blood Transfusions
Clinical question: Why do providers continue to transfuse blood products outside of recommended guidelines, despite best practice alerts (BPAs)?
Background: There is evidence that a restrictive approach to blood transfusion versus a liberal approach is beneficial in reducing cost, morbidity, and mortality. It is unclear why providers continue to order transfusions outside of recommended guidelines in spite of interruptive prompts.
Study design: Retrospective cohort.
Setting: Academic, tertiary care medical care center in California.
Synopsis: Researchers reviewed 10,642 blood transfusion-triggered BPAs. The BPA led to abortion of only 2% of the transfusions in this study. From the predefined institutional accepted transfusion indication list, acute bleeding was the most common (34%), followed by protocol-driven behaviors in specialty services, i.e., stem cell transplant service.
“Other” accounted for 56% of the responses; of these, only 37% entered a free text comment elaborating on the reason to override. Symptomatic anemia was the most common indication cited for these blood transfusions, followed by peri-operative transfusion and anticipation of imminent discharge. The vast majority of providers who interacted with the BPA were resident physicians (55%).
The major limitation of this study is the substantial portion (>60%) of nonspecific “other” overrides.
Bottom line: Protocol-driven behaviors and subjective indications for transfusion, such as symptomatic anemia, are unlikely to be influenced by BPAs.
Clinical question: Why do providers continue to transfuse blood products outside of recommended guidelines, despite best practice alerts (BPAs)?
Background: There is evidence that a restrictive approach to blood transfusion versus a liberal approach is beneficial in reducing cost, morbidity, and mortality. It is unclear why providers continue to order transfusions outside of recommended guidelines in spite of interruptive prompts.
Study design: Retrospective cohort.
Setting: Academic, tertiary care medical care center in California.
Synopsis: Researchers reviewed 10,642 blood transfusion-triggered BPAs. The BPA led to abortion of only 2% of the transfusions in this study. From the predefined institutional accepted transfusion indication list, acute bleeding was the most common (34%), followed by protocol-driven behaviors in specialty services, i.e., stem cell transplant service.
“Other” accounted for 56% of the responses; of these, only 37% entered a free text comment elaborating on the reason to override. Symptomatic anemia was the most common indication cited for these blood transfusions, followed by peri-operative transfusion and anticipation of imminent discharge. The vast majority of providers who interacted with the BPA were resident physicians (55%).
The major limitation of this study is the substantial portion (>60%) of nonspecific “other” overrides.
Bottom line: Protocol-driven behaviors and subjective indications for transfusion, such as symptomatic anemia, are unlikely to be influenced by BPAs.
Clinical question: Why do providers continue to transfuse blood products outside of recommended guidelines, despite best practice alerts (BPAs)?
Background: There is evidence that a restrictive approach to blood transfusion versus a liberal approach is beneficial in reducing cost, morbidity, and mortality. It is unclear why providers continue to order transfusions outside of recommended guidelines in spite of interruptive prompts.
Study design: Retrospective cohort.
Setting: Academic, tertiary care medical care center in California.
Synopsis: Researchers reviewed 10,642 blood transfusion-triggered BPAs. The BPA led to abortion of only 2% of the transfusions in this study. From the predefined institutional accepted transfusion indication list, acute bleeding was the most common (34%), followed by protocol-driven behaviors in specialty services, i.e., stem cell transplant service.
“Other” accounted for 56% of the responses; of these, only 37% entered a free text comment elaborating on the reason to override. Symptomatic anemia was the most common indication cited for these blood transfusions, followed by peri-operative transfusion and anticipation of imminent discharge. The vast majority of providers who interacted with the BPA were resident physicians (55%).
The major limitation of this study is the substantial portion (>60%) of nonspecific “other” overrides.
Bottom line: Protocol-driven behaviors and subjective indications for transfusion, such as symptomatic anemia, are unlikely to be influenced by BPAs.
Peri-Operative Atrial Fibrillation, Long-Term Risk of Ischemic Stroke
Clinical question: Is there an association between peri-operative AF and long-term risk of ischemic stroke in patients undergoing any type of surgery?
Background: Peri-operative AF is usually viewed as a transient response to physiological stress, and the long-term risk of stroke after peri-operative AF is unclear. The incidence of peri-operative AF ranges widely, from 1% to 40%. Data are scarce regarding the long-term risk of stroke from peri-operative AF in patients undergoing various types of surgery.
Study design: Retrospective cohort.
Setting: Nonfederal California acute care hospitals.
Synopsis: The goal of this study was to evaluate the relationship between peri-operative AF and long-term post-operative ischemic stroke by measuring newly diagnosed AF during the index hospitalization among 1,729,360 adult patients who underwent inpatient cardiac and noncardiac surgeries between 2007 and 2010. The main outcome variable was ischemic stroke in any hospital discharge diagnosis, which was adjusted for age, sex, race, insurance status, and cardiovascular comorbidities (hypertension, diabetes mellitus, coronary heart disease, congestive heart failure, peripheral vascular disease, chronic kidney disease, and chronic obstructive pulmonary disease). Kaplan-Meier survival statistics were used to calculate cumulative rates of stroke after surgery; cumulative stroke rates were stratified by the CHA2DS2VASc score.
