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Perioperative Hyperglycemia Increases Risk of Poor Outcomes in Nondiabetics
Clinical question: How does perioperative hyperglycemia affect the risk of adverse events in diabetic patients compared to nondiabetic patients?
Background: Perioperative hyperglycemia is associated with increased rates of infection, myocardial infarction, stroke, and death. Recent studies suggest that nondiabetics are more prone to hyperglycemia-related complications than diabetics. This study sought to analyze the effect and mechanism by which nondiabetics may be at increased risk for such complications.
Study design: Retrospective cohort study.
Setting: Fifty-three hospitals in Washington.
Synopsis: Among 40,836 patients who underwent surgery, diabetics had a higher rate of perioperative adverse events overall compared to nondiabetics (12% versus 9%, P<0.001). Perioperative hyperglycemia, defined as blood glucose 180 or greater, was also associated with an increased rate of adverse events. Ironically, this association was more significant in nondiabetic patients (odds ratio, 1.6; 95% CI, 1.3–2.1) than in diabetic patients (odds ratio, 0.8; 95% CI, 0.6–1.0). Although the exact reason for this is unknown, existing theories include the following:
- Diabetics are more apt to receive insulin for perioperative hyperglycemia than nondiabetics (P<0.001);
- Hyperglycemia in diabetics may be a less-reliable marker of surgical stress than in nondiabetics; and
- Diabetics may be better adapted to hyperglycemia than nondiabetics.
Bottom line: Perioperative hyperglycemia leads to an increased risk of adverse events; this relationship is more pronounced in nondiabetic patients than in diabetic patients.
Citation: Kotagal M, Symons RG, Hirsch IB, et al. Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg. 2015;261(1):97–103. TH
Visit our website for more physician reviews of hospitalist-focused literature.
Clinical question: How does perioperative hyperglycemia affect the risk of adverse events in diabetic patients compared to nondiabetic patients?
Background: Perioperative hyperglycemia is associated with increased rates of infection, myocardial infarction, stroke, and death. Recent studies suggest that nondiabetics are more prone to hyperglycemia-related complications than diabetics. This study sought to analyze the effect and mechanism by which nondiabetics may be at increased risk for such complications.
Study design: Retrospective cohort study.
Setting: Fifty-three hospitals in Washington.
Synopsis: Among 40,836 patients who underwent surgery, diabetics had a higher rate of perioperative adverse events overall compared to nondiabetics (12% versus 9%, P<0.001). Perioperative hyperglycemia, defined as blood glucose 180 or greater, was also associated with an increased rate of adverse events. Ironically, this association was more significant in nondiabetic patients (odds ratio, 1.6; 95% CI, 1.3–2.1) than in diabetic patients (odds ratio, 0.8; 95% CI, 0.6–1.0). Although the exact reason for this is unknown, existing theories include the following:
- Diabetics are more apt to receive insulin for perioperative hyperglycemia than nondiabetics (P<0.001);
- Hyperglycemia in diabetics may be a less-reliable marker of surgical stress than in nondiabetics; and
- Diabetics may be better adapted to hyperglycemia than nondiabetics.
Bottom line: Perioperative hyperglycemia leads to an increased risk of adverse events; this relationship is more pronounced in nondiabetic patients than in diabetic patients.
Citation: Kotagal M, Symons RG, Hirsch IB, et al. Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg. 2015;261(1):97–103. TH
Visit our website for more physician reviews of hospitalist-focused literature.
Clinical question: How does perioperative hyperglycemia affect the risk of adverse events in diabetic patients compared to nondiabetic patients?
Background: Perioperative hyperglycemia is associated with increased rates of infection, myocardial infarction, stroke, and death. Recent studies suggest that nondiabetics are more prone to hyperglycemia-related complications than diabetics. This study sought to analyze the effect and mechanism by which nondiabetics may be at increased risk for such complications.
Study design: Retrospective cohort study.
Setting: Fifty-three hospitals in Washington.
Synopsis: Among 40,836 patients who underwent surgery, diabetics had a higher rate of perioperative adverse events overall compared to nondiabetics (12% versus 9%, P<0.001). Perioperative hyperglycemia, defined as blood glucose 180 or greater, was also associated with an increased rate of adverse events. Ironically, this association was more significant in nondiabetic patients (odds ratio, 1.6; 95% CI, 1.3–2.1) than in diabetic patients (odds ratio, 0.8; 95% CI, 0.6–1.0). Although the exact reason for this is unknown, existing theories include the following:
- Diabetics are more apt to receive insulin for perioperative hyperglycemia than nondiabetics (P<0.001);
- Hyperglycemia in diabetics may be a less-reliable marker of surgical stress than in nondiabetics; and
- Diabetics may be better adapted to hyperglycemia than nondiabetics.