Of 1.73 million eligible patients with diagnoses of ischemic strokes after discharge from the index hospitalization for surgery, 24,711 had new-onset peri-operative AF during the index hospitalization, and 13,952 experienced a stroke after discharge.
At one year after hospitalization for cardiac surgery, cumulative rates of stroke were 0.99% in those with peri-operative AF and 0.83% in those without AF. At one year after noncardiac surgery, cumulative rates of stroke were 1.47% in those with peri-operative AF and 0.36% in those without AF.
In a Cox proportional hazards analysis accounting for potential confounders, peri-operative AF was associated with subsequent stroke after both cardiac and noncardiac surgery.
Bottom line: Among patients hospitalized for surgery, peri-operative AF was associated with an increased long-term risk of ischemic stroke, especially following noncardiac surgery.
Clinical question: Is there an association between peri-operative AF and long-term risk of ischemic stroke in patients undergoing any type of surgery?
Background: Peri-operative AF is usually viewed as a transient response to physiological stress, and the long-term risk of stroke after peri-operative AF is unclear. The incidence of peri-operative AF ranges widely, from 1% to 40%. Data are scarce regarding the long-term risk of stroke from peri-operative AF in patients undergoing various types of surgery.
Study design: Retrospective cohort.
Setting: Nonfederal California acute care hospitals.
Synopsis: The goal of this study was to evaluate the relationship between peri-operative AF and long-term post-operative ischemic stroke by measuring newly diagnosed AF during the index hospitalization among 1,729,360 adult patients who underwent inpatient cardiac and noncardiac surgeries between 2007 and 2010. The main outcome variable was ischemic stroke in any hospital discharge diagnosis, which was adjusted for age, sex, race, insurance status, and cardiovascular comorbidities (hypertension, diabetes mellitus, coronary heart disease, congestive heart failure, peripheral vascular disease, chronic kidney disease, and chronic obstructive pulmonary disease). Kaplan-Meier survival statistics were used to calculate cumulative rates of stroke after surgery; cumulative stroke rates were stratified by the CHA2DS2VASc score.
Of 1.73 million eligible patients with diagnoses of ischemic strokes after discharge from the index hospitalization for surgery, 24,711 had new-onset peri-operative AF during the index hospitalization, and 13,952 experienced a stroke after discharge.
At one year after hospitalization for cardiac surgery, cumulative rates of stroke were 0.99% in those with peri-operative AF and 0.83% in those without AF. At one year after noncardiac surgery, cumulative rates of stroke were 1.47% in those with peri-operative AF and 0.36% in those without AF.
In a Cox proportional hazards analysis accounting for potential confounders, peri-operative AF was associated with subsequent stroke after both cardiac and noncardiac surgery.
Bottom line: Among patients hospitalized for surgery, peri-operative AF was associated with an increased long-term risk of ischemic stroke, especially following noncardiac surgery.
Clinical question: Is there an association between peri-operative AF and long-term risk of ischemic stroke in patients undergoing any type of surgery?
Background: Peri-operative AF is usually viewed as a transient response to physiological stress, and the long-term risk of stroke after peri-operative AF is unclear. The incidence of peri-operative AF ranges widely, from 1% to 40%. Data are scarce regarding the long-term risk of stroke from peri-operative AF in patients undergoing various types of surgery.
Study design: Retrospective cohort.
Setting: Nonfederal California acute care hospitals.
Synopsis: The goal of this study was to evaluate the relationship between peri-operative AF and long-term post-operative ischemic stroke by measuring newly diagnosed AF during the index hospitalization among 1,729,360 adult patients who underwent inpatient cardiac and noncardiac surgeries between 2007 and 2010. The main outcome variable was ischemic stroke in any hospital discharge diagnosis, which was adjusted for age, sex, race, insurance status, and cardiovascular comorbidities (hypertension, diabetes mellitus, coronary heart disease, congestive heart failure, peripheral vascular disease, chronic kidney disease, and chronic obstructive pulmonary disease). Kaplan-Meier survival statistics were used to calculate cumulative rates of stroke after surgery; cumulative stroke rates were stratified by the CHA2DS2VASc score.
Of 1.73 million eligible patients with diagnoses of ischemic strokes after discharge from the index hospitalization for surgery, 24,711 had new-onset peri-operative AF during the index hospitalization, and 13,952 experienced a stroke after discharge.
At one year after hospitalization for cardiac surgery, cumulative rates of stroke were 0.99% in those with peri-operative AF and 0.83% in those without AF. At one year after noncardiac surgery, cumulative rates of stroke were 1.47% in those with peri-operative AF and 0.36% in those without AF.
In a Cox proportional hazards analysis accounting for potential confounders, peri-operative AF was associated with subsequent stroke after both cardiac and noncardiac surgery.
Bottom line: Among patients hospitalized for surgery, peri-operative AF was associated with an increased long-term risk of ischemic stroke, especially following noncardiac surgery.
Lower Health Literacy Contributes to Post-Discharge Medication Errors
Clinical question: What patient characteristics contribute to post-discharge medication errors?
Background: Post-discharge medication errors are common, but the characteristics of patients associated with those errors are not well understood.
Study design: Prospective study with patient data collected via baseline interview while hospitalized and then follow-up telephone calls at three, 30, and 90 days post discharge.
Setting: Vanderbilt Hospital, Nashville, Tenn.
Synopsis: Baseline information (race, ethnicity, education, marital status, income, social support, functional health literacy, cognition, self-rated health status, depression, preadmission medication adherence, and numeracy) was collected on adult hospitalized patients with acute coronary syndrome or acute decompensated heart failure. Post-discharge telephone interviews collected data on what medications (prescription and over the counter) patients were actually taking. Binomial logistic regression was used to determine patient characteristics that predicted discordance between the discharge medication list and the patient-reported list during the post-discharge medication review.
Of the 471 patients in the study (with a mean age of 59 years and mean total number of medications of 12), over half (51.4%) of patients were taking one or more discordant medications; 27.4% did not report a medication that was on their discharge list (omission); and 35.7% reported a medication that was not on their discharge list (commission). Further, over half (59.2%) of patients misunderstood an indication (i.e., clopidogrel is “for my stomach”), a dose, or a frequency.
Bottom line: Post-discharge medication errors are common. Lower health numeracy (the ability to use and understand numbers in daily life) and lower health literacy contributes to post-discharge medication errors.
Clinical question: What patient characteristics contribute to post-discharge medication errors?
Background: Post-discharge medication errors are common, but the characteristics of patients associated with those errors are not well understood.
Study design: Prospective study with patient data collected via baseline interview while hospitalized and then follow-up telephone calls at three, 30, and 90 days post discharge.
Setting: Vanderbilt Hospital, Nashville, Tenn.
Synopsis: Baseline information (race, ethnicity, education, marital status, income, social support, functional health literacy, cognition, self-rated health status, depression, preadmission medication adherence, and numeracy) was collected on adult hospitalized patients with acute coronary syndrome or acute decompensated heart failure. Post-discharge telephone interviews collected data on what medications (prescription and over the counter) patients were actually taking. Binomial logistic regression was used to determine patient characteristics that predicted discordance between the discharge medication list and the patient-reported list during the post-discharge medication review.
Of the 471 patients in the study (with a mean age of 59 years and mean total number of medications of 12), over half (51.4%) of patients were taking one or more discordant medications; 27.4% did not report a medication that was on their discharge list (omission); and 35.7% reported a medication that was not on their discharge list (commission). Further, over half (59.2%) of patients misunderstood an indication (i.e., clopidogrel is “for my stomach”), a dose, or a frequency.
Bottom line: Post-discharge medication errors are common. Lower health numeracy (the ability to use and understand numbers in daily life) and lower health literacy contributes to post-discharge medication errors.
Clinical question: What patient characteristics contribute to post-discharge medication errors?
Background: Post-discharge medication errors are common, but the characteristics of patients associated with those errors are not well understood.
Study design: Prospective study with patient data collected via baseline interview while hospitalized and then follow-up telephone calls at three, 30, and 90 days post discharge.
Setting: Vanderbilt Hospital, Nashville, Tenn.
Synopsis: Baseline information (race, ethnicity, education, marital status, income, social support, functional health literacy, cognition, self-rated health status, depression, preadmission medication adherence, and numeracy) was collected on adult hospitalized patients with acute coronary syndrome or acute decompensated heart failure. Post-discharge telephone interviews collected data on what medications (prescription and over the counter) patients were actually taking. Binomial logistic regression was used to determine patient characteristics that predicted discordance between the discharge medication list and the patient-reported list during the post-discharge medication review.
Of the 471 patients in the study (with a mean age of 59 years and mean total number of medications of 12), over half (51.4%) of patients were taking one or more discordant medications; 27.4% did not report a medication that was on their discharge list (omission); and 35.7% reported a medication that was not on their discharge list (commission). Further, over half (59.2%) of patients misunderstood an indication (i.e., clopidogrel is “for my stomach”), a dose, or a frequency.
Bottom line: Post-discharge medication errors are common. Lower health numeracy (the ability to use and understand numbers in daily life) and lower health literacy contributes to post-discharge medication errors.
Use, Interpretation of SpO2 Treatment for Pediatric Bronchiolitis Is Questioned
Clinical question: Does artificial elevation of pulse oximetry measurement in bronchiolitis patients during ED evaluations affect hospitalization rates?