Bottom line: Perioperative hyperglycemia leads to an increased risk of adverse events; this relationship is more pronounced in nondiabetic patients than in diabetic patients.
Citation: Kotagal M, Symons RG, Hirsch IB, et al. Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg. 2015;261(1):97–103. TH
Visit our website for more physician reviews of hospitalist-focused literature.
LISTEN NOW: My iPad Went to Medical School
Mobile devices put information in the palm of your hand. For hospitalists, this presents real opportunities to engage patients, improve care, and streamline hospital workflows. Two hospitalists who were early adopters of mobile tech in their practices, Dr. Henry Feldman of Beth Israel Deaconess and Dr. Richard Pittman of Emory University/Grady share their lessons learned, and their advice for other hospital clinicians and informaticists on using mobile tech in their practices.
Mobile devices put information in the palm of your hand. For hospitalists, this presents real opportunities to engage patients, improve care, and streamline hospital workflows. Two hospitalists who were early adopters of mobile tech in their practices, Dr. Henry Feldman of Beth Israel Deaconess and Dr. Richard Pittman of Emory University/Grady share their lessons learned, and their advice for other hospital clinicians and informaticists on using mobile tech in their practices.
Mobile devices put information in the palm of your hand. For hospitalists, this presents real opportunities to engage patients, improve care, and streamline hospital workflows. Two hospitalists who were early adopters of mobile tech in their practices, Dr. Henry Feldman of Beth Israel Deaconess and Dr. Richard Pittman of Emory University/Grady share their lessons learned, and their advice for other hospital clinicians and informaticists on using mobile tech in their practices.
Leadership 101: Basic skills for early-career hospitalists
Early career hospitalists may think leadership roles automatically yield more money and free time, Dr. Gundersen says. Actually, being a leader requires stamina and the ability to weather the ups and downs that come with the leadership role. For example, will you be able to handle situations in which your decisions make others unhappy?
Deliver on Promises
Honest self-assessment is one of the most critical elements in becoming a leader, agrees Steven Deitelzweig, MD, MMM, FACP, FSVMB, RVT, VPMA, system chairman of hospital medicine and medical director of regional business development for Ochsner Health System in the greater New Orleans area. In addition to having good interpersonal skills, showing enthusiasm, and promoting your organization sincerely—what Dr. Deitelzweig labels “emotional intelligence”—prospective leaders need to be cognizant of delivering on promises.
“This is something I call a high ‘say/do’ ratio,” he explains, “and, simply put, it means that you accomplish what you say you will. At the end of the day, the only way anybody moves up is by being good at achieving results.”
If you start missing deadlines, you communicate that you are not reliable. Not all project implementation goes according to plan, of course, so when you encounter difficulties, early communication about obstacles is also key, he says.
Nuts and Bolts
Through SHM’s Leadership Academy, hospitalists can be trained in team management and other key leadership skills. An October 2015 session is scheduled in Austin.
Having trusted mentors is crucial, agreed both physicians, so that you can keep polishing your skill set and obtain honest feedback. These mentors should not be people to whom you directly report, and they need not be in the healthcare industry.
In fact, Dr. Gundersen says he’s known mentors for years “who have not been in the same specialty or even the same field, but who give me guidance and have helped make me into the leader I am.”
How do you assert your desire to be a leader? Dr. Deitelzweig suggests making your aspirations clear to your own group leaders. The annual review is an excellent juncture at which to discuss this, he says.
If you do not yet have project management or communications experience, ask your leaders whether they are familiar with training to help you develop those skills. In the current healthcare environment, the Affordable Care Act and reimbursement regulations mean that change will continue to be part of the leadership challenge.
“If you really want to be a leader,” Dr. Deitelzweig says, “you cannot be a naysayer. Make change work for you, look at it as an opportunity for you to innovate, and then show how valuable you can be.”
Gretchen Henkel is a freelance writer in California.
Listen Now
Listen to Dr. Gundersen dive further into the importance of mentors and assessing your personal qualities to be a good leader.