Background: Bronchiolitis is the leading cause of hospitalization for infants younger than one year, leading to direct medical costs in the U.S. of $543 million in 2002. Compromised oxyhemoglobin saturation in bronchiolitis often leads to hospitalization and is assessed by pulse oximetry (SpO2) more commonly than by arterial blood gas (SaO2) due to ease, cost, and comfort considerations.
SpO2 can vary due to fever, acidosis, hemoglobinopathies, underperfusion, and poor probe placement. An American Academy of Pediatrics clinical practice guideline published in 2006 recommended supplemental oxygen if SpO2 drops below 90% in previously healthy infants, but the data supporting this cutoff are sparse.
Recommendations for supplemental oxygen, and thus hospitalization, are variable, with recommended minimum SpO2 ranging from 90 to 95%.
Study design: Single-center randomized, double-blind, parallel-group trial.
Setting: ED at 370-bed, urban, tertiary care children’s hospital.
Synopsis: Over a 50-month period, previously healthy infants aged four weeks to 12 months who were diagnosed with bronchiolitis in the ED and had initial triage SpO2 above 88% were enrolled by investigators. Subjects were excluded if severe respiratory distress, as measured by the Respiratory Distress Assessment Instrument (RDAI), or impending respiratory failure was present. Subjects were randomized to two groups: The control group had their true SpO2 displayed during their ED stay, and the intervention group had an SpO2 that was three points higher displayed. ED physicians were not aware of the primary hypothesis being tested. All subjects underwent concealed continuous oximetry for safety reasons, with monitors alarming if SpO2 dropped below 92%. Study nurses telephoned participants discharged home 72 hours after enrollment.
The primary outcome of hospitalization was defined as admission to an inpatient ward, hospital care provided for more than six hours in the ED if no hospital beds were available, or hospitalization after discharge if within 72 hours of enrollment. Secondary outcomes included supplemental oxygen administration, length of stay in the ED, and unscheduled return visits for bronchiolitis within 72 hours. Exploratory outcomes included delayed hospitalizations within 72 hours, active hospital treatment for more than six hours (with inhaled bronchodilators, oxygen, or intravenous fluids), and hospitalization at the index visit.
Of 1,812 patients assessed, 213 were randomized after exclusion criteria and consent. The “true” group and the “altered” group were similar in initial RDAI (8.0 vs. 8.3 respectively); 41% of children in the “true” oximetry group were hospitalized within 72 hours, compared with 25% in the “high” oximetry group (P 0.005). There were no significant differences in the secondary outcomes. The only exploratory outcome to show a significant difference was treatment for longer than six hours, with 37% of the “true group” receiving treatment for longer than six hours, compared to 20% of the “altered” group (P 0.01).
Bottom line: Perception of improved oxygenation based on falsely elevated SpO2 alone can reduce the inclination of a clinician to admit children with bronchiolitis. This brings into question the use and interpretation of SpO2 in treating children with bronchiolitis.
Citation: Schuh S, Freedman S, Coates A, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014;312(7):712-728.
Clinical question: Does artificial elevation of pulse oximetry measurement in bronchiolitis patients during ED evaluations affect hospitalization rates?
Background: Bronchiolitis is the leading cause of hospitalization for infants younger than one year, leading to direct medical costs in the U.S. of $543 million in 2002. Compromised oxyhemoglobin saturation in bronchiolitis often leads to hospitalization and is assessed by pulse oximetry (SpO2) more commonly than by arterial blood gas (SaO2) due to ease, cost, and comfort considerations.
SpO2 can vary due to fever, acidosis, hemoglobinopathies, underperfusion, and poor probe placement. An American Academy of Pediatrics clinical practice guideline published in 2006 recommended supplemental oxygen if SpO2 drops below 90% in previously healthy infants, but the data supporting this cutoff are sparse.
Recommendations for supplemental oxygen, and thus hospitalization, are variable, with recommended minimum SpO2 ranging from 90 to 95%.
Study design: Single-center randomized, double-blind, parallel-group trial.
Setting: ED at 370-bed, urban, tertiary care children’s hospital.
Synopsis: Over a 50-month period, previously healthy infants aged four weeks to 12 months who were diagnosed with bronchiolitis in the ED and had initial triage SpO2 above 88% were enrolled by investigators. Subjects were excluded if severe respiratory distress, as measured by the Respiratory Distress Assessment Instrument (RDAI), or impending respiratory failure was present. Subjects were randomized to two groups: The control group had their true SpO2 displayed during their ED stay, and the intervention group had an SpO2 that was three points higher displayed. ED physicians were not aware of the primary hypothesis being tested. All subjects underwent concealed continuous oximetry for safety reasons, with monitors alarming if SpO2 dropped below 92%. Study nurses telephoned participants discharged home 72 hours after enrollment.