[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/03/Gundersen_CareerCenter1_FINAL_012515.mp3"][/audio]
Early career hospitalists may think leadership roles automatically yield more money and free time, Dr. Gundersen says. Actually, being a leader requires stamina and the ability to weather the ups and downs that come with the leadership role. For example, will you be able to handle situations in which your decisions make others unhappy?
Deliver on Promises
Honest self-assessment is one of the most critical elements in becoming a leader, agrees Steven Deitelzweig, MD, MMM, FACP, FSVMB, RVT, VPMA, system chairman of hospital medicine and medical director of regional business development for Ochsner Health System in the greater New Orleans area. In addition to having good interpersonal skills, showing enthusiasm, and promoting your organization sincerely—what Dr. Deitelzweig labels “emotional intelligence”—prospective leaders need to be cognizant of delivering on promises.
“This is something I call a high ‘say/do’ ratio,” he explains, “and, simply put, it means that you accomplish what you say you will. At the end of the day, the only way anybody moves up is by being good at achieving results.”
If you start missing deadlines, you communicate that you are not reliable. Not all project implementation goes according to plan, of course, so when you encounter difficulties, early communication about obstacles is also key, he says.
Nuts and Bolts
Through SHM’s Leadership Academy, hospitalists can be trained in team management and other key leadership skills. An October 2015 session is scheduled in Austin.
Having trusted mentors is crucial, agreed both physicians, so that you can keep polishing your skill set and obtain honest feedback. These mentors should not be people to whom you directly report, and they need not be in the healthcare industry.
In fact, Dr. Gundersen says he’s known mentors for years “who have not been in the same specialty or even the same field, but who give me guidance and have helped make me into the leader I am.”
How do you assert your desire to be a leader? Dr. Deitelzweig suggests making your aspirations clear to your own group leaders. The annual review is an excellent juncture at which to discuss this, he says.
If you do not yet have project management or communications experience, ask your leaders whether they are familiar with training to help you develop those skills. In the current healthcare environment, the Affordable Care Act and reimbursement regulations mean that change will continue to be part of the leadership challenge.
“If you really want to be a leader,” Dr. Deitelzweig says, “you cannot be a naysayer. Make change work for you, look at it as an opportunity for you to innovate, and then show how valuable you can be.”
Gretchen Henkel is a freelance writer in California.
Listen Now
Listen to Dr. Gundersen dive further into the importance of mentors and assessing your personal qualities to be a good leader.
[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/03/Gundersen_CareerCenter1_FINAL_012515.mp3"][/audio]
Early career hospitalists may think leadership roles automatically yield more money and free time, Dr. Gundersen says. Actually, being a leader requires stamina and the ability to weather the ups and downs that come with the leadership role. For example, will you be able to handle situations in which your decisions make others unhappy?
Deliver on Promises
Honest self-assessment is one of the most critical elements in becoming a leader, agrees Steven Deitelzweig, MD, MMM, FACP, FSVMB, RVT, VPMA, system chairman of hospital medicine and medical director of regional business development for Ochsner Health System in the greater New Orleans area. In addition to having good interpersonal skills, showing enthusiasm, and promoting your organization sincerely—what Dr. Deitelzweig labels “emotional intelligence”—prospective leaders need to be cognizant of delivering on promises.
“This is something I call a high ‘say/do’ ratio,” he explains, “and, simply put, it means that you accomplish what you say you will. At the end of the day, the only way anybody moves up is by being good at achieving results.”
If you start missing deadlines, you communicate that you are not reliable. Not all project implementation goes according to plan, of course, so when you encounter difficulties, early communication about obstacles is also key, he says.
Nuts and Bolts
Through SHM’s Leadership Academy, hospitalists can be trained in team management and other key leadership skills. An October 2015 session is scheduled in Austin.
Having trusted mentors is crucial, agreed both physicians, so that you can keep polishing your skill set and obtain honest feedback. These mentors should not be people to whom you directly report, and they need not be in the healthcare industry.
In fact, Dr. Gundersen says he’s known mentors for years “who have not been in the same specialty or even the same field, but who give me guidance and have helped make me into the leader I am.”
How do you assert your desire to be a leader? Dr. Deitelzweig suggests making your aspirations clear to your own group leaders. The annual review is an excellent juncture at which to discuss this, he says.
If you do not yet have project management or communications experience, ask your leaders whether they are familiar with training to help you develop those skills. In the current healthcare environment, the Affordable Care Act and reimbursement regulations mean that change will continue to be part of the leadership challenge.
“If you really want to be a leader,” Dr. Deitelzweig says, “you cannot be a naysayer. Make change work for you, look at it as an opportunity for you to innovate, and then show how valuable you can be.”
Gretchen Henkel is a freelance writer in California.
Listen Now
Listen to Dr. Gundersen dive further into the importance of mentors and assessing your personal qualities to be a good leader.
[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/03/Gundersen_CareerCenter1_FINAL_012515.mp3"][/audio]
Federal Program to Cut Hospital Readmissions Turns Out Modest Results
A new report has found that only a small number of groups included in a government-funded experiment to cut Medicare readmissions actually produced results. However, the less-than-hoped-for results don't necessarily indicate failure, a hospitalist and readmissions expert says.
The Community-based Care Transitions Program (CCTP) is one of several test care-delivery models created by the Affordable Care Act. Its main goal is to improve transitions of Medicare patients from the hospital to community-based settings, such as nursing homes, rehabilitation facilities, and government agencies that provide services to the elderly, and thereby reduce readmissions.
However, a new report [PDF] commissioned by the Centers for Medicare & Medicaid Services found that only four CCTP groups of the 48 studied significantly cut readmissions compared with those of a control group. The report was finished in May 2014 but wasn't made public until January.
"There are so few examples in healthcare where resource alignment makes sense with what we believe are the ideal ways of practicing," says Jeffrey L. Greenwald, MD, associate professor of medicine at Harvard Medical School and a member of the Inpatient Clinician Educator Service at Massachusetts General Hospital, both in Boston. "Things like CCTP, where you have an opportunity to partner a hospital with a community-based organization that can help to support patient transitions still looks promising despite its warts."
CCTP, funded with $300 million over five years, signed its first round of deals with community agencies in late 2011. The report covered partial 2012 results from groups participating in the early rounds.
Dr. Greenwald is one of the cofounders of SHM's Project BOOST, a yearlong QI program in which hospital teams are paired with mentors to help them improve care transitions. He explained that BOOST teams typically need at least 18-24 months to show positive results on length-of-stay or readmissions reductions.
"These are long processes that don't turn around overnight," Dr. Greenwald adds. "If they do, it's probably because [the hospital team] put in place something that is not sustainable, and the minute they stop measuring and keeping an eye on it, it will likely deteriorate.
"There's no magic bullet in care transitions."
Visit our website for more information on ways hospitals can reduce readmissions.
A new report has found that only a small number of groups included in a government-funded experiment to cut Medicare readmissions actually produced results. However, the less-than-hoped-for results don't necessarily indicate failure, a hospitalist and readmissions expert says.
The Community-based Care Transitions Program (CCTP) is one of several test care-delivery models created by the Affordable Care Act. Its main goal is to improve transitions of Medicare patients from the hospital to community-based settings, such as nursing homes, rehabilitation facilities, and government agencies that provide services to the elderly, and thereby reduce readmissions.
However, a new report [PDF] commissioned by the Centers for Medicare & Medicaid Services found that only four CCTP groups of the 48 studied significantly cut readmissions compared with those of a control group. The report was finished in May 2014 but wasn't made public until January.
"There are so few examples in healthcare where resource alignment makes sense with what we believe are the ideal ways of practicing," says Jeffrey L. Greenwald, MD, associate professor of medicine at Harvard Medical School and a member of the Inpatient Clinician Educator Service at Massachusetts General Hospital, both in Boston. "Things like CCTP, where you have an opportunity to partner a hospital with a community-based organization that can help to support patient transitions still looks promising despite its warts."
CCTP, funded with $300 million over five years, signed its first round of deals with community agencies in late 2011. The report covered partial 2012 results from groups participating in the early rounds.
Dr. Greenwald is one of the cofounders of SHM's Project BOOST, a yearlong QI program in which hospital teams are paired with mentors to help them improve care transitions. He explained that BOOST teams typically need at least 18-24 months to show positive results on length-of-stay or readmissions reductions.
"These are long processes that don't turn around overnight," Dr. Greenwald adds. "If they do, it's probably because [the hospital team] put in place something that is not sustainable, and the minute they stop measuring and keeping an eye on it, it will likely deteriorate.
"There's no magic bullet in care transitions."