The primary outcome of hospitalization was defined as admission to an inpatient ward, hospital care provided for more than six hours in the ED if no hospital beds were available, or hospitalization after discharge if within 72 hours of enrollment. Secondary outcomes included supplemental oxygen administration, length of stay in the ED, and unscheduled return visits for bronchiolitis within 72 hours. Exploratory outcomes included delayed hospitalizations within 72 hours, active hospital treatment for more than six hours (with inhaled bronchodilators, oxygen, or intravenous fluids), and hospitalization at the index visit.
Of 1,812 patients assessed, 213 were randomized after exclusion criteria and consent. The “true” group and the “altered” group were similar in initial RDAI (8.0 vs. 8.3 respectively); 41% of children in the “true” oximetry group were hospitalized within 72 hours, compared with 25% in the “high” oximetry group (P 0.005). There were no significant differences in the secondary outcomes. The only exploratory outcome to show a significant difference was treatment for longer than six hours, with 37% of the “true group” receiving treatment for longer than six hours, compared to 20% of the “altered” group (P 0.01).
Bottom line: Perception of improved oxygenation based on falsely elevated SpO2 alone can reduce the inclination of a clinician to admit children with bronchiolitis. This brings into question the use and interpretation of SpO2 in treating children with bronchiolitis.
Citation: Schuh S, Freedman S, Coates A, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014;312(7):712-728.
Clinical question: Does artificial elevation of pulse oximetry measurement in bronchiolitis patients during ED evaluations affect hospitalization rates?
Background: Bronchiolitis is the leading cause of hospitalization for infants younger than one year, leading to direct medical costs in the U.S. of $543 million in 2002. Compromised oxyhemoglobin saturation in bronchiolitis often leads to hospitalization and is assessed by pulse oximetry (SpO2) more commonly than by arterial blood gas (SaO2) due to ease, cost, and comfort considerations.
SpO2 can vary due to fever, acidosis, hemoglobinopathies, underperfusion, and poor probe placement. An American Academy of Pediatrics clinical practice guideline published in 2006 recommended supplemental oxygen if SpO2 drops below 90% in previously healthy infants, but the data supporting this cutoff are sparse.
Recommendations for supplemental oxygen, and thus hospitalization, are variable, with recommended minimum SpO2 ranging from 90 to 95%.
Study design: Single-center randomized, double-blind, parallel-group trial.
Setting: ED at 370-bed, urban, tertiary care children’s hospital.
Synopsis: Over a 50-month period, previously healthy infants aged four weeks to 12 months who were diagnosed with bronchiolitis in the ED and had initial triage SpO2 above 88% were enrolled by investigators. Subjects were excluded if severe respiratory distress, as measured by the Respiratory Distress Assessment Instrument (RDAI), or impending respiratory failure was present. Subjects were randomized to two groups: The control group had their true SpO2 displayed during their ED stay, and the intervention group had an SpO2 that was three points higher displayed. ED physicians were not aware of the primary hypothesis being tested. All subjects underwent concealed continuous oximetry for safety reasons, with monitors alarming if SpO2 dropped below 92%. Study nurses telephoned participants discharged home 72 hours after enrollment.
The primary outcome of hospitalization was defined as admission to an inpatient ward, hospital care provided for more than six hours in the ED if no hospital beds were available, or hospitalization after discharge if within 72 hours of enrollment. Secondary outcomes included supplemental oxygen administration, length of stay in the ED, and unscheduled return visits for bronchiolitis within 72 hours. Exploratory outcomes included delayed hospitalizations within 72 hours, active hospital treatment for more than six hours (with inhaled bronchodilators, oxygen, or intravenous fluids), and hospitalization at the index visit.
Of 1,812 patients assessed, 213 were randomized after exclusion criteria and consent. The “true” group and the “altered” group were similar in initial RDAI (8.0 vs. 8.3 respectively); 41% of children in the “true” oximetry group were hospitalized within 72 hours, compared with 25% in the “high” oximetry group (P 0.005). There were no significant differences in the secondary outcomes. The only exploratory outcome to show a significant difference was treatment for longer than six hours, with 37% of the “true group” receiving treatment for longer than six hours, compared to 20% of the “altered” group (P 0.01).
Bottom line: Perception of improved oxygenation based on falsely elevated SpO2 alone can reduce the inclination of a clinician to admit children with bronchiolitis. This brings into question the use and interpretation of SpO2 in treating children with bronchiolitis.
Citation: Schuh S, Freedman S, Coates A, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014;312(7):712-728.
Hospitalist Joshua Allen-Dicker, MD, MPH, Optimistic About Future of Hospital Medicine
As a young student and resident, Joshua Allen-Dicker, MD, MPH, was stunned to see the flip side of medicine—miscommunication, disenfranchised patients, unnecessary testing, and, worst of all, medical errors. But then he saw a cast of doctors working against that tide and realized he wanted to be one of them.