Visit our website for more information on ways hospitals can reduce readmissions.
A new report has found that only a small number of groups included in a government-funded experiment to cut Medicare readmissions actually produced results. However, the less-than-hoped-for results don't necessarily indicate failure, a hospitalist and readmissions expert says.
The Community-based Care Transitions Program (CCTP) is one of several test care-delivery models created by the Affordable Care Act. Its main goal is to improve transitions of Medicare patients from the hospital to community-based settings, such as nursing homes, rehabilitation facilities, and government agencies that provide services to the elderly, and thereby reduce readmissions.
However, a new report [PDF] commissioned by the Centers for Medicare & Medicaid Services found that only four CCTP groups of the 48 studied significantly cut readmissions compared with those of a control group. The report was finished in May 2014 but wasn't made public until January.
"There are so few examples in healthcare where resource alignment makes sense with what we believe are the ideal ways of practicing," says Jeffrey L. Greenwald, MD, associate professor of medicine at Harvard Medical School and a member of the Inpatient Clinician Educator Service at Massachusetts General Hospital, both in Boston. "Things like CCTP, where you have an opportunity to partner a hospital with a community-based organization that can help to support patient transitions still looks promising despite its warts."
CCTP, funded with $300 million over five years, signed its first round of deals with community agencies in late 2011. The report covered partial 2012 results from groups participating in the early rounds.
Dr. Greenwald is one of the cofounders of SHM's Project BOOST, a yearlong QI program in which hospital teams are paired with mentors to help them improve care transitions. He explained that BOOST teams typically need at least 18-24 months to show positive results on length-of-stay or readmissions reductions.
"These are long processes that don't turn around overnight," Dr. Greenwald adds. "If they do, it's probably because [the hospital team] put in place something that is not sustainable, and the minute they stop measuring and keeping an eye on it, it will likely deteriorate.
"There's no magic bullet in care transitions."
Visit our website for more information on ways hospitals can reduce readmissions.
Hospitalists Gear Up for HM15
Hospital medicine will descend on Washington, D.C., again.
At least 2,500 attendees are expected at SHM's annual meeting, HM15, which kicks off March 29 at the Gaylord National Resort & Convention Center in National Harbor, Md. The four-day conference—SHM's third in the nation's capital in six years—ends April 1 and encompasses:
- Seven pre-courses on March 29 that can be applied toward continuing medical education credits;
- Dozens of educational sessions over three days, including the debut of its "Young Hospitalists" track on March 30;
- The largest Research, Innovations, and Clinical Vignettes poster competition ever; and
- Plenary sessions from patient-safety guru Peter Pronovost, MD, PhD, FCCM; HM pioneer Robert Wachter, MD, MHM; and Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement.
"The opportunity to learn about faculty development, the opportunity to learn about administrative concerns in running a hospital medicine program, the opportunity to address quality improvement…the opportunity to meet other folks who are doing very similar work and learn from them, all of those things exist,” says assistant course director Melissa Mattison, MD, SFHM.
In addition, SHM's advocacy event, Hospitalists on the Hill Day, is scheduled for April 1 and will see physicians holding hundreds of meetings with Capitol Hill legislators and staffers.
"Every congressman has physicians in their community, and they value the opinion of those physicians," SHM Public Policy Committee Chair Ron Greeno, MD, MHM, says. "Nothing is more effective than having one of our members meet with a representative from their home district about the issues that we care about."
Visit our website for more information on HM15.
Hospital medicine will descend on Washington, D.C., again.
At least 2,500 attendees are expected at SHM's annual meeting, HM15, which kicks off March 29 at the Gaylord National Resort & Convention Center in National Harbor, Md. The four-day conference—SHM's third in the nation's capital in six years—ends April 1 and encompasses:
- Seven pre-courses on March 29 that can be applied toward continuing medical education credits;
- Dozens of educational sessions over three days, including the debut of its "Young Hospitalists" track on March 30;
- The largest Research, Innovations, and Clinical Vignettes poster competition ever; and
- Plenary sessions from patient-safety guru Peter Pronovost, MD, PhD, FCCM; HM pioneer Robert Wachter, MD, MHM; and Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement.
"The opportunity to learn about faculty development, the opportunity to learn about administrative concerns in running a hospital medicine program, the opportunity to address quality improvement…the opportunity to meet other folks who are doing very similar work and learn from them, all of those things exist,” says assistant course director Melissa Mattison, MD, SFHM.
In addition, SHM's advocacy event, Hospitalists on the Hill Day, is scheduled for April 1 and will see physicians holding hundreds of meetings with Capitol Hill legislators and staffers.
"Every congressman has physicians in their community, and they value the opinion of those physicians," SHM Public Policy Committee Chair Ron Greeno, MD, MHM, says. "Nothing is more effective than having one of our members meet with a representative from their home district about the issues that we care about."
Visit our website for more information on HM15.
Hospital medicine will descend on Washington, D.C., again.
At least 2,500 attendees are expected at SHM's annual meeting, HM15, which kicks off March 29 at the Gaylord National Resort & Convention Center in National Harbor, Md. The four-day conference—SHM's third in the nation's capital in six years—ends April 1 and encompasses:
- Seven pre-courses on March 29 that can be applied toward continuing medical education credits;
- Dozens of educational sessions over three days, including the debut of its "Young Hospitalists" track on March 30;
- The largest Research, Innovations, and Clinical Vignettes poster competition ever; and
- Plenary sessions from patient-safety guru Peter Pronovost, MD, PhD, FCCM; HM pioneer Robert Wachter, MD, MHM; and Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement.
"The opportunity to learn about faculty development, the opportunity to learn about administrative concerns in running a hospital medicine program, the opportunity to address quality improvement…the opportunity to meet other folks who are doing very similar work and learn from them, all of those things exist,” says assistant course director Melissa Mattison, MD, SFHM.
In addition, SHM's advocacy event, Hospitalists on the Hill Day, is scheduled for April 1 and will see physicians holding hundreds of meetings with Capitol Hill legislators and staffers.
"Every congressman has physicians in their community, and they value the opinion of those physicians," SHM Public Policy Committee Chair Ron Greeno, MD, MHM, says. "Nothing is more effective than having one of our members meet with a representative from their home district about the issues that we care about."
Visit our website for more information on HM15.
2011 Resident Work Hour Reforms Had No Effect on Mortality or Readmissions
Clinical question
Did the 2011 Accreditation Council for Graduate Medical Education resident work hour reforms affect patient outcomes?
Bottom line
Resident work hour reforms were proposed by the Accreditation Council for Graduate Medical Education (ACGME) to reduce resident fatigue (and thus potentially reduce the risk of medical errors), but implementation of the work hour changes also led to concerns over patient safety because of increased handoffs in care. This study shows that work hour reforms had no impact, either positive or negative, on the important patient outcomes of mortality and readmission rates. Other outcomes such as length of stay and number of intensive care unit transfers may need to be examined in future studies to detect more subtle differences. (LOE = 2b)
Reference
Study design: Cohort (retrospective)
Funding source: Government
Allocation: Uncertain
Setting: Inpatient (any location)
Synopsis
In 2011, the ACGME instituted work hour reforms for residents that reduced the work hour limit from 30 consecutive hours to 16 hours for first-year residents and 24 hours for all other residents. Investigators in this study evaluated the effect of the 2011 ACGME reforms on 30-day all-location mortality and 30-day all-cause readmissions. Patients included in the study were Medicare patients who were admitted to acute care US hospitals from 2009 to 2012 with acute myocardial infarction, stroke, gastrointestinal bleeding, or congestive heart failure, or those admitted for general, orthopedic, or vascular surgery. Hospitals were classified by their level of teaching intensity using a resident-to-bed ratio defined as the number of residents divided by the number of staffed beds.
In an analysis that adjusted for demographics, co-morbidities, and the presence of surgical complications, the implementation of work hour reforms did not affect 30-day mortality or readmissions in more-intensive teaching hospitals relative to less-intensive teaching hospitals during the postreform year as compared with 2 years before the reform. Multiple factors beyond the implementation of work hour reforms, may have contributed to this lack of effect. First, adherence to the new reforms by residency programs in the first year is unclear. Second, concurrent initiatives to improve patient outcomes during this time may have affected all hospitals, teaching and nonteaching. Finally, the authors suggest that the greater emphasis on resident supervision with the new reforms may have counterbalanced any negative effects of increased resident handoffs.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Did the 2011 Accreditation Council for Graduate Medical Education resident work hour reforms affect patient outcomes?