“I was shocked at the existence of these problems but struck by the fervor of those physicians who worked to build systems that promoted safe and effective care,” Dr. Allen-Dicker says. “More often than not, these physicians were hospitalists. I was inspired to learn more about hospital medicine. I found that the core skills of the hospitalist—teamwork, problem-solving, communication, and leadership—were key areas that I wanted to develop.”
And so he has. Dr. Allen-Dicker recently joined the division of general medicine and primary care at Beth Israel Deaconess Medical Center in Boston. He’s also an instructor in medicine at Harvard Medical School and was previously in the division of hospital medicine at Icahn School of Medicine at Mount Sinai in New York City. He is a member of SHM’s Physicians in Training Committee, is on the faculty for HM15 in Washington, D.C., and is scheduled to speak as part of the new Young Hospitalists track.
Dr. Allen-Dicker, one of six new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory group, clearly loves his chosen profession. But as a young doctor in HM, a specialty that is itself often described as being in its adolescence, he admits there is one irksome question he hears a lot.
Hospitalists can be residency program directors, hospital administrators, important academics, lauded teachers, and even the CMO of Medicare. None of those things are possible without first being a good clinical hospitalist, which is what I’m focusing on right now.–Dr. Allen-Dicker
“I struggle with the question, ‘So what do you want to be when you grow up?’” he says. “Hospital medicine is a young field, and many patients, families, and occasionally some older physicians are not aware that [it] is a long-term career option. As hospitalists continue to demonstrate leadership in clinical care, academics, and education, this question will fade away.”
Question: What’s the best advice you ever received?
Answer: Just be yourself. People are exceptionally skilled at identifying when you’re not being authentic with them.
Q: What’s the worst advice you ever received?
A: Just be yourself. People rarely get things consistently right in healthcare without the right training. I say, “Be yourself, but practice first.”
Q: Did you have a mentor during training?
A: It wasn’t until I moved to New York City for my hospitalist position that I clearly saw how much I owed my residency mentors. I recognized that, with each interaction we have—with nurses, patients, families, other physicians—we make a decision about what kind of doctor we are going to be that day. For me, choosing to channel little parts of my mentors made my move to a new city less lonely and helped me to figure out how to be the doctor I wanted to be. ‘How would Tony answer that question? What would Anjala do right now?’ And if I didn’t know the answer, I acted as if there were someone who might want to channel me someday.
Q: Have you tried to mentor others?
A: There is a new generation of future hospitalists—students who never experienced a hospital without hospitalists and young physicians who have known they wanted a career in hospital medicine since beginning medical school. They are hungry for guidance and eager to be engaged. We are starting a hospital medicine interest group at my hospital to help create a formal pathway for those interested in hospital medicine mentorship. I am really excited about this project.
Q: What’s the biggest change you would like to see in HM?
A: I’m interested to see how hospital medicine engages students and trainees who are interested in hospital medicine. How we educate them, and how much we allow them to educate and change us, will be a defining issue as hospital medicine comes of age.
Q: What aspect of teaching in the 21st century is most difficult? And, what is most enjoyable?
A: As technology becomes increasingly integrated into healthcare and education, there are so many different modalities for engaging learners. Picking a topic and learning points is easy—picking how to teach it is the tough part! Seeing learners take knowledge you’ve imparted—whether it relates to management of renal failure, high-value care, or the patient experience—and put it into clinical practice is amazing.
Q: What is your biggest professional reward?
A: Remaining open to new ideas is a challenge and reward. It’s easy to get caught up in “this is the way we’ve always done this and thought about this.” For me, part of trying to become a better doctor means learning something new each day. I don’t always succeed, but it feels so good when I do.
Q: What SHM event has made the most lasting impression on you?
A: My first national HM conference as a PGY-2 resident. It was an amazing and energizing feeling to sit in the large plenary session with 3,000 hospitalists. I thought to myself, ‘This is a movement that is changing healthcare. I want in.’
Q: Where do you see yourself in 10 years?
A: One of the great things about hospital medicine is how flexible it can be as a career choice. Hospitalists can be residency program directors, hospital administrators, important academics, lauded teachers, and even the CMO of Medicare. None of those things are possible without first being a good clinical hospitalist, which is what I’m focusing on right now.
Q: What impact do you feel devices like smartphones and tablets have had on HM?
A: It’s amazing to see how much bottom-up innovation Apple and Google have inspired with their products. Without waiting for large, hospital-wide investments (e.g. electronic health records), physicians, start-ups, and patients are empowering themselves and changing healthcare. I would just recommend avoiding the mentality that every problem can be solved by buying patients/physicians/staff an iPad. Technology is not a substitute for well-designed healthcare delivery systems.
Richard Quinn is a freelance writer in New Jersey.
As a young student and resident, Joshua Allen-Dicker, MD, MPH, was stunned to see the flip side of medicine—miscommunication, disenfranchised patients, unnecessary testing, and, worst of all, medical errors. But then he saw a cast of doctors working against that tide and realized he wanted to be one of them.