Bottom line
Resident work hour reforms were proposed by the Accreditation Council for Graduate Medical Education (ACGME) to reduce resident fatigue (and thus potentially reduce the risk of medical errors), but implementation of the work hour changes also led to concerns over patient safety because of increased handoffs in care. This study shows that work hour reforms had no impact, either positive or negative, on the important patient outcomes of mortality and readmission rates. Other outcomes such as length of stay and number of intensive care unit transfers may need to be examined in future studies to detect more subtle differences. (LOE = 2b)
Reference
Study design: Cohort (retrospective)
Funding source: Government
Allocation: Uncertain
Setting: Inpatient (any location)
Synopsis
In 2011, the ACGME instituted work hour reforms for residents that reduced the work hour limit from 30 consecutive hours to 16 hours for first-year residents and 24 hours for all other residents. Investigators in this study evaluated the effect of the 2011 ACGME reforms on 30-day all-location mortality and 30-day all-cause readmissions. Patients included in the study were Medicare patients who were admitted to acute care US hospitals from 2009 to 2012 with acute myocardial infarction, stroke, gastrointestinal bleeding, or congestive heart failure, or those admitted for general, orthopedic, or vascular surgery. Hospitals were classified by their level of teaching intensity using a resident-to-bed ratio defined as the number of residents divided by the number of staffed beds.
In an analysis that adjusted for demographics, co-morbidities, and the presence of surgical complications, the implementation of work hour reforms did not affect 30-day mortality or readmissions in more-intensive teaching hospitals relative to less-intensive teaching hospitals during the postreform year as compared with 2 years before the reform. Multiple factors beyond the implementation of work hour reforms, may have contributed to this lack of effect. First, adherence to the new reforms by residency programs in the first year is unclear. Second, concurrent initiatives to improve patient outcomes during this time may have affected all hospitals, teaching and nonteaching. Finally, the authors suggest that the greater emphasis on resident supervision with the new reforms may have counterbalanced any negative effects of increased resident handoffs.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Did the 2011 Accreditation Council for Graduate Medical Education resident work hour reforms affect patient outcomes?
Bottom line
Resident work hour reforms were proposed by the Accreditation Council for Graduate Medical Education (ACGME) to reduce resident fatigue (and thus potentially reduce the risk of medical errors), but implementation of the work hour changes also led to concerns over patient safety because of increased handoffs in care. This study shows that work hour reforms had no impact, either positive or negative, on the important patient outcomes of mortality and readmission rates. Other outcomes such as length of stay and number of intensive care unit transfers may need to be examined in future studies to detect more subtle differences. (LOE = 2b)
Reference
Study design: Cohort (retrospective)
Funding source: Government
Allocation: Uncertain
Setting: Inpatient (any location)
Synopsis
In 2011, the ACGME instituted work hour reforms for residents that reduced the work hour limit from 30 consecutive hours to 16 hours for first-year residents and 24 hours for all other residents. Investigators in this study evaluated the effect of the 2011 ACGME reforms on 30-day all-location mortality and 30-day all-cause readmissions. Patients included in the study were Medicare patients who were admitted to acute care US hospitals from 2009 to 2012 with acute myocardial infarction, stroke, gastrointestinal bleeding, or congestive heart failure, or those admitted for general, orthopedic, or vascular surgery. Hospitals were classified by their level of teaching intensity using a resident-to-bed ratio defined as the number of residents divided by the number of staffed beds.
In an analysis that adjusted for demographics, co-morbidities, and the presence of surgical complications, the implementation of work hour reforms did not affect 30-day mortality or readmissions in more-intensive teaching hospitals relative to less-intensive teaching hospitals during the postreform year as compared with 2 years before the reform. Multiple factors beyond the implementation of work hour reforms, may have contributed to this lack of effect. First, adherence to the new reforms by residency programs in the first year is unclear. Second, concurrent initiatives to improve patient outcomes during this time may have affected all hospitals, teaching and nonteaching. Finally, the authors suggest that the greater emphasis on resident supervision with the new reforms may have counterbalanced any negative effects of increased resident handoffs.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Chlorhexidine Bathing Does Not Reduce Nosocomial Infections
Clinical question: For critically ill patients, does daily bathing with chlorhexidine reduce health care–associated infections?
Bottom line
These results show that daily chlorhexidine bathing does not significantly affect the incidence of health care–associated infections. These data conflict with data from prior research, suggesting that more investigation is needed before incorporating chlorhexidine bathing into routine practice, especially given the increased cost with its use and the possibility of the development of chlorhexidine resistance. (LOE = 1b)
Study design: Cross-over trial (randomized)
Funding source: Government
Allocation: Concealed
Setting: Inpatient (ICU only)
Synopsis
Previous studies have shown benefit of daily chlorhexidine bathing in patients at high risk of nosocomial blood stream infections (Daily POEM 7-31-2013; Daily POEM 4-26-2013). In this study, investigators randomized 5 intensive care units at a tertiary care hospital to provide daily bathing of all patients with either 2% chlorhexidine-impregnated cloths or with nonantimicrobial cloths. Each unit followed the assigned protocol for 10 weeks, followed by a 2-week washout period, and then crossed over to the alternate protocol for another 10 weeks. All units crossed over 3 times during the study. Almost 10,000 patients were included in the study. The primary outcome was a composite of health-care associated infections, including central-line associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated pneumonia, and Clostridium difficile infections. There was no significant difference detected in the rate of the primary outcome between the chlorhexidine group and the control group with approximately 3 infections per 1000 patient-days in both groups. Adjusting for factors including demographics, co-morbidities, and the unit of admission also did not reveal a difference.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question: For critically ill patients, does daily bathing with chlorhexidine reduce health care–associated infections?
Bottom line
These results show that daily chlorhexidine bathing does not significantly affect the incidence of health care–associated infections. These data conflict with data from prior research, suggesting that more investigation is needed before incorporating chlorhexidine bathing into routine practice, especially given the increased cost with its use and the possibility of the development of chlorhexidine resistance. (LOE = 1b)
Study design: Cross-over trial (randomized)
Funding source: Government
Allocation: Concealed
Setting: Inpatient (ICU only)
Synopsis
Previous studies have shown benefit of daily chlorhexidine bathing in patients at high risk of nosocomial blood stream infections (Daily POEM 7-31-2013; Daily POEM 4-26-2013). In this study, investigators randomized 5 intensive care units at a tertiary care hospital to provide daily bathing of all patients with either 2% chlorhexidine-impregnated cloths or with nonantimicrobial cloths. Each unit followed the assigned protocol for 10 weeks, followed by a 2-week washout period, and then crossed over to the alternate protocol for another 10 weeks. All units crossed over 3 times during the study. Almost 10,000 patients were included in the study. The primary outcome was a composite of health-care associated infections, including central-line associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated pneumonia, and Clostridium difficile infections. There was no significant difference detected in the rate of the primary outcome between the chlorhexidine group and the control group with approximately 3 infections per 1000 patient-days in both groups. Adjusting for factors including demographics, co-morbidities, and the unit of admission also did not reveal a difference.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question: For critically ill patients, does daily bathing with chlorhexidine reduce health care–associated infections?
Bottom line
These results show that daily chlorhexidine bathing does not significantly affect the incidence of health care–associated infections. These data conflict with data from prior research, suggesting that more investigation is needed before incorporating chlorhexidine bathing into routine practice, especially given the increased cost with its use and the possibility of the development of chlorhexidine resistance. (LOE = 1b)
Study design: Cross-over trial (randomized)
Funding source: Government
Allocation: Concealed
Setting: Inpatient (ICU only)
Synopsis
Previous studies have shown benefit of daily chlorhexidine bathing in patients at high risk of nosocomial blood stream infections (Daily POEM 7-31-2013; Daily POEM 4-26-2013). In this study, investigators randomized 5 intensive care units at a tertiary care hospital to provide daily bathing of all patients with either 2% chlorhexidine-impregnated cloths or with nonantimicrobial cloths. Each unit followed the assigned protocol for 10 weeks, followed by a 2-week washout period, and then crossed over to the alternate protocol for another 10 weeks. All units crossed over 3 times during the study. Almost 10,000 patients were included in the study. The primary outcome was a composite of health-care associated infections, including central-line associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated pneumonia, and Clostridium difficile infections. There was no significant difference detected in the rate of the primary outcome between the chlorhexidine group and the control group with approximately 3 infections per 1000 patient-days in both groups. Adjusting for factors including demographics, co-morbidities, and the unit of admission also did not reveal a difference.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
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Although patients with blood clots are oftentimes not admitted to the hospital, there are some exceptions. Monal Shah, MD, physician advisor for Parkland Hospital in Dallas, Texas, and the former section head of hospital medicine at the University of Texas Southwestern Medical Center, discusses some exceptions.