“I was shocked at the existence of these problems but struck by the fervor of those physicians who worked to build systems that promoted safe and effective care,” Dr. Allen-Dicker says. “More often than not, these physicians were hospitalists. I was inspired to learn more about hospital medicine. I found that the core skills of the hospitalist—teamwork, problem-solving, communication, and leadership—were key areas that I wanted to develop.”
And so he has. Dr. Allen-Dicker recently joined the division of general medicine and primary care at Beth Israel Deaconess Medical Center in Boston. He’s also an instructor in medicine at Harvard Medical School and was previously in the division of hospital medicine at Icahn School of Medicine at Mount Sinai in New York City. He is a member of SHM’s Physicians in Training Committee, is on the faculty for HM15 in Washington, D.C., and is scheduled to speak as part of the new Young Hospitalists track.
Dr. Allen-Dicker, one of six new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory group, clearly loves his chosen profession. But as a young doctor in HM, a specialty that is itself often described as being in its adolescence, he admits there is one irksome question he hears a lot.
Hospitalists can be residency program directors, hospital administrators, important academics, lauded teachers, and even the CMO of Medicare. None of those things are possible without first being a good clinical hospitalist, which is what I’m focusing on right now.–Dr. Allen-Dicker
“I struggle with the question, ‘So what do you want to be when you grow up?’” he says. “Hospital medicine is a young field, and many patients, families, and occasionally some older physicians are not aware that [it] is a long-term career option. As hospitalists continue to demonstrate leadership in clinical care, academics, and education, this question will fade away.”
Question: What’s the best advice you ever received?
Answer: Just be yourself. People are exceptionally skilled at identifying when you’re not being authentic with them.
Q: What’s the worst advice you ever received?
A: Just be yourself. People rarely get things consistently right in healthcare without the right training. I say, “Be yourself, but practice first.”
Q: Did you have a mentor during training?
A: It wasn’t until I moved to New York City for my hospitalist position that I clearly saw how much I owed my residency mentors. I recognized that, with each interaction we have—with nurses, patients, families, other physicians—we make a decision about what kind of doctor we are going to be that day. For me, choosing to channel little parts of my mentors made my move to a new city less lonely and helped me to figure out how to be the doctor I wanted to be. ‘How would Tony answer that question? What would Anjala do right now?’ And if I didn’t know the answer, I acted as if there were someone who might want to channel me someday.
Q: Have you tried to mentor others?
A: There is a new generation of future hospitalists—students who never experienced a hospital without hospitalists and young physicians who have known they wanted a career in hospital medicine since beginning medical school. They are hungry for guidance and eager to be engaged. We are starting a hospital medicine interest group at my hospital to help create a formal pathway for those interested in hospital medicine mentorship. I am really excited about this project.
Q: What’s the biggest change you would like to see in HM?
A: I’m interested to see how hospital medicine engages students and trainees who are interested in hospital medicine. How we educate them, and how much we allow them to educate and change us, will be a defining issue as hospital medicine comes of age.
Q: What aspect of teaching in the 21st century is most difficult? And, what is most enjoyable?
A: As technology becomes increasingly integrated into healthcare and education, there are so many different modalities for engaging learners. Picking a topic and learning points is easy—picking how to teach it is the tough part! Seeing learners take knowledge you’ve imparted—whether it relates to management of renal failure, high-value care, or the patient experience—and put it into clinical practice is amazing.
Q: What is your biggest professional reward?
A: Remaining open to new ideas is a challenge and reward. It’s easy to get caught up in “this is the way we’ve always done this and thought about this.” For me, part of trying to become a better doctor means learning something new each day. I don’t always succeed, but it feels so good when I do.
Q: What SHM event has made the most lasting impression on you?
A: My first national HM conference as a PGY-2 resident. It was an amazing and energizing feeling to sit in the large plenary session with 3,000 hospitalists. I thought to myself, ‘This is a movement that is changing healthcare. I want in.’
Q: Where do you see yourself in 10 years?
A: One of the great things about hospital medicine is how flexible it can be as a career choice. Hospitalists can be residency program directors, hospital administrators, important academics, lauded teachers, and even the CMO of Medicare. None of those things are possible without first being a good clinical hospitalist, which is what I’m focusing on right now.
Q: What impact do you feel devices like smartphones and tablets have had on HM?
A: It’s amazing to see how much bottom-up innovation Apple and Google have inspired with their products. Without waiting for large, hospital-wide investments (e.g. electronic health records), physicians, start-ups, and patients are empowering themselves and changing healthcare. I would just recommend avoiding the mentality that every problem can be solved by buying patients/physicians/staff an iPad. Technology is not a substitute for well-designed healthcare delivery systems.
Richard Quinn is a freelance writer in New Jersey.
As a young student and resident, Joshua Allen-Dicker, MD, MPH, was stunned to see the flip side of medicine—miscommunication, disenfranchised patients, unnecessary testing, and, worst of all, medical errors. But then he saw a cast of doctors working against that tide and realized he wanted to be one of them.
“I was shocked at the existence of these problems but struck by the fervor of those physicians who worked to build systems that promoted safe and effective care,” Dr. Allen-Dicker says. “More often than not, these physicians were hospitalists. I was inspired to learn more about hospital medicine. I found that the core skills of the hospitalist—teamwork, problem-solving, communication, and leadership—were key areas that I wanted to develop.”
And so he has. Dr. Allen-Dicker recently joined the division of general medicine and primary care at Beth Israel Deaconess Medical Center in Boston. He’s also an instructor in medicine at Harvard Medical School and was previously in the division of hospital medicine at Icahn School of Medicine at Mount Sinai in New York City. He is a member of SHM’s Physicians in Training Committee, is on the faculty for HM15 in Washington, D.C., and is scheduled to speak as part of the new Young Hospitalists track.
Dr. Allen-Dicker, one of six new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory group, clearly loves his chosen profession. But as a young doctor in HM, a specialty that is itself often described as being in its adolescence, he admits there is one irksome question he hears a lot.
Hospitalists can be residency program directors, hospital administrators, important academics, lauded teachers, and even the CMO of Medicare. None of those things are possible without first being a good clinical hospitalist, which is what I’m focusing on right now.–Dr. Allen-Dicker
“I struggle with the question, ‘So what do you want to be when you grow up?’” he says. “Hospital medicine is a young field, and many patients, families, and occasionally some older physicians are not aware that [it] is a long-term career option. As hospitalists continue to demonstrate leadership in clinical care, academics, and education, this question will fade away.”
Question: What’s the best advice you ever received?
Answer: Just be yourself. People are exceptionally skilled at identifying when you’re not being authentic with them.
Q: What’s the worst advice you ever received?
A: Just be yourself. People rarely get things consistently right in healthcare without the right training. I say, “Be yourself, but practice first.”
Q: Did you have a mentor during training?
A: It wasn’t until I moved to New York City for my hospitalist position that I clearly saw how much I owed my residency mentors. I recognized that, with each interaction we have—with nurses, patients, families, other physicians—we make a decision about what kind of doctor we are going to be that day. For me, choosing to channel little parts of my mentors made my move to a new city less lonely and helped me to figure out how to be the doctor I wanted to be. ‘How would Tony answer that question? What would Anjala do right now?’ And if I didn’t know the answer, I acted as if there were someone who might want to channel me someday.
Q: Have you tried to mentor others?
A: There is a new generation of future hospitalists—students who never experienced a hospital without hospitalists and young physicians who have known they wanted a career in hospital medicine since beginning medical school. They are hungry for guidance and eager to be engaged. We are starting a hospital medicine interest group at my hospital to help create a formal pathway for those interested in hospital medicine mentorship. I am really excited about this project.
Q: What’s the biggest change you would like to see in HM?
A: I’m interested to see how hospital medicine engages students and trainees who are interested in hospital medicine. How we educate them, and how much we allow them to educate and change us, will be a defining issue as hospital medicine comes of age.
Q: What aspect of teaching in the 21st century is most difficult? And, what is most enjoyable?
A: As technology becomes increasingly integrated into healthcare and education, there are so many different modalities for engaging learners. Picking a topic and learning points is easy—picking how to teach it is the tough part! Seeing learners take knowledge you’ve imparted—whether it relates to management of renal failure, high-value care, or the patient experience—and put it into clinical practice is amazing.
Q: What is your biggest professional reward?
A: Remaining open to new ideas is a challenge and reward. It’s easy to get caught up in “this is the way we’ve always done this and thought about this.” For me, part of trying to become a better doctor means learning something new each day. I don’t always succeed, but it feels so good when I do.
Q: What SHM event has made the most lasting impression on you?
A: My first national HM conference as a PGY-2 resident. It was an amazing and energizing feeling to sit in the large plenary session with 3,000 hospitalists. I thought to myself, ‘This is a movement that is changing healthcare. I want in.’
Q: Where do you see yourself in 10 years?
A: One of the great things about hospital medicine is how flexible it can be as a career choice. Hospitalists can be residency program directors, hospital administrators, important academics, lauded teachers, and even the CMO of Medicare. None of those things are possible without first being a good clinical hospitalist, which is what I’m focusing on right now.
Q: What impact do you feel devices like smartphones and tablets have had on HM?
A: It’s amazing to see how much bottom-up innovation Apple and Google have inspired with their products. Without waiting for large, hospital-wide investments (e.g. electronic health records), physicians, start-ups, and patients are empowering themselves and changing healthcare. I would just recommend avoiding the mentality that every problem can be solved by buying patients/physicians/staff an iPad. Technology is not a substitute for well-designed healthcare delivery systems.
Richard Quinn is a freelance writer in New Jersey.